Chesapeake Physician July/August 2015 Issue

EVOLUTION IN ORTHOPAEDIC TREATMENTS

THE STATE OF TRANSPLANTS

PATIENT-CENTERED SPECIALTY PRACTICES

DEVELOPING PHYSICIAN LEADERS

Maryland/DC/Virginia PhysicianYOUR PRACTICE. YOUR LIFE.

C H E S A P E A K E

VOLUME 5: ISSUE 4 JULY/AUGUST 2015

chesphysician.com

10 Evolution in Orthopaedic Treatment

16 The State of Transplants:Advances & New Approaches

F E AT U R E S

D E PA R T M E N T S

ContentsVOLUME 5: ISSUE 4 JULY/AUGUST 2015

168 10

Cases | 7 | Collagenase Injection: An Alternative to Surgery for Dupuytren’s Contracture

Solutions | 8 | Developing Physician Leaders for Tomorrow

HIT | 20 | The Medical Home Gets a New Neighborhood

Policy | 28 | Today’s Skilled Nursing Facility: Not Your Parents’ Nursing Home

Our Bay | 30 | Celebration of the Chesapeake Bay

On the Cover: Michael Barr, MD, MBA, FACP, executive vice president of the NCQA

Physician

“Q” is for quality patient care. At a photo shoot with NCQA Executive VicePresident Michael Barr, MD, for this issue’sHealthcare IT feature (see page 20), I zoomed in on a gift he’d received, a brightly lit letter“Q.” The “Q” recognizes Dr. Barr’s nationalleadership in promoting the foundations ofquality patient care and making it part of anational agenda. Similarly, I’ve made a focus on quality patient care a cornerstone of theChesapeake Physician brand.

The Chesapeake Physician mission, dedicated to building a regional physician andhealthcare stakeholder network with a commitment to achieving the highest standardsof quality patient care, is deeply rooted in me, embedded in my earliest memories. Mydad, Nathan A. Cohen, MD, was the one who lit that light for me. Each and every dayof his professional career, his commitment to delivering quality care was part of everydecision he made as the director of a community hospital medical lab, and part of hismentoring, from his medical school students to lab techs. Sadly, as this issue was indevelopment, my family and I lost him to Alzheimer’s. His disease actually gave me a gift, allowing me to connect with him on an issue he had been focused on 20 to 30years earlier, at a time when he and I did not share a professional commonality.

On Father’s Day 2012, I had a long telephone chat with my dad when, because of his disease, he was reliving a moment in 1980 and he was distraught that hospitalleadership was failing to recognize the incredible work of his teams, which kept thatmedical lab humming 24 hours a day, saving patients’ lives. Thanks to the hundreds of folks I’ve had the privilege of speaking with as part of our editorial development, I was able to have a conversation with my dad where I could help to gently guide himthrough some ideas for conflict resolution. It was a remarkable experience. My mindwas in 2012 and his was somewhere around 1980.

What better way to honor my dad’s memory than by going outside our leading-edgeregional providers for subject-matter expertise to another physician who is driven by a commitment to quality, and who was equally inspired by my dad. My sister andboard-certified orthopaedic surgeon, Jessica Brown, MD, is this issue’s contributor to our Cases department, discussing advances in treating Dupuytren’s contractures(see Cases page 7). That topic is part of our clinical focus this issue on advances invarious aspects of orthopaedics, from zero profile cervical devices to advanced PTtreatments and healthier bones in children.

My team and I have heard from many of you that you are interested in hearing eachother’s stories. What led you to become a physician? What are your personal challengesas a physician? What do you love about being a physician and what do you hate aboutit? Please, share your story like I often share mine. Help us to build the Chesapeake-based regional network I’m passionate about. Every page of this magazine is an integralpart of that mission.

To life!

Jacquie Cohen RothFounder/Publisher/Executive [email protected]

@chesphysician

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JACQUIE COHEN ROTHFOUNDER/PUBLISHER/EXECUTIVE EDITOR

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PHOTOGRAPHYTracey Brown, Papercamera Photography

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DISCUSSION: Dupuytren’scontracture is created by excessivecollagen deposition that typicallycauses contracture in themetacarpophalangeal and/orproximal interphalangeal joints.Progressive fibromatosis typicallyleads to the formation of nodulesand painless tissue contraction,generally progressing slowly. Thecause is unknown, but may beassociated with an autoimmunereaction. It may also causecontractures of the penis(Peyronie’s disease) or feet(lederhosen disease).

Dupuytren’s affects seven timesas many males as females, typicallyafter 50 years of age. Other riskfactors include northern Europeandescent like this patient, a familyhistory of the disease, smoking,alcohol use and diabetes. It is anautosomal dominant condition,requiring that only one parent havethe abnormal gene.

Diagnosis is typically madethrough a thorough history andphysical examination of the hands,including strength, range ofmotion, presence and location ofany nodules. An X-ray may beordered, but no additional testingis required. While fine motorcoordination is usually not affectedsince the thumb, index and middlefingers are not affected, patientsoften present complaining ofdifficulty with activities such asgrasping objects, putting on glovesor shaking hands.

Studies of Xiaflex found thatthe average patient required 1.7injections to eliminate thecontracture and create a ‘tabletop’flat hand. Some 30 to 50% ofpatients require re-treatment withinfive years. After completion of

Phase-3 clinical trials, Xiaflex wasapproved by the FDA in February2010 for treating Dupuytren's.

Treatment ApproachesMild Dupuytren’s contracture maybe treated conservatively with heat,massage and by using padded,built-up handles during dailyactivities that involve grasping.Stretching and splinting arecontraindicated. When conservativemeasures are insufficient, surgeryused to be the primary treatmentoption, but minimally invasiveoptions, such as needle apon-eurotomy and collagenase injectionto disrupt the cords and restorerange of motion, have becomemore widespread. This case reflectsthe growing trend to move towardchemical treatment of medicalproblems in place of surgicaltreatment.

Needle aponeurotomy uses ahypodermic needle under localanesthetic to ‘break’ the cord oftissue that causes the contractures.The procedure can be repeatedwhen contractures recur. Theprocedure can be performed onmore than one finger at the sametime, and requires little or nophysical therapy post-procedure. Its use, however, is usually restrictedto the palm, as nerve and tendondamage can occur in the finger.

Collagenase injections into thecollagen cord can soften thecontracture to allow the physician tomanipulate the hand and straightenthe fingers. The injection needs to be given by a trained physician toavoid risk of tendon rupture. Jessica Brown, MD, is an orthopaedic

surgeon who is fellowship-trained in

hand surgery. She can be reached at

[email protected].

CASE: A 49-year-old woman with blueeyes and fair skin presented with severeDupuytren’s contracture of her little finger.She first noted thickening of her palmarfascia and a nodule in her 30s. She had apositive family history of Dupuytren’s thatincluded her father, brother and severalcousins. At the time of onset of palmarfascia thickening, she had consulted withher primary care physician, who referredher to a hand surgeon. However, due to the fact that her family members hadexperienced poor outcomes after receivingsurgical treatment for their contractures,she had refused surgery. Her palmgradually developed contractures, and shewas seeking an alternative to surgery.

Dupuytren’s diagnosis was confirmedupon physical examination. Treatment alternatives, including open fasciectomyand needle fasciotomy, were discussed.The patient rejected all surgical options,not only because of the poor results of family members’ surgeries, but also becauseshe knew surgery carried other risks, such as stiffness and infection. Becausediseased tissue may attach to the skin, surgical removal can be difficult and mayrequire skin grafting. Fat pads may also haveto be removed during surgery. Physicaltherapy is typically required, and recoverygenerally takes several weeks to months.

Instead, the patient received a single injection, in the office, of collagenase, isolated from clostridium histolyticum (Xiaflex) into the contracted collagen cord.The following day, she returned to the office where the cord was popped and herhand was straightened. Two weeks post injection, her results were superior to typicalsurgical results. Results are expected to lastfor approximately five years, when a repeatinjection can be given if appropriate.

JULY/AUGUST 2015 | 7

Collagenase Injection: An Alternative to Surgery forDupuytren’s Contracture

By Jessica Brown, MD

CASES


SOLUTIONS

Developing Physician Leaders for Tomorrow

S HEALTHCAREdelivery models become more complex,and reimbursement transitions from fee-for-service to population health-based approaches, strong physicianleadership is more essential than ever.Yet few programs exist to helpphysicians develop the skills they needto go beyond managing organizations to effectively leading them.

That’s why Mark Rulle, EdD,president, Maryland HealthcareEducation Institute (MHEI), is sopassionate about a new program hisorganization launched last fall called the Physician Leadership Initiative.Designed specifically to meet the needsof tomorrow’s physician leaders, theinitiative offers a four-day program in the fall that includes discussions,readings and onsite experiences atcompanies that are at the forefront ofleadership development, followed bythree breakfast meetings in the spring.

Rulle describes the rationale for thisprogram. “I see physicians getting intomore formalized leadership positionsnow – we’ve really come full circle.Physicians used to lead hospitals, but in the 1970s, lots of professionaladministrators came out of school tomanage increasingly complex jobs.Today, clinical care has become soimportant again that it’s incumbent on physicians to develop into leaders.The role of chief of staff still exists, but it’s more important than ever, and doctors find themselves ill preparedfor these roles.

“We only accept 15 people into our leadership program, and most are leaders under age 40. Most of our participants are just starting andwondering how leadership works. They often have no peers or mentorsthey can count on. First we discusschanges at the 30,000-foot level. Then

A we talk them through a particularsituation, such as how to haveconstructive conversations with othercaregiving staff or how to balance theirclinical duties with their administrativeresponsibilities.

“They can discuss what they havetried in their own workplaces, then getinput from the others in the group,” he adds. “Experienced physiciansfacilitate the discussions. Our goal is not to give them an answer, but to armthem with some skills to developpotential solutions to their problems.Our attempt is a first step in formalizingthe leadership process and starting toconnect them with peers and olderphysicians for support.

“The sessions cover critical leadershiptopics such as how to build trust andhow to engage people, even when you have no direct reports. Physiciansare encouraged to develop their listeningskills and their ability to understandother people’s viewpoints, characteristicsthat are critical to effective leadership.We concentrate on getting results anddiscuss how you hold everyoneaccountable within the current culture,which likely is not ideal. We also talk about whether you take anincremental approach or try to changethe culture in one fell swoop.”

Leadership Requires EmotionalIntelligence“Leadership is not the same asadministrative work or paperwork,”Rulle remarks. “An MBA can providefinancial and business skills, strategicplanning and the like, but you aren’tnecessarily trained in how to change the culture, how to engage employees,and other leadership skills. Being the boss

Being the boss is notthe same as being agood leader. – Mark Rulle, EdD

By Linda Harder • Photography by Tracey Brown

Mark Rulle, EdD, president,Maryland Healthcare EducationInstitute (MHEI)


is not the same as being a good leader.”He reminds physicians that being a

leader is less about your title and moreabout who you are and how you act in a given situation.

Drewry White, MD, MBA, FACEP,chief of Emergency Medicine at CarrollHospital Center in Westminster, Md.,and the regional medical director ofEmergency Medical Associates (EMA), a large group of about 250 physiciansand 100 PAs that staffs 16 ED sites,concurs with Rulle. He says, “The key leadership criterion is emotionalintelligence. It’s less and less about yourIQ – everyone who graduated frommedical school is smart. The keys areskills such as how you react to otherpeople, and how you get buy-in forsomething when it’s not popular.”

Leadership Academy for Emergency PhysiciansHaving received his own MBA in theearly 2000s, Dr. White co-chairs thegroup’s Leadership Academy, whichprovides administrative and leadershiptraining to potential leaders within EMA.

“Medicine is becoming an increasinglycomplex profession,” Dr. Whiteobserves. “Medicine self-selects forpeople who like to continue learningthroughout their lives. All of ourdoctors practice good medicine, but we take one to two with leadershippotential from each site and providehalf-day sessions every other month forone year, plus assignments. All doctorscan benefit from good leadership skills,whether leading the medical staff or a team of nurses, or meeting C-Suiteleaders in the hallway.”

He outlines some of the content hisgroup’s Leadership Academy covers.“We teach promising leaders a variety of skills, including how to have difficultconversations, such as during an annualevaluation, how to conduct meetingsand how to survive office politics. We also cover accounting, finance andhuman resources skills. I use real emailsI’ve received to demonstrate emailetiquette, and inappropriate socialmedia posts to show what not to do. We walk attendees through politicallycharged situations and talk about howto handle them.”

Leadership ResourcesRulle recommends several resources forphysicians interested in honing theirleadership skills. The first is TheLeadership Challenge by James Kouzes

and Barry Posner, first published 25 years ago. The 25th anniversaryedition of the book features over 100 new case studies and examples, anddescribes the five practices of exemplaryleadership. Other resources used in thecourse include components of StephenCovey’s work, from his popular books,The 7 Habits of Highly Effective People,The 8th Habit: From Effectiveness toGreatness and Principle-CenteredLeadership. And the course includessome TED talks by Simon Sinek, aleadership expert and author.

MHEI also offers an annual leadershipconference each fall that can serve as aresource for area physicians in leadershippositions, and the 2015 conference willfeature Sinek as a keynoter.

Dr. White contributes, “The Emerging Leaders Program inMontgomery County, Md., is anothergreat leadership training program.” It involves eight monthly interactivesessions for leaders under age 35 wholive or work in the county, and is notlimited to healthcare leaders.

Rulle also notes that a servantleadership approach, a term coined byRobert K. Greenleaf in The Servant asLeader, an essay first published in 1970,can help physicians become moreeffective leaders. He explains, “Theservant leader recognizes that he is notthere to give orders but to serve otherpeople. That allows you to engage withthose you work with, and hear them on their terms. I’m also a proponent of

recognizing that the people reporting toyou know what they’re doing.Engagement works better than getting it done by decree. Healthcare has manyeducated, talented people, and you’rewasting talent if you don’t engage themand allow them to speak up.”Mark Rulle, EdD, president, Maryland

Healthcare Education Institute

Drewry White, MD, MBA, FACEP, regionalmedical director of Emergency Medical

Associates and chief of Emergency Medicine

at Carroll Hospital Center

The key leadership criterion is emotionalintelligence. – Drewry White, MD, MBA, FACEP

Drewry White, MD, MBA, FACEP, chief of Emergency Medicine at Carroll HospitalCenter in Westminster, Md.

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NEWER TECHNIQUES FORCERVICAL FUSIONThe cliché ‘pain in the neck’ has its roots in a common orthopaedic problem,with about one-third of spine problemsrelated to cervical pain. For patientssuffering pain without compression ofthe cervical nerve roots or spinal cord,conservative treatments generally suffice.But when stenosis or herniated discsimpinge on these structures, somepatients will require surgery.

Ira Fedder, MD, a fellowship-trainedspine surgeon with Towson OrthopaedicAssociates, describes how to differentiatepatients with radiculopathy from thosewith myelopathy. “Radiculopathyinvolves compression of a nerve, whilemyelopathy involves compression of the spinal cord. Radiculopathy oftenpresents with arm pain, weakness and

numbness and abnormally low reflexes –lower motor neuron issues. In contrast,patients with cervical myelopathy willhave abnormally ‘brisk’ reflexes –positive Hoffman’s and Babinski’s,clonus and positive scapular humeralreflex above C3.”

Dr. Fedder notes that radiculopathycan be treated conservatively, withprogression to surgery only ifconservative measures fail. However, he recommends that patients withmyelopathy be referred to a spinesurgeon immediately.

Myelopathy Symptoms May Be Overlooked“The thing that confuses people aboutspinal stenosis is that the neck pain isunimportant, but problems with finemotor skills, such as putting on jewelry

In this issue, expertsexplain the advantagesof zero profile devicesfor cervical fusion,discuss new challengesand therapies inpediatric bone healthand describe how to getthe most from physicaltherapy referrals.

ORTHOPAEDIC TREATMENT

BY LINDA HARDER • PHOTOGRAPHS BY TRACEY BROWN

EVOLUTION IN

zero profile devices, I can visualize onelevel at a time because there’s no platerunning the entire length of the repair.”

If only one or two cervical levels areinvolved, Dr. Fedder and colleagues cancreate a tiny incision in the front of theneck. With three or more levels, he usedto make a vertical incision, but waspersuaded to try a horizontal incision.“These incisions heal beautifully,” heexclaims.

Dr. Fedder describes the followingadvantages of the zero profile approach:

z Shorter operative timez Ability to perform segmental

insertionz Narrow footprintz Lower intra-esophageal pressurez Reduced esophageal retractionz Less dysphagiaz Fewer revisionsz Bone healing visible sooner in

some patientsz No protrusion of a plate to

displace soft tissues

Impressive ResultsWhile acknowledging that the zeroprofile devices still have many skeptics,he notes, “Our results have beenimpressive. In four years, we’ve put1,539 of these devices in 788 patients,and at two years out, we’ve had onlyeight levels that required reoperation,

or makeup, are significant formyelopathy,” he continues. “Patientsoften say they’re fine, but they may havestopped wearing jewelry or may haveprogressed to having their spouse dotheir buttons for them without realizingthis is cervical stenosis. Instead, theyoften attribute their issues to carpaltunnel or arthritis. I advise people to gohome and take inventory of the dailyactivities they’ve stopped doing.”

He adds, “Surprisingly, myelopathycan affect people of all ages. It’s notunusual to find it in people in their 30sand 40s, and genetics can play a role. I had one mother and son withmyelopathy, and the son had a moresevere case at an earlier onset than hismother. Even older patients in goodhealth with myelopathy can benefit from surgery – I had a 91-year-oldpatient who had surgery and can nowwalk and do his activities of daily livingindependently again.”

Surgery is generally a way to preventdisease progression, not a cure. “A lackof progression of symptoms constitutes a good outcome for surgical treatment of myelopathy – it’s important to getthem referred early to keep them fromprogressing,” Dr. Fedder notes.

Anterior Cervical DiscectomySurgery for radiculopathy andmyelopathy involves anterior cervicaldiscectomy and fusion (ACDF), whichwas developed at Johns Hopkins morethan 50 years ago. The anteriorapproach creates better access to thecervical spine and causes less pain than a posterior approach. Traditionally, this procedure involved removing theaffected disc(s), and distracting the spineto permit the insertion of a bone

allograft or autograft, then screwing ona titanium plate to increase stability. A problem with these plates is that they require larger exposure and maydisplace the esophagus, frequentlycausing dysphagia.

Zero Profile Cervical DevicesTo address the problems associated with titanium plates, Dr. Fedder and hispartners started using a new approachcalled ‘zero profile’ devices in 2010. He explains, “With the titanium plates,patients frequently couldn’t swallow oreat normally. With zero profile devices,the surgical technique is segmental, andeven when we include more levels theseverity of dysphagia is dramaticallyimproved. With some exceptions,patients can eat and drink right aftersurgery, compared with a typical wait of two to four days following theconventional approach.”

Using a zero profile device, surgeonsdrill pins into the cervical bone, retractingone level at a time to view the spinalcord, rather than having to retract theentire esophagus as is necessary in atraditional approach. The device can be used on up to four levels.

“A zero profile device is easier to putin,” Dr. Fedder notes. “When using aplate, I can’t see one level when viewinganother – I have to go back and forthconstantly from top to bottom. With

Laura Tosi, MD, director of the Children’s National Health System Bone Health Program in Washington, DC

With zero profile devices, I can visualize one level at a time becausethere’s no plate running the entirelength of the repair.

– Ira Fedder, MD

plus five documented screw fractures.The company we use is very responsiveand very engineering-driven. I haven’tused a traditional plate since 2010, and personally haven’t had to revise asingle patient.”

PEDIATRIC BONE HEALTHLaura Tosi, MD, brings herextraordinary enthusiasm and joie devivre to her work as director of theChildren’s National Health System BoneHealth Program in Washington, DC, oneof the few such programs in the country.“When I started out in pediatricorthopaedics, the expectation was thatmany children with birth defects orsevere illnesses such as cancer would not survive to adulthood. Well, thingshave changed! The new paradigm is that MOST children will survive, and a significant number will have a normallife expectancy. The challenge is thatfrequently the disorders and/or theirtreatments damage the skeleton, leavingchildren vulnerable to painful anddisabling fractures,” she says.

The Bone Health Program addressesthis growing challenge. Dr. Tosi notes,“Making sure that survivors ofchildhood-onset conditions don’tfracture is one of the best things I can do to improve the quality of life andindependence of this rapidly expandingpopulation. We initiated the program in2004 and it has grown beyond ourwildest expectations. We now treat thefull spectrum of metabolic, treatment-induced and genetic conditions thatimpact bone quality in children.”

Clinicians and families must rememberthat bone is a “use it or lose it”proposition, she argues, and weight-bearing exercise is critical to buildingand maintaining a strong skeleton.

A Resurgence of RicketsA big surprise has been the number ofyoung children who present with old-fashioned rickets. “The pendulum hasswung back to breastfeeding infants andavoiding formula. Overall that is a verypositive change. But breast milk doesn’ttransmit much Vitamin D to the infant.Without adequate Vitamin D, an infantcannot absorb the calcium needed tobuild a strong skeleton.”

Dr. Tosi explains, “One of my greatjoys is when a young toddler presentslooking like an elderly citizen – and thenreturns in a few weeks as a running andjumping normal child. I am thrilled

when parents ‘accuse’ me of giving theirchildren a personality transplant!”

She imparts an important reminder topediatricians: All breastfed babies needVitamin D supplementation. “Just a few weeks ago, a colleague referred aone-year-old breastfed fellow who wasbeing evaluated for developmental delay.I found that the child had an almostundetectable Vitamin D level. I ampleased to report that after just six weeksof treatment with Vitamin D, the child is walking and developing normally.”

The clinic serves as the training site forthe NIH’s Skeletal Clinical Studies Unit(NIDCR). The trainees are able to learnto care for children with a wide varietyof metabolic problems, as well as otherbone disorders such as skeletal dysplasia.

Overuse Injuries in Young AthletesDr. Tosi also sees young athletes withoveruse injuries that are failing to heal.“Most fractures heal in about six weeks.However, children who participate inonly one sport, don’t cross-train, havelow Vitamin D and avoid milk or othercalcium-rich food-stuffs can developwhat is commonly called a stress fractureor overuse injury.” In this injury, thebone fails to remodel quickly enough to accommodate the significantworkload imposed by vigorous sportsparticipation. As a result, bone canbreak, crush or even collapse, causingextreme pain. The X-ray is often normalearly on, and the diagnosis may requirean MRI.

“Bone is fabulous, as long as youprovide adequate nutrition and build itin slow increments,” notes Dr. Tosi. “If someone starts playing competitivetennis at a very young age, at puberty his or her serving forearm can be asmuch as one-third larger than a ‘normal’forearm. The bone ‘remodels’ toaccommodate the demands being placedon it. But too much demand, applied tooquickly, can lead to these slow-healingand painful injuries.”

Exciting New Therapies For some bone disorders, new therapiesoffer considerable promise. That’s thecase for osteogenesis imperfecta (OI),also called ‘brittle bone disease,’ which is caused by one or more of over 1,500genetic variants.

Dr. Tosi comments, “The geneticdefect in OI typically leads to thedevelopment of an inadequate meshworkto support the calcium critical to makingthe bone strong. Imagine building thefoundation of a skyscraper. You begin by using stainless steel cables to supportthe cement used in the foundation. In severe cases of OI, it is as though the stainless steel was replaced bytoothpicks. Thus the foundation of theskeleton is very weak and prone toinjury. There is no cure for this disorderyet. However, the Bone Health Programis one of a handful of pediatric programsnationally to offer specialized bone-altering medications to these children.We offer pamidronate infusions, a bisphosphonate drug that helpsstrengthen OI bone by slowing boneresorption, an important step in boneremodeling.”

Dr. Tosi adds, “Pamidronate can also interrupt the vicious cycle ofrepeated fractures in other children withdisabilities. We are carefully exploringthe impact of medical treatment forchildren with other disorders that canlead to bone fragility, as well.”

“Bone formation is time-limited – you have to make the strongest possibleskeleton when you’re young,” Dr. Tosiconcludes. “Unfortunately, the closer a child is to puberty when she or hebecomes ill, the less time they have torepair their bone health. We are eager to meet and evaluate all children withdisorders that are impairing normal boneformation as early as possible, so that wewill have the maximum possible time tohelp them improve their bone health andachieve their full genetic potential.”


…breast milk doesn’t transmitmuch Vitamin D tothe infant. Withoutadequate Vitamin D,an infant cannot absorb the calciumneeded to build astrong skeleton.– Laura Tosi, MD


PROMPT PT REFERRALSGetting the most out of physical therapy(PT) may depend in large part on atimely referral. Tom Perone, DPT,director of Physical Therapy at MidAtlantic Sports Therapy and Rehab,urges physicians to refer patients whoare not getting significant improvementin pain and function two weeks after an injury to an orthopaedist and/ordirectly to a PT.

“Rest, ice and anti-inflammatories areappropriate treatment for the first two

weeks,” he says, “but then patients whoaren’t improving by at least 50 to 80%need to be referred out for furtherdifferential diagnosis. As long as there’s no suspicion of a serioustraumatic injury such as a rotator cuff,ACL or meniscal tear, you can refer basic strains and sprains directly to a PT rather than an orthopaedist. Patientsalso can refer themselves directly to a PT, in most cases without risking the loss of insurance coverage.”

Perone describes the process. “We

check the patients’ insurance benefitsfirst, and then we can prescribe PTdirectly without a physician referral. We refer appropriate patients to anorthopaedist, and we send an initialevaluation and monthly progress notesto the primary care physician andorthopaedist as appropriate.”

Among the most common issuesPerone treats are shoulder and kneeinjuries in active middle-age populationsand in high school athletes.

Studies have shown that a frequentcause of knee pain is imbalancedstructures in the hip. “A lot of knee pain comes from the hip, with weak hipabductors and external rotators, whichincrease the stress on the knee,” Peroneexplains. “We use a variety of techniquesfor pain relief, including icing andelectrical stimulation, as well asstrengthening and stretching. Often,manually loosening the lateral quads inthe iliotibial band area can help.”

Graston TechniqueThe Graston Technique® is a form of instrument-assisted soft-tissuemobilization that allows PTs andchiropractors to effectively break down scar tissue and fascial restrictions.It employs a set of stainless steelinstruments to identify and treat areasthat are chronically inflamed or fibrotic.

“It breaks up fibrotic soft tissue andpromotes healing,” notes Perone. “We use lotion along with one or moreof the metal tools in the kit to loosen the myofascial tissue.”

The Graston Technique can treat both chronic and acute post-surgicalproblems, offering advantages thatinclude:

z Decreasing overall time of treatment

z Promoting faster recoveryz Reducing the need for anti-

inflammatory medicationz Resolving chronic conditions

thought to be permanent

Providers must attend a 12-hour M1-Basic Training course before beingqualified to treat patients with thistechnique.

Trigger Point Dry Needling (TDN)Appropriate for patients who are notresponding to less-invasive approaches,TDN generates a twitch response fromfibrotic tissues that releases the

Tom Perone, DPT, director of Physical Therapy at Mid Atlantic Sports Therapy and Rehab

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superficial muscles and allows therapiststo access the injured joint moreeffectively. The technique uses the same microfilament needles found inacupuncture, but involves a differentapproach based on Western medicalresearch and principles, not traditionalChinese medicine.

Called dry needling because it doesnot involve injecting a solution, TDN is useful for reducing muscle tension and spasm resulting from arthritis, nerve irritation, muscle or ligamentstrain, or herniated discs. Injuredmuscles typically go into a protectivecontracture and inflamed state thatbecomes hypoxic and results infibroblast buildup.

“Because it is more invasive and can be uncomfortable, I usually tryother techniques first,” Perone explains, “and I discuss using TDN with the referring physicians beforeusing it. It works well in conjunctionwith other techniques, and data hasproven its success in short-term painrelief and increased mobility. It can take six to eight sessions to get themaximum results.”

PTs Now Need DoctorateFor the last decade, PTs have beenrequired to get a doctorate degree thatinvolves a science-related undergraduatedegree plus seven semesters of PTtraining. The curriculum typicallyincludes biology, exercise physiology,kinesiology, anatomy, jointmobilization/manipulation, and alsobasic training in imaging, pharmacologyand differential diagnosis. PTs inpractice prior to the new requirementscould be grand-fathered in withoutadditional training.

PT assistants must get an associatedegree that involves a five-semesterprogram. They can perform dailytreatments but not evaluations orreassessments, and they cannotindependently make changes to the plan of care.


Ira Fedder, MD, a fellowship-trained

spine surgeon with Towson Orthopaedic

Associates

Laura Tosi, MD, director of the BoneHealth Program at Children’s National

Health System

Tom Perone, DPT, director of PhysicalTherapy at Mid Atlantic Sports Therapy

and Rehab

EVERY INCH.

EVERY FOOT.

EVERY MILE. EVERY STEP.

UNTIL BREAST CANCER DOES.YOU WON’T STOP

#ONESTEPCLOSER

REGISTER AT KOMENMD.ORG/2015SUNDAY, OCTOBER 25, 2015HUNT VALLEY, MD


BY LINDA HARDER

Medical experts from the Chesapeake regiondiscuss how pre-clinicaltrials are benefiting a widerange of transplants, andwhat’s new and exciting in liver transplantation.

IMMUNOSUPPRESSION RESEARCH ADVANCES COMPLEX TRANSPLANTSTransplanting several genetically distincttypes of cells, as is required to transplant aface or hand, was once deemed impossible.The development of a new field,vascularized composite allograft (VCA),was critical for enabling these complextransplants involving multiple cell types,including skin, bone, muscles, bloodvessels, nerves and connective tissue.

Results from pre-clinical transplantmodels conducted over the past 10 yearsat the University of Maryland inBaltimore are now paving the way notonly for the long-term success of face andhand transplants, but also to improvemore typical organ transplants such asliver, pancreas and kidneys.

Rolf Barth, MD, associate professor ofSurgery at the University of MarylandSchool of Medicine and director of LiverTransplantation at the University ofMaryland Medical Center, completed apost-doctoral fellowship inTransplantation Immunology and hasspecial expertise in pre-clinicaltransplantation models.

Pre-Clinical Trials Pay OffHe recalls, “When I arrived at theUniversity of Maryland in 2006, Dr.Stephen Bartlett had initiated pre-clinicalstudies in face transplantation, that I

The state of

Rolf Barth, MD, associate professor of Surgery at the University of Maryland Schoolof Medicine and director ofLiver Transplantation at the University of Maryland Medical Center

transplants

joined, along with Dr. Eduardo Rodriguez,a reconstructive surgeon. Our goal wasto understand as much as possible abouttransplants via pre-clinical models first,before we undertook clinical transplants.We received over $10 million in fundingto set up a rigorous program for pre-clinical hand and face transplants. Wespent the first four years in the lab tounderstand the unique challenges andpitfalls of these transplants.”

The first successful hand transplantwas performed in 1999, and the first of over 25 face transplants took place in2005. However, these transplants werecontroversial, sporadic and the long-termoutcomes were unknown. Most of theface transplants also were partial.

The research at University ofMaryland is helping to change that. Dr. Barth explains, “We explored thepotential for long-term success beforeundertaking any clinical trials, andreached a series of findings that led toour initial clinical trial. Short-term results had been encouraging inexperimental transplants elsewhere, but we resolved to demonstrate that along-term approach was viable.”

He adds, “Some pre-clinical trials have demonstrated that infusing bonemarrow at the time of transplant can be beneficial. That motivated us toconduct clinical trials. Getting throughthe review board process took over ayear, and we had to also work with thedonor side, but we’re used to long waittimes in the transplant field. We alsolearned that some immunosuppressiondrugs could be predicted not to workwith the face, and we identified somenew types of infection.”

One of their more encouragingfindings was that transplants containingbone and bone marrow might protectskin cells, despite the fact that these cellsare highly subject to rejection. Whilesome 90 to 100% of results showed earlyrejection, Dr. Barth and his colleaguesfound that, as long as the transplantcontained bone marrow, the results werereversible. And if they could successfullyuse FDA-approved and tolerable levels ofimmunosuppression drugs to get patientsthrough the short term, they could bemore successful in the long term.

Research Results in a World-FamousFace TransplantThe research that Dr. Barth and hiscolleagues performed paved the way for

the highly publicized face transplant forRichard Norris in 2012. Norris, who hadaccidentally shot himself in the face 15years prior, was a rare full-face transplant,and was considered the most ambitiousto date. He received upper and lowerjaw, tongue, blood vessels, skin, nerves,and bone from a deceased organ donor.

Dr. Barth notes with a laugh, “Thiswas the first time our work had beenpublished in the likes of GQ Magazine,rather than strictly in medical journals.”

However, being able to successfullyperform face and hand transplants hasless to do with cosmetic outcomes for ahandful of civilians like Norris, and moreto do with the growing number ofmilitary personnel who survive blastsfrom improvised explosive devices andsimilar catastrophic events.

“We’re awaiting final approval from the Department of Defense to perform a second face transplant, which helpsfund our research,” states Dr. Barth.

“We think we’ll have approval to enrollour second patient within the nextmonth, but then we still have to find theright blood type and physical match forthis patient. We ideally match size,coloration, gender, immunology andblood compatibility. The ideal patient is someone with complicated injuries that can’t be restored with a traditionalapproach.”

He adds, “The advantage of VCA is that we can fix function as well asappearance in only one operation.However, patients still need lifelongmedications at a higher level than thatneeded for organ transplants. Andimmunosuppression creates a higher risk of malignancies, infections and other medical problems. We’re seeking to decrease the level of immuno-suppression needed, but we’re happywith achieving stable graft function. It’san exciting development for the field.”

This immunosuppression research alsohas exciting implications for other organtransplants, which are far more common.There are over 100,000 people in the US waiting for transplants, and 18,000of those are waiting for livers. Half ofthose patients won’t survive over a year.

Vascularized Bone MarrowDr. Barth explains, “We’re seeking to better understand the role thatvascularized bone marrow plays inprotecting transplanted cells. It appearsto be far better to transplant a piece ofbone marrow than to infuse marrow into the blood. For organ transplants, we can separately transplant a piece ofbone to provide that protection. It’s liketransplanting a whole ‘factory’ ofimmune cell development.”

In a 2015 letter to the editor of theAmerican Journal of Transplantation, Dr. Barth wrote, “We have previouslyshown in a nonhuman primate (NHP) a facial transplantation model that co-transplanted vascularized bonemarrow (VBM) in the allograft improvedoutcomes when compared to VCAwithout VBM… No animal with infusedBMC [bone marrow cells] demonstratedany evidence of chimerism, in contrast tothree of four VCA+VBM animals that

demonstrated transient chimerism…These data suggest that compared toinfused bone marrow, VBM may improveVCA outcomes by minimizing pre-transplant conditioning and chronicimmunosuppression, thus reducingrejection episodes.”

Dr. Barth underscores the importance of pre-clinical research. “While much of transplantation is focused on sewingthings into people, the future is in the lab,”he concludes. “That lets us make possiblethings that were never possible before.”

NEW APPROACHES FOR LIVER TRANSPLANTSMedStar Georgetown Transplant Institute is a busy place, where 116 liver transplants and some 350 totaltransplants were performed in 2014.Thomas Fishbein, MD, executive directorof the Institute, discusses the evolution of liver transplant approaches that are allowing more people to benefit, and describes the shift in medical issues thatnecessitate this major procedure.

First, Dr. Fishbein notes that the one-year survival rates after liver transplanthave increased to about 95%, thanks inlarge part to the new medications that


It appears to be far better to transplant a piece ofbone marrow than to infuse marrow into the blood.– Rolf Barth, MD

cure hepatitis C – currently the mostprevalent indication for livertransplantation in adults. “Many babyboomers have hepatitis C. Three to sixmonths post transplant, if their virusreappears, we can treat them with one of the new medications to cure theirunderlying hepatitis. We’ve virtuallyeliminated the main cause of death post transplant,” he says.

Medications for hepatitis B also have improved significantly, preventingrecurrence of this disease in patients post transplant.

Early Consult and Treatment Are CriticalAccording to Dr. Fishbein, some primarycare physicians mistakenly believe thatpatients with large liver tumors oradvanced cirrhosis are ineligible foranything except palliative care. “Get a consult early,” he stronglyrecommends. “Scarring of the liver isoften reversible and we can often treattumors if we see them in time.”

Non-alcoholic liver disease (‘fattyliver’) is increasing rapidly in the US atthe same time that new hepatitis Ccurative medications are available. “It takes 20 to 30 years for hepatitis C to cause cirrhosis,” Dr. Fishbein notes.“But many patients with acute liverfailure from drugs, such as treatment forhigh cholesterol, can create an urgentsituation where patients must receive a transplant within weeks. These are a higher priority for a transplant.”

Liver Tumors Benefit from TransplantLiver tumors are a growing reason for

transplantation. “We can cure cancer withtransplants by resecting the liver whenthere is only one tumor affecting a smallarea, or removing the entire liver when thepatient has multiple tumors,” explains Dr. Fishbein. “Today, some 30 to 40% of transplants are performed to cure livercancer. Adenomas will turn malignant ifnot removed, and we’re seeing growingnumbers of patients with as many as 10 adenomas. They ideally should bereferred before they get to this stage.”

Even patients with tumors over fivecentimeters may be eventual transplantcandidates when radiation therapyadministered prior to surgery can shrinkthe tumor. Dr. Fishbein states, “Peopleoften assume nothing can be done forthese patients, but we can take tumorsthat wouldn’t be candidates anddownstage them using radiationoncology or other methods. For example,we can shrink a six-centimeter tumor to four, then perform a transplant.”

The center also treats patients with anykind of bile duct or hepatobiliary tumors.

Pediatric Liver DiseaseCongenital anomalies are the primaryindication for pediatric liver transplants,such as biliary atresia, where the bileducts don’t form during embryogenesis.The second-largest cause is acute liverfailure, typically from an autoimmunedisease or a virus. “These childrentypically present as confused and withjaundice,” Dr. Fishbein explains. “Thethird-greatest cause – but the fastestgrowing – is metabolic liver diseases,which includes maple syrup urine disease

(MSUD) and nearly 30 other suchdiseases in which an enzyme is missing.

“In MSUD, children don’t getcirrhosis, but the missing enzyme createsa buildup of toxins that leads to anelevated ammonia level and braindamage,” he continues. “Working withChildren’s National Medical Center inWashington, DC, we stabilize thesechildren medically, then send them for atransplant. Consanguineous marriages,such as those in the Mennonite or Amishpopulations, put children at higher riskfor these disorders.”

These defects can be addressed with‘domino transplants,’ in which the childgets a cadaveric liver and passes their liveron to an adult. While the metabolic defectin the liver is fatal to the child because thesame defect is present in his or her musclecells, the defect is harmless in someonewithout the congenital disorder.

Opt-Out System Would Increase Available Livers“We need major changes in the system to address the limited supply of availablelivers to transplant,” Dr. Fishbein states.“We perform about 6,000 transplants ayear in the US, a number that has beensteady for decades. If there were asufficient supply of livers, the demandwould vastly increase the number oftransplants performed.”

He continues, “We need to remove the disincentives to donation and providereimbursement for living donors, wholose productivity. Also, in our currentsystem, getting permission for cadavericlivers can delay the funeral and increasecosts for the family. Some nonprofitgroups, such as the Donor Alliance, areworking to establish limited trials toprovide this support.

“We also need an opt-out system, not an opt-in system,” concludes Dr. Fishbein. “In Europe, they presumeconsent as a donor until proven otherwise.I’m an advocate for having to check off a box when filling out your tax form tohelp increase supply.”


Rolf Barth, MD, associate professor ofSurgery at the University of Maryland

School of Medicine in Baltimore, and

director of Liver Transplantation at the

University of Maryland Medical Center

Thomas Fishbein, MD, executive director of the MedStar Georgetown

Transplant Institute

Thomas Fishbein, MD, executivedirector of the MedStar Georgetown Transplant Institute

PHOTO

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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]

PhysicianYOUR PRACTICE. YOUR LIFE.

C H E S A P E A K E

Maryland/DC/Virginia www.chesphysician.com

The Patient Centered Medical Home(PCMH) concept is now part of aburgeoning neighborhood that includesspecialists and urgent care centers. InMarch 2013, The National Committeefor Quality Assurance (NCQA) launchedthe Patient-Centered Specialty Practice™

(PCSP), a program that allows specialiststo receive similar recognition to primarycare physicians. And in March 2015,they added a new program tocomplement the existing PCMHrecognition program that includes retailclinics, urgent care centers and otherambulatory care sites in the Patient-Centered Connected Care™ (PCCC)recognition program.

Today there are nearly 50,000clinicians in over 10,000 sites across the country that have achieved PCMHrecognition. The far newer PCSPprogram has nearly 600 clinicians in 65 sites, which are presentlyconcentrated in New York, Oregon,Kansas and Pennsylvania. The brand-new PCCC program is currentlyavailable in about 50 sites, the first fourof which are in the mid-Atlantic states.

Patient-Centered Specialty PracticeMichael Barr, MD, MBA, FACP,executive vice president of the NCQA,

leads the nonprofit’s efforts to promotedelivery system reform and performancemeasurement, research, analysis andconsulting work. He was formerly asenior vice president at the AmericanCollege of Physicians (ACP). He notes,“PCMH evolved from the medicalprofessional societies’ efforts to create a better environment for patient care

and to make primary care moreattractive to young doctors. But abouthalf of ACP’s members are subspecializedand they felt left out. We askedourselves, ‘What would be a good model of care for these specialists?’”

Answering that question led to the development of a policy paper by the ACP about the medical home


HEALTHCARE IT

BY LINDA HARDER • PHOTOGRAPH BY TRACEY BROWN

The Medical hoMe geTs a new

neighborhoodPATIENT-CENTERED SPECIALTY PRACTICES

Michael Barr, MD, MBA, FACP, executive vice president of the NCQA


“neighborhood” and the PCSP byNCQA. All medical specialties orsubspecialties are eligible, along withnurse practitioners, physician assistants,certified nurse midwives and manybehavioral health professionals. PCSP is geared to specialty practices that areplaying a larger role in coordinatingpatient care, including cardiologists,oncologists, endocrinologists andrheumatologists. It is less appropriate for more procedure-oriented physicians,such as gastroenterologists.

Dr. Barr explains, “The spectrum of care by specialists falls into threecategories – those who are chieflyproviding an opinion to a primary carephysician or co-managing patient care,those who provide the dominant level of care – as in treating HIV – and thosewho provide the vast majority of care,such as medical oncologists for patientsin active treatment of a malignancy.”

NCQA consulted with medicalspecialty societies before developing thefollowing criteria for PCSP:

z Track and coordinate referrals withother specialists and PCPs.

z Provide enhanced access andcommunication that includes timely appointments, after-hourcommunications, and patient-centered training for employees that allows them to practice to thefull extent of their license or role.

z Identify and coordinate patientpopulations by capturing key clinical and administrative data and by using evidence-based tools to manage their care.

z Plan and manage patient care,including creating a patient-centeredcare plan and managing medicationsand referrals to community servicesas appropriate.

z Track and coordinate care, includinglab and imaging data, from the pointof request through receipt and patientnotification, and track patientsthrough care transitions.

z Measure and improve performanceon a number of clinical processes oroutcomes, as well as patients’experiences, and share data withinand beyond the practice.

A PCSP Specialist’s PerspectiveHarry Bigham, MD, is a cardiologist

with Johns Hopkins CommunityPhysicians in Bethesda, Md. An earlyadopter of electronic medical records, heswitched from NextGen to an Epic EHRwhen his group merged with Hopkinsseveral years ago. Today, he is again inthe forefront of medical care as one ofthe first recognized PCSP specialists.

He states, “PCSP is good because itforces us to look at everything we’redoing. You think you’re sending

information and reminders to all of your patients and referring physicians,but when you measure it, you realizeyou’re not doing it as well as youthought, and you clean up existingsystems. We benefited from being part of a larger organization that had theresources to help us.

“The PCSP credentialing process isworth it in the end,” Dr. Bigham adds.“However, it’s a lot of work andsomeone has to be a champion to drivethe process. It’s better for patients, andcan create a tighter relationship withreferring physicians. It’s also helping usreinvigorate a team approach to caringfor patients.”

MACRA Likely to Incentivize PCSPPCSP is likely to grow more slowly than PCMH, in part because specialistscurrently have less of a financialincentive to participate in this programthan primary care physicians have forPCMH. Yet specialists that adopt somePCSP concepts may find that they boost their efficiency, as well as theirenjoyment of practicing medicine. The new Medicare Access and CHIPReauthorization Act of 2015 (MACRA)established the Merit-Based IncentivePayment System (MIPS), which will givecredit to recognized practices for thepractice-improvement component of

the incentive payment. It is likely thatPCMH and PCSP will qualify.

“It’s a lot of work to go through thePCSP recognition process, and it costsmoney,” Dr. Barr acknowledges.“However, there are many aspects thatdon’t cost a lot of dollars but that helppractices operate more efficiently.Specialists can look at their access issuesand address them even if they don’tbecome credentialed, using selected

criteria as a guide for their practice.”He continues, “When people have

access to care, studies have found thathealth disparities melt away. We’relooking at new ways to increase access,including non face-to-face encounters,such as through telehealth and patientportals. However, specialists that are‘too booked’ to see patients within areasonable timeframe remain an issue.”

While it’s too early to have seen resultsyet from the PCSP program, Dr. Barrbelieves that it will foster practices that are better organized, more efficient,and that have more complete patientrecords because they communicate more effectively with primary carepractitioners – ordinarily a commonproblem for specialists. PCSP alsopromotes bidirectional conversations,and more conversations with patientsand their families.

Patient-Centered Connected CareDr. Barr notes that Patient-CenteredConnected Care, the latest programdeveloped by the NCQA, was developedbecause, “People are increasingly using retail clinics and urgent carecenters for their healthcare, and we’reconcerned that they don’t have a primary care physician or that thesecenters aren’t coordinating with primarycare doctors.”

…there are many aspects [of recognition] that don’t cost a lot of dollars but that helppractices operate more efficiently.– Michael Barr, MD, MBA, FACP


The goals of this recognition programare to:z Support the use of evidence-based

guidelines in treating patients.z Provide a consensus-driven

framework for including non-PCMHand non-specialty sites within themedical home neighborhood, andconnecting them to primary care.

z Help providers become a part of the medical home neighborhood,resulting in better outcomes andimproved patient experience.

z Improve trust among providers.z Help reduce waste in the healthcare

system, such as duplication ofprocedures and unnecessaryreadmissions or hospitalizations.

Updating the PCMH ProgramThe NCQA, established a quarter of a century ago, is working hard to beresponsive to physician concerns withthe original PCMH requirements.Originally launched in 2008, theprogram has been revised in both 2011 and 2014.

“There were critiques of the programthat it was more checkbox-oriented

than outcome-oriented,” Dr. Barrconcedes. “We heard that practices feltthere was insufficient guidance andengagement from NCQA. After talkingto lots of people involved with theprogram, we announced our redesignstrategy in March 2015. In the future,instead of having applicants workthrough the process on their own andsubmit their documentation, we willassign a member of our team to workwith practices over the course of theirpreparation.”

After conducting extensive researchthat included focus groups, NCQA will also lessen the documentationrequirements for new practices andemploy more web-based tools.

“Many small practices have achievedPCMH recognition, even though officesof five to 15 clinicians might have moreinternal resources to support therecognition process,” Dr. Barr remarks.

The recognition process typically takes between six and 18 months,depending on how quickly the practicewants to convert. “We’re also planningto use data already generated bypractices, such as that for the PQRS

program, to support their recognitionfor PCMH,” says Dr. Barr. “And inplace of the current requirement thatpractices go through the process everythree years, we are considering atransition to a more streamlined annualprocess for practices that have alreadyachieved recognition.”

He adds, “Additionally, the onlineplatform is getting a complete overhaulwith the help of usability experts. We’ll have some pilot projects in thesecond half of 2015 and will introducesome of the new concepts then, and we’ll probably roll out the fullyredesigned platform in 2017, thoughyou’ll see some changes sooner thanthat. We’re working to become morecustomer-friendly and to have anattractive, useful model.”

Michael S. Barr, MD, MBA, FACP,executive vice president of the NCQA

Harry Bigham, MD, a cardiologist with

Johns Hopkins Community Physicians in

Bethesda, Md.

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

A Division of the Center for Vascular Medicine™

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

VOLUME 1 ISSUE 3

SPECIAL ADVERTIS ING SECTION

Sanjiv Lakhanpal, MD

Tom Militano, MD

Gaurav Lakhanpal, MD

Krutiben Patel, PA-C

Mike Malone, MD

Vinay Satwah, DO

Shekeeb Sufi an, MD

T he Affordable Care Act (ACA) was created with the goals to expand healthcare access, control costs and improve quality. Signed by

President Obama in 2010, it introduced the possibil-ity of unprecedented access to healthcare for patients throughout the United States. This legislation, which contains over a thousand pages of provisions and re-quirements, represents the largest overhaul of the US healthcare system since the introduction of Medicare in 1965, 45 years earlier.

Of the ACA’s numerous requirements of employers, patients and insurance companies, one of the most important is the requirement that insurers provide coverage regardless of pre-existing medical condi-tions. For the fi rst time, patients must be offered cov-erage despite previous disease diagnoses. This is vi-tally important to the tens of thousands of Americans who suffer with chronic conditions such as vascular and kidney disease.

Although there is continuing debate regarding the ACA, it is clear that more patients today have health-care insurance coverage than ever before. An extensive study by the Rand Corporation (Modern Healthcare, May 6, 2015) reports that 17 million more Ameri-cans have health insurance coverage since the launch of the ACA. This tremendous increase in patients with coverage has resulted in the demand for enhanced ac-cess to both primary care and specialty services.

The ACA also encourages the use of safe and cost- effective healthcare delivery models. The goal is to re-duce the growth of healthcare spending that accounts

THE CENTER FOR VASCULAR MEDICINE MEETS THE TRIPLE AIM OF THE AFFORDABLE CARE ACTJEANNE SANDERS, RN, FACHEVICE PRESIDENT, CENTER FOR VASCULAR MEDICINE

for 17.4% of the Gross Domestic Product (Congressional Budget Offi ce, December 2014). It appears that the em-phasis on cost effectiveness is working. The 2013 rate of growth was only 3.6%, the lowest increase ever re-corded (Health Affairs, December 2014).

The Center for Vascular Medicine (CVM) is commit-ted to the ACA goals of expanding access to coverage, controlling costs and improving quality. Our clinical of-fi ces in Greenbelt, Annapolis, Prince Frederick, Glen Burnie and, Silver Spring, Md., offer patients from a wide geographic region convenient access to board-certifi ed vascular specialists. Patients requiring treatment for ve-nous and/or arterial disorders can typically be treated in our state-of-the-art minimally invasive outpatient angi-ography suites in Greenbelt, Annapolis and Prince Fred-erick. eHealthcare costs in outpatient offi ce-based suites are lower than inpatient facilities due to the tighter con-trol of staffi ng, supplies and scheduling (Becker’s ASC Review, January 2015). Our commitment to improved eHealthcare quality is consistently demonstrated by our participation in the Physician Quality Reporting System (PQRS) and our Intersocietal Accreditation Commission (IAC) accreditation. CVM also submits quality data to Medicare to demonstrate our performance.

The Affordable Care Act contains additional provi-sions that will be introduced in the future. The physicians and providers at the Center for Vascular Medicine will continue to be leaders in demonstrating our commit-ment to the goals of enhanced access, controlled costs and improved quality. For us the future is now!

www.cvmus.com


Post-thrombotic syndrome is the de-velopment of symptoms and signs of chronic venous insuffi ciency fol-

lowing deep vein thrombosis (DVT). It is a common, burdensome and costly com-plication. The term “post-thrombotic” replaces the prior terminology “post-phlebitic” syndrome.

Pathophysiology: Post-thrombotic syndrome develops as a consequence of long-standing venous hypertension. A combination of refl ux due to valvular incompetence, and venous hyperten-sion due to thrombotic obstruction, is thought to contribute to post-throm-botic syndrome. Acute DVT causes ob-struction of venous outfl ow, which can be partial or complete. The infl amma-tory response to acute thrombosis and the process of recanalization directly damages venous valves.

Refl ux occurs early, progressively in-creasing from 17% of patients at one week to 69% at one year following the diagnosis of DVT.

Epidemiology: The reported incidence of post-thrombotic syndrome varies widely. Among studies that use validated diagnostic criteria, the incidence is ap-proximately 50% in the fi rst year in spite of anticoagulation. Severe post-thrombotic syndrome occurs in 5 to 10% of patients.

Risk Factors: Patient-specifi c factors that may increase the risk for post-throm-botic syndrome include pre-existing

primary venous insuffi ciency, older age, obesity and varicose veins. There does not appear to be a consistent relation-ship between gender and the develop-ment of post-thrombotic syndrome.

The development of recurrent ipsilat-eral DVT is strongly associated with the risk for the post-thrombotic syndrome.

Proximal DVT increased the risk for post-thrombotic syndrome twofold compared with distal DVT. The risk of post-thrombot-ic syndrome is greater in patients who do not maintain adequate anticoagulation during initial treatment for their DVT. The use of thrombolytic therapy to treat acute proximal DVT may decrease the risk of post-thrombotic syndrome by reducing clot burden or possibly preventing proxi-mal vein valve dysfunction; however, it is not clear whether the benefi ts outweigh the risks involved.

Clinical Features: Symptoms and signs can include extremity pain, ve-nous dilation, edema, pigmentation, skin change, and venous ulcers. Edema occurs in approximately two-thirds of pa-tients with post-thrombotic syndrome, skin pigmentation in about one-third, and venous ulceration in less than 5%.

Diagnosis: The diagnosis of post-thrombotic syndrome is predominantly clinical. Venous imaging, typically duplex ultrasound, may be useful for patients in whom the clinical signs of chronic venous insuffi ciency are not obvious, those with

a clinical history that suggests DVT but that did not undergo studies, and those with severe symptoms.

Treatment: Conservative manage-ment includes exercise, limb elevation, compression therapy, and possibly phar-macologic therapy.

Venous intervention: Endovascular or surgical interventions in appropriately selected patients with venous obstruc-tion or refl ux may decrease the incidence of recurrent ulceration and skin changes and improve quality-of-life in patients with chronic venous disease. Occluded or ste-notic iliac vein segments can be treated using percutaneous angioplasty, with or without stenting, venous bypass or endo-phlebectomy. Surgical vein bypass is an option for selected patients with severe proximal venous refl ux, but only if percu-taneous intervention has failed to restore fl ow; however, it is limited to certain high-volume referral centers. Patients with fo-cal symptoms and venous ulceration may benefi t from treatment of incompetent superfi cial veins.

Quality of Life: Post-thrombotic syn-drome causes signifi cant disability and economic burden for patients and the healthcare system. In a study of patients two years after DVT treatmens, quality of life measures of patients with post-thrombotic syndrome were comparable to published norms for those with an-gina, cancer, or congestive heart failure.

POST-THROMBOTIC SYNDROME: A COSTLY COMPLICATION OF DVTBY GAURAV LAKHANPAL, MD, FACC, RPVI

REFERENCES: Kahn SR, Partsch H, Vedan-tham S, et al. Defi nition of post-thrombotic syndrome of the leg for use in clinical investiga-tions: a recommendation for standardization. J Thromb Haemost 2009; 7:879.

Porter JM, Moneta GL. Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Dis-ease. J Vasc Surg 1995; 21:635.

Franzeck UK, Schalch I, Jäger KA, et al. Pro-spective 12-year follow-up study of clinical and hemodynamic sequelae after deep vein throm-bosis in low-risk patients (Zürich study). Circula-tion 1996; 93:74.

Bergan JJ, Schmid-Schönbein GW, Smith PD, et al. Chronic venous disease. N Engl J Med 2006; 355:488.

Prandoni P, Kahn SR. Post-thrombotic syn-drome: prevalence, prognostication and need for progress. Br J Haematol 2009; 145:286.

Yamaki T, Nozaki M, Sakurai H, et al. High peak refl ux velocity in the proximal deep veins is a strong predictor of advanced post-throm-botic sequelae. J Thromb Haemost 2007; 5:305.

Nicolaides AN, Hussein MK, Szendro G, et al. The relation of venous ulceration with ambu-

latory venous pressure measurements. J Vasc Surg 1993; 17:414.

Araki CT, Back TL, Padberg FT, et al. The sig-nifi cance of calf muscle pump function in ve-nous ulceration. J Vasc Surg 1994; 20:872.

Welkie JF, Comerota AJ, Katz ML, et al. He-modynamic deterioration in chronic venous disease. J Vasc Surg 1992; 16:733.

Roumen-Klappe EM, Janssen MC, Van Ros-sum J, et al. Infl ammation in deep vein throm-bosis and the development of post-thrombotic syndrome: a prospective study. J Thromb Hae-most 2009; 7:582.

Shbaklo H, Holcroft CA, Kahn SR. Levels of infl ammatory markers and the development of the post-thrombotic syndrome. Thromb Hae-most 2009; 101:505.

Kahn SR, Shbaklo H, Shapiro S, et al. Effective-ness of compression stockings to prevent the post-thrombotic syndrome (the SOX Trial and Bio-SOX biomarker substudy): a randomized controlled trial. BMC Cardiovasc Disord 2007; 7:21.

Markel A, Manzo RA, Bergelin RO, Strand-ness DE Jr. Valvular refl ux after deep vein thrombosis: incidence and time of occurrence. J Vasc Surg 1992; 15:377.

Prandoni P, Frulla M, Sartor D, et al. Vein abnormalities and the post-thrombotic syn-drome. J Thromb Haemost 2005; 3:401.

Meissner MH, Zierler BK, Bergelin RO, et al. Coagulation, fi brinolysis, and recanalization af-ter acute deep venous thrombosis. J Vasc Surg 2002; 35:278.

Bergqvist D, Jendteg S, Johansen L, et al. Cost of long-term complications of deep venous thrombosis of the lower extremities: an analysis of a defi ned patient population in Sweden. Ann Intern Med 1997; 126:454. Bergqvist D, Jendteg S, Johansen L, et al. Cost of long-term complica-tions of deep venous thrombosis of the lower ex-tremities: an analysis of a defi ned patient popula-tion in Sweden. Ann Intern Med 1997; 126:454.

Kahn SR, Shbaklo H, Lamping DL, et al. De-terminants of health-related quality of life dur-ing the 2 years following deep vein thrombosis. J Thromb Haemost 2008; 6:1105.

Ashrani AA, Silverstein MD, Rooke TW, et al. Impact of venous thromboembolism, venous stasis syndrome, venous outfl ow obstruction and venous valvular incompetence on qual-ity of life and activities of daily living: a nested case-control study. Vasc Med 2010; 15:387.

www.cvmus.com

W ith advances in the medical fi eld and prolonged survival rates, hemodialysis patients are a rapidly growing population that provides a unique set of

challenges to outpatient vascular laboratories. Currently, hemo-dialysis allows more than 550,000 patients in the United States to live with the disease.

FISTULA-FIRST CATHETER-LAST WORKSHOP COALITIONThe Fistula-First Catheter-Last Workshop Coalition, formed in 1995, is important in the management of hemodialysis access patients today. Its mission is focused on supporting the renal community and End Stage Renal Disease (ESRD) networks to improve vascular access outcomes. This group realizes that appropriate vascular access is the lifeline for these patients. The development and implementation of system changes that support arteriovenous (AV) fi stula placement in suitable hemo-dialysis patients is key to sustainable access. At the same time, this approach reduces central venous catheter use. The use of an AV fi stula leads to lower infection, hospitalization and mor-tality rates while preserving vital Medicare measures.

INITIAL CONSULTATIONAt the initial consultation, the vascular team assesses the patient and formulates an appropriate operative plan to ensure proper care given the patient’s clinical scenario. As outlined in the Fistula First initiative, all attempts are made to use an autogenous vein as a source of conduit if at all possible. To that end, all patients undergo noninvasive venous duplex ultrasound to evaluate the size of the basilic and cephalic veins as possible conduits for he-modialysis. In addition, the patient undergoes duplex ultrasound of the subclavian and jugular veins to assess for patency. Many of these chronic patients may have had central lines for hemodi-alysis in the past, and to that end these veins may be scarred or damaged. This allows the clinician to glean additional informa-tion about the condition of the central venous vasculature, which may be helpful in preoperative planning, as well as in determin-ing a possible source of the problem if the access does fail.

OPERATIVE PROCEDUREBased on the fi nding of the initial assessment and noninvasive evaluation, the patient is scheduled for one of three vascular procedures to provide access for hemodialysis. Ideally, the pa-tient is scheduled for an autogenous arteriovenous fi stula where a surgical connection is made between an artery and vein either at the wrist, forearm or upper arm. Autogenous arteriovenous fi stulas have the highest patency and lowest infection rates. If an appropriate vein for creating an autogenous fi stula is found, the next step is to place a synthetic AV graft. In this instance, a synthetic graft joins the artery to the vein to provide a loca-tion where the graft can be accessed for dialysis. Finally, if no suitable conduit is available for creating an arteriovenous fi stula and no vein is available for graft placement, then a tunneled catheter can be used for dialysis.

CURRENT STRATEGIES FOR MANAGING HEMODIALYSIS PATIENTS IN THE OUTPATIENT SETTING


MICHAEL D. MALONE, MD, FACS

THE FAILING DIALYSIS ACCESSThis subset of patients have had an access procedure that has either occluded or is malfunctioning and needs to be corrected. In the past, these patients would have required an operative procedure to correct their occluded or failing dialysis access. However, with the current technology available at CVM, these patients can be treated on an outpatient basis in our freestand-ing catheterization laboratory.

CLINICAL ASSESSMENTThe clinician can determine whether this is an acute problem or a chronic problem with a history of prolonged dialysis run times or elevate d fl ow pressures. A history of any hypercoagulable may contribute to premature access failure. On physical examination, clinicians look for a bruit or a thrill to determine if the access is pat-ent on initial assessment. A duplex ultrasound can be performed to look for fl ow, assess for narrowing or stricture formation and determine non-invasively if there is thrombus formation. In addi-tion, the duplex ultrasound can determine if there are any intrinsic factors such as hematoma or seroma that may be compromising fl ow in the fi stula or graft due to compression. In a slowly matur-ing AV fi stula, side branches can be assessed that may have to be treated at a later date to allow the fi stula to mature adequately. This study can be performed in the offi ce in a relatively short pe-riod and can help to formulate an appropriate game plan.

CONTRAST STUDIES/PERCUTANEOUS TREATMENTIn these patients, a percutaneous study can be performed either with a fi stulogram or graft study to evaluate the patency of the access site. A declotting procedure can be performed during which a small balloon is inserted under fl uoroscopic guidance, and any newly formed thrombus can be removed. Further, clot dissolving agents such as TPA can be used to assist in remov-ing thrombus. Mechanical thrombolytic devices can be used to mechanically dissolve and suction out the thrombus at the time of the contrast study. Once the thrombus is removed, a contrast study can be performed to look for any areas of nar-rowing in the access site that are amenable to angioplasty. As in the coronary population or in the peripheral arterial disease (PAD) population, a small balloon can be inserted to open up any blocked areas of the graft or native vessels of the fi stula or graft. After successful angioplasty, a repeat contrast study can be performed to check for improvement or correction of any abnormalities. If there still appears to be evidence of residual narrowing, a percutaneous stent can be placed as a ‘scaffold’ to correct abnormalities and allow dialysis to continue.

To meet the needs of the steadily growing hemodialysis pop-ulation, an action plan has to be developed when their dialy-sis access graft is not functioning. With newer technology and advances in outpatient catheterization suites (like Center for Vascular Medicine), a great number of these procedures can be performed in a safe outpatient setting that allows these delicate patients to get the individualized attention they deserve.

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

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T he Center for Vascular Medicine (CVM) has been recognized as a national leader in the utilization of

intravascular ultrasound (IVUS) in the out-patient setting due to the expertise of its physicians. CVM has become a national training site for physicians that wish to expand their knowledge of this diagnos-tic technology. In an effort to provide the highest quality of care to patients, CVM has been utilizing IVUS for over two years as a standard diagnostic tool for those suffering from Deep Venous Disease.

What is IVUS?Intravascular ultrasound, which uses a catheter equipped with a camera to vi-sualize a vessel from the inside, was fi rst introduced to vascular medicine providers in the late 1980s. It is inserted via a sheath, and is valuable in assessing the patency of a vessel. It is also useful in determining the possibility and degree of obstruction and narrowing.It can also allow the inter-ventionalist to obtain dimensions of the vessel wall for the purpose of stent sizing. CVM has applied this technology as a di-agnostic modality for deep vein disease.

How does IVUS affect patient care?Many patients may suffer from venous

INTRAVASCULAR ULTRASOUND – CUTTING-EDGE TECHNOLOGY PROVIDES LIFE-CHANGING RESULTS

problem from within the vessel and ex-trinsic obstruction results from an exter-nal structure causing compression. Both will cause an increase in resistance to blood fl ow as it attempts to return from the leg.

Who is at risk for venous outfl ow obstruction?

to post-thrombotic scarring of the vessel wall

or lower abdominal surgeries

(>2)

BY VINAY SATWAH, DO, FACOI, RPVI

outfl ow obstruction (i.e., iliac vein com-pression) for years without a diagnosis.

lowing symptoms:

IVUS provides a three-dimensional view of the interior of vessels, allowing physicians to determine the presence and degree of venous disease. In ad-dition, and perhaps more importantly, this technology will determine whether the compression is intrinsic or extrinsic. Intrinsic obstruction occurs due to a

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BY LINDA HARDER

OE DEMATTOS, JR., MA,president of the Health FacilitiesAssociation of Maryland (HFAM), an organization that represents morethan 150 long-term care providers in the state, including assisted living, post-acute, rehabilitation and skillednursing facilities (SNFs), discusses therole of long-term-care facilities inkeeping patients healthier while reducinghealthcare system costs.

Q: What impact has CMS’ two-midnight rule, which is on hiatus, had on the industry and what do you see as the future of this rule?It’s a national challenge. One of thethings we did at HFAM several years ago is that we worked with Sen. DoloresKelley to pass legislation that requiresMaryland hospitals to inform patientsthat they’re on observation status andmay not qualify for a stay in a long-term-care facility. Senator Kelley was areal and gifted leader in this work. We’verun into this issue many times, and shewas an incredibly passionate advocate.

I’ve encountered this problem bothpersonally and professionally. Somepatients with a hospital dischargedocument in place that need rehabilitationservices in a SNF don’t realize until theyshow up at the SNF that they might nothave a qualifying stay.

Q: Is there movement on thenational front? Nationally, theImproving Access to Medicare CoverageAct of 2015 (HR 1571) was introducedby Congressman Joe Courtney (D-CT) in March of 2015; the Republican leadon the bill is Representative Joe Heck(R-NV). It currently has 55 co-sponsors.

The Senate version is S. 843,introduced by Senator Sherrod Brown

(D-OH). It currently has10 co-sponsors, includingSenator Ben Cardin. But the rub is that theCongressional BudgetOffice doesn’t score thesavings on the hospitalside from this move, itjust scores the increase inspending on the skillednursing side. That’s whythis issue has never gainedtraction. Sen. Cardin hasbeen a leader on this issuebecause he realizes that,net-net, there will besavings for the system,and that SNFs cost one-third to one-half of thehospital stay.

Q: Does Maryland’snew waiver have thepotential to impact thisissue? Yes. WhereMaryland has a uniqueadvantage on this front is in our new hospitalwaiver, which the staterenegotiated over the last two years.Even with the requirement that hospitalshave to inform patients if they don’thave a qualifying stay, patients some-times show up with their family notknowing if they’re covered or not.

The old waiver set prices forprocedures but it didn’t limit volumes,and it didn’t link the procedures tohealthier outcomes. The new waiver caps total hospital spending and the rate of growth in spending, and it trackshospital readmissions as a qualitymeasure. We’re just now in the first yearof that new waiver and the state isstarting to think about how to modifythe waiver for the years ahead.

What we could do in Maryland is to create a pilot program where youeliminate the three-day-stay requirementunder certain circumstances. We thinkthat can improve outcomes, reduce costsand make it better for families.

Q: What advice do you have forpracticing physicians and how willtheir practices be affected by thetrend towards value-based care?The first thing I’d say to physicians isthat they’re more important than everand the immediate future will bechallenging because we’ve entered intoan era where talk is turning into action.

POLICY

Today’s Skilled Nursing Facility: Not Your Parents’ Nursing Home

JJoe DeMattos, Jr., MA, presidentof the Health Facilities Associationof Maryland (HFAM)

PHOTO

COURTE

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Payers will expect better clinicaloutcomes with more targeted utilizationand less of a spend. Also, physiciansmore likely than not will maintain morecontact with their patients across caresettings. For example, I think we’ll see, at least in efficient long-term-carecenters, that the cardiologist willcontinue working with his or her patientwhen they’re in a rehab facility.

This is likely to especially impactcardiology, orthopaedics, endocrinologyand psychiatric care, because thereadmission rate for these diagnoses ishigh. Today, the primary care physicianmay have an electronic health record(EHR), the hospital will have an EHR,but the SNF may not have an EHR thatcan be used for Meaningful Use. Soyou’ll see an integration of the EHRs.The Chesapeake Regional InformationSystem for Our Patients (CRISP) is agood beginning, but it provides only

reports, not the images themselves. Only a handful of rehab centers areplugged into CRISP, although about half have an EHR.

Q: How prevalent are EHRs inskilled nursing facilities? Six years ago,about 35% of SNFs had EHRs forMeaningful Use, and today it’s about55%. Almost every SNF has some typeof EHR in place for billing and forpharmacy, but for Meaningful Use, it’s almost half that.

I don’t believe providers can becompetitive in the coming years withouthaving a Meaningful Use EHR. I thinkit’s a minimum bar for success in thenear term. SNFs were not federallysubsidized for EHRs like other settingswere, so our members have to pay forthese systems.

Having an EHR for Meaningful Use isa minimum requirement for any providerto deliver quality care. Pharmacy is amajor factor in preventable events so it’sa driver for electronic communicationand provides a competitive advantage.Key in any center’s development of a

Meaningful Use EHR is to assign aninterdisciplinary team, and to challengethat team to work with external partnerslike physicians and hospitals.

Q: What should physicians look forwhen selecting an SNF? If I were aphysician in practice and had a choice of working with one SNF over another,I’d look at whether they have an EHRand whether they either directly employphysicians or have a long-establishedrelationship with a quality physicianpractice. Many of my members, such as FutureCare and Genesis Healthcare,employ physicians. Others use servicesthat act like employed physicians butthat are co-employed. That makes upabout half of the marketplace.

A third thing I’d consider is selectingcenters that have a vigorous chronicdisease management program. What

you’re likely to see in the future fordiabetes, COPD, congestive heart failureand psych issues, is that the primary care physician remains connected withthe patient across all settings. In the bestcases, physicians may actually visit thepatient in the SNF, or at least beinvolved in the protocols. They sharedocuments with the hospital and theirclinical teams, and with the primary care physician. They literally have onedocument that’s their ‘playbook.’

Q: How have SNFs changed overthe years? Where Maryland is at thecutting edge is that, 30 years ago, itcreated a rate-setting system thatincentivized SNFs to take care ofhospital-level patients – really medicallysick patients. Patients used to walk intoSNFs, but today they’re too sick to walkin. In our state, we have 233 centerswith some 30,000 beds that are in everypolitical jurisdiction. Northern Virginiais somewhat comparable today, buthasn’t had the same system for as long asMaryland. In DC, the income disparity is more dramatic district-wide than it is

in Virginia or Maryland state-wide, and you have fewer centers in a smallergeographic area.

Genesis has a building, PowerBackRehabilitation, in Lutherville, Maryland,that, by special agreement with the state,is 100% rehab. The facility is a conciergemodel, with food on demand. Theyimmediately tell you what your dischargedate is and provide intensive rehab to get patients home as soon as possible.

Another provider, Lorien, offers Wi-Fi and iPads on loan to patients.Their Encore building has a pub onsite.FutureCare, which also offers à-la-cartedining, was voted several years in a row as a top employer by the BaltimoreSun, and has buildings certified to treat wounded warriors faced withamputations.

At FutureCare Centers, a familymember can come in for any meal andpay only $2. At some Lorien Centersduring the summer, grandchildren cancome to visit, eat at the pub and use the pool. Another Lorien facility in Bel Air, Maryland, has a restaurant that’s open to the public.

The truth is that many, if not all, ofHFAM’s member centers are innovatingquality care in some way. It’s not whatpeople think of when they think ofnursing homes – today’s SNFs are nottheir fathers’ nursing centers.

Q: Long-term care used to beperceived as a less attractive place tobe a provider or a patient. How wouldyou characterize it today? Certainly,there remain extremes in SNFs inMaryland and across the country. It’s a challenge because lower-qualityfacilities do exist. But as a whole, thesereally are mini post-acute hospitals set in the community.

Physicians should realize that intoday’s healthcare world, where wefocus on doing more with less andproviders are more accountable to keep people as healthy as they can, SNFs have most of the capabilities ofhospitals at tremendously reduced costs.We have an opportunity to make thesecenters part of the solution. And we’reproving that now, in terms of improvingtransitional care, infection control andreducing the off-label use of psychiatricmedicines.Joe DeMattos, Jr., MA, president of theHealth Facilities Association of Maryland

…SNFs have most of the capabilities of hospitals at tremendously reduced costs. We have an opportunity to make these centerspart of the solution.


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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.

IMMEDIATE APPOINTMENTS AVAILABLEAnnapolis | Glen Burnie | Greenbelt | Prince Frederick | Silver Spring


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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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