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Archive for June, 2009

Medical Association of Atlanta Speaks to Universal Health Coverage

Wednesday, June 17th, 2009

June 2009

By Ivey L. Dennard

On Thursday, April 23, the Medical Association of Atlanta held its 2009 spring meeting in the form of a spirited debate. The group gathered at Anthony’s restaurant over fried green tomatoes, surf n’ turf and pecan pie to address a concern that is at the forefront of both medical and public interests alike: Is universal health coverage the federal government’s responsibility?

Dr. Arthur Kellermann, professor of medicine and Associate Dean for Health Policy at Emory Medical University, began the pro-opening statement by relating his clinical experience in trauma to the life threat of U.S. health care on our suffering economy. “Critics of President Obama don’t understand why he is so focused on health care in the middle of the greatest economic crisis since the great depression. The answer is simple: to stop the bleeding.”

Dr. Kellermann cited statistics that demonstrated the critically high cost of health care in the U.S., adding, “The Congressional Budget Office considers health care costs the greatest fiscal threat to our country.” At $2.2 trillion a year, America spends twice as much as its competitors.  He also indicated that despite these high costs, the U.S. falls far behind its competitors in the quality of health care provided.

Dr. Kellermann recognized that the average American does not trust government involvement, but maintained that they do not trust big business either and are reliant on a residual trust in doctors themselves. He emphasized fair rules, a public health insurance option for those that could not otherwise afford one and finally “up-to-date information” for doctors.   He concluded, “We can do better; we must do better, by combining private sector ingenuity with public sector fairness.”

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Wayne Oliver, Project Director at the Center for Health Transformation (founded by Newt Gingrich), opened his case in opposition to the motion by jovially introducing himself as “a recovering lobbyist” and marking his territory, “I am seated to your right for a number of reasons …”

While Oliver agreed that everyone should have access to affordable health care, he disputed that health care be controlled by the government rather than the private sector. He argued that government involvement has a torpedo effect on competition, private sector ingenuity and scientific discovery, saying, “Big government does not need to stick its nose into private markets, much less compete in them.” And in the end, the public option would be the only option.

Oliver went on to stress that a lack of competition leads to higher cost, then fewer choices and ultimately, lower quality.  He maintained that President Obama’s “so-called public health care plan” will not only create a government bureaucracy, but will also threaten the security and coverage of the 130 million currently insured Americans.

The audience was not without contribution as they approached the mic with a range of opinions and questions. However, poll results showed a fairly even-handed room went unwavering, with 45% in support and 55% in opposition at both the start and end of the evening.

The give-and-take forum was well received by Medical Association of Atlanta.  Compelling discussions spoke to the heart of one of the most significant social policy questions facing our current administration.  In the end, whether in support or in opposition, between speakers and audience alike, there was one common sentiment: The current system is broken, the problem is critical and what are we going to do now?

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The Path to Cardiac-Medicine Leadership

Wednesday, June 17th, 2009

June 2009

By Julie Budnik

How do you make a good thing better? This is the challenge that everyone confronts at some point in his or her personal or professional life. Stepping outside of a comfortable successful place not only takes courage, but also vision. Four years ago, the leadership team at WellStar Health System decided it was time for a big step.

Under the direction of former president and CEO Dr. Robert Lipson and current President and CEO Dr. Gregory L. Simone, along with a team of top cardiologists, cardiovascular surgeons and staff, WellStar Health System was successful in obtaining a certificate of need for an open heart and angioplasty program.  The leadership team decided to present its application for a unique program that would establish a partnership with Emory Healthcare to provide a cardiac residency training program and provide the cardiac angioplasty services needed by the community but only available at Atlanta hospitals. Although initially opposed by two other hospitals, ultimately the state Supreme Court ruled in favor of the program and the building and physician recruitment process began. “It has been a great marriage,” says William Cooper, M.D., Medical Director of Cardiovascular Surgery at WellStar Kennestone Hospital and assistant professor of surgery at Emory. “The program has allowed Emory to link with core referral groups and with the second busiest ER in the state, WellStar Kennestone wouldno longer have to transport cardiac cases elsewhere from the northern corridor.” Prior to the agreement, cardiologists at WellStar Kennestone Hospital were driving to Atlanta to do interventional procedures, which was problematic, and patients who needed cardiac surgery were referred to Atlanta hospitals. Currently, cardiac  catheter-based interventional procedures are done at both WellStar Kennestone and Cobb hospitals with physician residents rotating through the program at four-month intervals. “As a provision of the program, we have cardiovascular surgeons to meet volume demands, a medical director, fellows, perfusion services and physician services,” says Pat Jansen, Vice President of Cardiac Services for WellStar Health System.

“We were the new kids on the block in the shadow of cardiac giants like Emory, St. Joseph’s and Piedmont,” says Dr. Cooper. “We had to overcome the infant against the veterans standing and prove that we could do this and do it well.” Although there were growing pains in terms of creating the infrastructure for the program, the staff and physicians stepped forward to make the open heart program a success. The program is currently rated in the top 10th percentile by the National Quality Forum for cardiac surgery nationwide. “We were very methodical in the process and put together a good plan for administration, finance, infrastructure and doctor buy-in and support,” says Dr. Cooper. Dr. Cooper studied other successful business models including the books The Southwest Airlines Way and Good to Great to discern key strategies for success.

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The team at WellStar Health System has defined itself by offering a cutting-edge full-service cardiology program, with the exception of transplant services. The WellStar Health System cardiology program is providing a continuum of care to the patient population in northwest Georgia. Three of the hospitals within WellStar Health System, Cobb, Douglas and Kennestone, all accredited chest pain centers, combined have four labs, including one electrophysiology lab, two cath labs and one swing lab for cardiac and peripheral procedures.

Two-and-a-half years ago, WellStar Cobb Hospital had the opportunity to apply to be part of the Cardiovascular Patient Outcomes Research Team, which originated at Johns Hopkins Medical Center.  The study began in an effort to determine if percutaneous coronary interventions (PCIs) could safely be performed without open heart surgical facilities being available on site. Out of a group of 25 hospitals, 10 were selected and WellStar Cobb Hospital was the only hospital that had cardiac surgery access within its own system at WellStar Kennestone Hospital. “We knew we could provide the needed services,” says Jansen. “We see a large volume of cardiac patients, and we are the sole acute care hospital in the areas where we are located.” Jansen does caution that it is critical that patients be assessed accurately to ensure that they are in the right facility if they are at higher risk.

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In January 2009, two physician practices joined WellStar Health System: Cardiovascular Medicine (CVM) and Thoracic Surgery Associates. “We began to explore different ways we could work with WellStar and decided the best way was to join the system in order to form a service line, which would allow us to have more impact and give us the resources we needed to reach out to the community,” said Barry Mangel M.D., Chief Cardiology Officer and President of WellStar CVM.  The 28 physicians and staff at WellStar CVM offer all forms of diagnostics, including echocardiography, nuclear studies, cardiac caths, coronary angioplasty and electrophysiology. “We are defined by the care we provide and the high level of service and quality of care we deliver across the spectrum.” In April 2009, East Cobb Cardiology joined WellStar CVM.

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WellStar Health System was recently awarded the Better Performer distinction by the Medical Group Management Association (MGMA). “We were compared to like-sized groups across the country in areas like quality of care, practice management and cost effectiveness,” says Dr. Mangel. Additionally, WellStar Kennestone Hospital achieved the 100% Gold Standard for door-toballoon time established by the Center for Medicare and Medicaid Services (CMM) Core Measures for treating patients with heart attack in 90 minutes or less. The goal is to have patients’ arteries open as soon as possible to prevent heart muscle damage. Patients are metro atlanta m.d. news june 2009 | 19 assessed in the field by EMS with portable EKG equipment, which is then transmitted to ER physicians at WellStar Cobb or Kennestone hospitals. “We worked with EMS and emergency departments to makesure care was coordinated and the patient was on the way to the hospital with capability to open blocked arteries if needed,” says Jansen. “Everyone had their eyes open to a possible MI or need for angioplasty.” The average door-to-balloon time for WellStar Kennestone Hospital is now 55 minutes, well below the national standard of 90 minutes.  Jansen also noted that they coordinate with the Emory LifeNet heliambulances that bring in patients from the north Georgia mountains and west Georgia.

The concept of a continuum of cardiac care for patients is ever present with the WellStar Health System physicians and staff. The cycle begins with primary prevention through community educational programs, which include health screenings, smoking cessation classes, stress management, CPR and first aid classes and cardiac health education. In the last few months, over 200 patients with risk factors were screened with a calcium CT scan and a significant number were identified as having asymptomatic heart disease. Getting the message out to young people about making healthy choices is a priority at WellStar Health System.  “We recently had one of our doctors go to Paulding County High School and assess the entire ninth grade class for risk factors for heart disease,” says Dr. Mangel. “He talked to them about lifestyle, nutrition and exercise.”

Episodic and emergent care is of the highest caliber at WellStar Health System. An array of cutting-edge diagnostic tools are available, including EKG, CT scans, nuclear cardiology, EP studies and diagnostic cardiac catheterization, just to name a few. Once the patient is fully assessed by the medical team, a treatment plan is established to maximize a positive outcome. Treatments range from percutaneous coronary intervention, medical management, pacemakers and defibrillators to cardiac surgery. All of these treatments are available in house through the talented team of cardiologists and cardiovascular surgeons.

Once the patient is stabilized and treated, secondary prevention comes into play. Ultimately the health care team wants to be a partner in ensuring that patients return to their active lives and stay healthy. Through cardiac rehabilitation programs at three WellStar hospitals, registered nurses, rehab specialists and social workers are just a few of the professionals that help cardiac patients achieve their wellness goals. WellStar Health Place, a health and wellness facility on the WellStar Kennestone Hospital campus, has a stateof- the-art gym, pool and weight loss center supervised by highly qualified professionals. Patients can even enroll in a program that provides three meals a day so that caloric intake and weight loss may be carefully monitored. “We have a continuum of care, and we are trying to go from prevention to rehab,” says Dr. Mangel. “The patients who go through the rehab process have a wonderful experience and they are educated on the importance of exercise, diet, weight loss and smoking cessation.”

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Cardiac medicine is steadily moving towards more minimally invasive procedures including artery take downs and valve surgeries.  WellStar physicians are future focused on this concept. “I think what sets us apart is that 90% of our surgeries are off-pump or beating heart surgeries,” says Jansen. “Dr. Cooper prefers this method and has worked with it extensively.” WellStar Health System surgeons are also moving into the area of robotic surgery for valve cases. “WellStar is becoming physician led and physician driven,” says Dr. Mangel. “We have an awesome opportunity to build a successful program for the communities we serve.” Dr. Cooper believes that building a strong foundation is all about leadership and motivation. “You must have people at the top who are committed and you must have buy-in from the physicians,” says Dr. Cooper. “You can have the brightest and best, but without consolidation, leadership and community support, you will not be successful.” The thriving WellStar cardiology program is part of an integrated health care system led by over 400 physicians. “We are community citizens and want to improve the quality of life for our patients through world-class cardiology services, preventative care and education,” says Jansen. “We live our mission of providing the best care at the right time.” This talented group of health care professionals is poised to do just that.

The vision of WellStar Health System is to deliver world-class health care. WellStar, a not-for-profit health system, includes Cobb, Douglas, Kennestone, Paulding and Windy Hill hospitals; WellStar Physicians Group; Urgent Care Centers; Health Place; Homecare; Hospice; Atherton Place; Paulding Nursing Center; and WellStar Foundation. For more information, call (770) 956-STAR or visit www.wellstar.org.

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Stroke: ER to Rehab

Wednesday, June 17th, 2009

June 2009

By Julie Budnik

Stroke was first recognized over 2,400 years ago by Hippocrates and labeled as “apoplexy,” meaning “struck down by violence.” An apt description given that the victim had sudden onset of paralysis and dramatic physical changes. Early Greek physicians had very few ideas about the cause of apoplexy, let alone how to treat it. Stroke is the third leading cause of death in the United States today behind heart disease and cancer.  In Georgia, which is located in the center of the “stroke belt,” the stroke death rate is twice that when compared with the rest of the nation. Luckily, today’s stroke patients have a much better chance of survival and positive outcomes when treated at a stroke center.

North Fulton Regional Hospital is a premier leader in stroke medicine in the north Georgia area. In 2005, North Fulton Regional Hospital was awarded the Gold Seal of Approval for stroke care when the Joint Commission on Accreditation of Healthcare Organizations named the hospital as a Primary Stroke Center after an extensive on-site review. Emergency room practices, inpatient care, appropriate use of medications and rehabilitation facilities are just a few of the factors that came in to play in the evaluation.

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The highly skilled team of health care professionals at North Fulton Regional Hospital Stroke Center realize that time is of the essence when dealing with a stroke victim. The center is supported by over 100 nurses and therapists trained in advanced stroke life support as well as five board-certified neurologists available 24 hours a day, seven days a week. A coordinated multifaceted approach is used to ensure that patients are given the best possible chance for a successful recovery.

When the initial EMS call comes in from the field, the ER team, led by Dr. Michael Lipscomb, Medical Director of the emergency department, is alerted that a potential stroke case is en route. The North Fulton Regional Hospital team uses the trauma approach to treat strokes by activating multiple areas including radiology, laboratory and the hospital’s rapid response team. “The stroke coordinator oversees the stroke program and ensures that the overall process runs smoothly,” says Dr. Lipscomb.

The ER physicians will be waiting for the patient to confirm the field diagnosis with blood work, EKG and CT. North Fulton Regional Hospital has preloaded orders for CT scans in the system for ER physicians to easily access. Patients are immediately sent to one of two dedicated CT scanners to determine the type of stroke-ischemic or hemorrhagic.

While the workup is in progress, a neurologist will be on the way to assess the patient as a candidate for treatment with tissue plasminogen activator (tPA).

tPA is a fibrinolytic agent involved in the breakdown of blood clots but is approved for use in patients who present within three hours of the initial onset of symptoms. Newly published data from the ECASS III trial in The New England Journal of Medicine suggests that the time period may be extended by 1½ hours and still be effective.

“Out of a group of 100 stroke patients that present to the ER, it is likely that only four or five will be considered eligible to receive tPA,” says Dr. Lipscomb. “It is important to know the potential complications and risks inherent with the medication.  Families should be consulted and fully informed on the benefits and risks of tPA. “There is a 6-7% increased risk of intracranial hemorrhage with tPA administration. Gastrointestinal and retroperitoneal hemorrhage may also occur.

In some cases, tPA can be a wonder drug.  Dr. Frank Puhalovich, Director of the Stroke Program at North Fulton Regional Hospital, points to the case of an 89-yearold man brought in by EMS within one hour of exhibiting stroke symptoms. “His stroke was massive and would have meant substantial neurological deficit,” says Dr. Puhalovich.  “He was given tPA and had a remarkable response to the medication and today has only minor issues on his left side.”

Subacute strokes are treated entirely differently because the time factor does not come into play. “Patients come in with a focal deficit, which indicates stroke,” says Dr. Puhalovich. If a patient is not tPA eligible, they are admitted to the hospital and begin pharmacological treatment as well as receive physical, occupational and speech therapy.

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As a neurologist, it is Dr. Puhalovich’s responsibility to evaluate patients for the best treatment option. Although the assessment process for stroke is virtually unchanged from past years, treatment is much broader in terms of options. “In some cases, intra-arterial tPA and mechanical manipulation of the clot is being used to clear blockages. Most recently there is a trend toward using tPA and other modalities such as transcranial ultrasound to break up and agitate the clot. This is less invasive and does not require a specialist,” says Dr. Puhalovich. Dextrans are still used in some patients and statin drugs are starting to show promise in terms of preventing stroke recurrence. “Neuroprotective medications like calcium channel blockers are not as effective as we had hoped they would be, perhaps because they are lowering blood pressure at a time when we need increased pressure,” says Dr. Puhalovich.

Approximately 20% of stroke patients are admitted with a hemorrhagic stroke. A small percentage of these may require surgical intervention. Of the few studies that have been performed, there are mixed results as to the benefits of surgery.

junecover_2.jpg“The indications for surgery in intracranial hemorrhage are a bit of a controversial subject,” say Dr. Charles Weaver Jr., M viagraindian.com.D., Ph.D. “Neuroimaging capabilities including conventional angiogram, CT angiogram and the North Fulton Regional Hospital’s 3-tesla MRI have improved our ability to identify underlying lesions that increase a patient’s risk for further bleeding.” The hospital’s 3-tesla MRI is one of only a few in the state and provides the highest imaging resolution and anatomic detail available.

In hemorrhages with no underlying lesion, the decision to operate is individualized and dependent on the patient’s neurologic symptoms, the location and size of the hemorrhage, patient age and other medical conditions.

“You have to take into account the family’s wishes regarding surgical intervention for hemorrhagic stroke,” says Dr. Weaver. “In some cases, surgery is considered a ‘heroic’ intervention in the case of a potentially devastating illness.”

In order to receive and maintain Primary Stroke Center Certification, a neurosurgeon must be available within two hours of initial notification. Dr. Weaver and his partner, Dr. Steven Disch, actively practice at North Fulton Regional Hospital.junecover_4.jpg

Once the patient is diagnosed, stabilized and treated, the rehabilitation process begins. Usually within a 24- to 72-hour period, patients will have some type of intervention by the rehab team.  “The Critical Care and Medical Telemetry Units have physical, occupational and speech therapists assigned directly to their acute areas,” says Dr. Alan Harben, who serves as the Medical Director for the Department of Rehabilitation Medicine at North Fulton Regional Hospital. Some patients will be transferred to the 33-bed Comprehensive Acute Rehabilitation Unit and have a nurse assigned to them to manage pulmonary, swallowing, bowel and bladder and skin health issues.

Dr. Harben, who is board certified in physical medicine and rehabilitation and pain management, works in close collaboration with the neurologists and neurosurgeons to develop a treatment strategy specific to each patient’s need. “With a team approach, it is possible to streamline the whole hospital process so the patients can move more quickly from the acute care areas to rehab,” says Dr. Harben.

The rehabilitation team is striving to maximize recovery from stroke while minimizing complications. There is a whole host of rehab options that are available to stroke patients at North Fulton Regional Hospital. In the early days of stroke rehab, choices were limited to splinting, casting and alcohol blocks. Today, pharmacologic and surgical options are on the table as well. With the advent of botulinum toxin or Botox for spasticity and pain relief, patients can experience the benefit of spasticity reduction without the side effects of alcohol blocks. Most recently, intrathecal baclofen implanted pumps have been introduced as a programmable way to manage pain. The catheter is placed into the spinal column and baclofen is delivered directly to the area where spasticity originates.

Spasticity management is just one area that the rehab team evaluates. Pharmacologic management of patients involves a combination therapy of antidepressants and stimulant medications that promote arousal and attention to help with recovery. “We work in conjunction with neurology to select medications that will help with arousal and memory,” says Dr. Harben. Different unique combinations of medications are explored to improve arousal and awareness. “Some intervention begins even in ICU with stimulant medications. If there is severe spasticity, we may use Botox injection therapy.” In addition, surgical intervention may be necessary to control spasticity for a better patient outcome.

Dr. Harben and his staff conduct rounds on a daily basis to monitor patients for behavior, motor and cognitive changes. Each patient has a case manager to establish a care plan for rehabilitation. Once patients are discharged, Dr. Harben continues to monitor their progress and will follow them in his office to adjust medications and spasticity or for pain management. If late complications develop in terms of pain issues, patients may be referred to North Fulton Regional Hospital’s pain management group.

The stroke care team at North Fulton Regional Hospital reports all of its stroke data to the Coverdell Stroke Registry, which was named after longtime Georgia Sen. Paul Coverdell, who died in 2000 from a cerebral hemorrhage.

Well-known risk factors for stroke include hypertension, diabetes, hyperlipidemia, smoking, obesity, physical inactivity, atrial fibrillation and carotid disease. North Fulton Regional Hospital’s dedicated team is focused on the future and trying to educate the community about the dangers and prevention of stroke.  Community health events are offered periodically and include cholesterol and carotid bruit screenings. In addition, the community education team provides stroke lectures for varying local organizations and first responders such as EMS and fire departments.  “We are trying to reverse, minimize and prevent future stroke,” says Dr. Lipscomb.

North Fulton Regional Hospital’s stroke team is dedicated to providing full-service quality care for patients and their families. “North Fulton has a really good interdisciplinary approach to stroke care with a full spectrum of services,” says Dr. Harben.  Capable of treating patients from the time they enter the emergency department through the acute care process, potential surgical intervention and rehabilitation, North Fulton Regional Hospital offers a continuum of care for stroke patients that is unique in Metro Atlanta.

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Atlanta MGMA

Thursday, June 11th, 2009

June 11, 2009 – at the Ashford Club.  For more information, visit www.atlantamgma.com.

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