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The New War on Alzheimer’s UAB Alzheimer’s Disease Center Advances On Multiple Fronts By Laura Freeman

Jim Freeman survived D-Day. He survived Rommel’s tanks rolling over his foxhole in North Africa, and even made it home after lying wounded in the snow at the Battle of the Bulge. He didn’t want his memories to burden his family. It wasn’t until he was fighting his last battle in a war he couldn’t win that he began to tell his stories, hoping someone would remember. War had taken all but one of his friends. Now Alzheimer’s was taking everything else. At 19, the boy from Alabama braved machine guns on Omaha Beach to cut barbed wire and free his squad from the killing zone. Now, family dinners were frightening. An echo of the person he had been, his struggle to follow the conversation and to seem like the same Uncle Jim brought him and everyone at the table near to tears. Dying from Alzheimer’s is like falling off a cliff in slow motion. It inflicts terrible collateral damage, taking not only the life of the patient but also the lives caretakers might have

Periacetabular Osteotomy for Hip

Dysplasia Can Prevent Joint Replacement Abnormal development in the hip joint in adolescents and young adults is more common than was once thought. The condition can lead to hip dysplasia and hip impingement and usually requires surgery to correct the problem ... 5

(CONTINUED ON PAGE 4)

David Geldmacher, MD consults with a patient.

WOMEN’S HEALTH

Increasing Number of Women Diagnosed with Lung Cancer

Alzheimer’s Association Sees Increase in Federal Support

Patients, Researchers, Caregivers All Score Wins

By marti WeBB sLay

In late March, President Donald Trump signed the massive $1.3 trillion omnibus spending bill into law to fund the federal government ... 14

Pulmonologist Sandra Gilley, MD says that COPD and lung cancer are a very real risk for women. And she wants physicians to be aware of the current screening recommendations. “More women die of lung cancer than breast cancer,” Gilley said. “Lung cancer in women is on the rise. Rates of smoking in women increased in the 1970s due to targeted advertising, and that population has now aged to the point where they are getting diseases like COPD and lung cancer. And lung cancer doesn’t respond to treatment as well as breast cancer does.” Current guidelines suggest that patients over the age of 55 with a smoking history of a 30-pack year (a pack a day for 30 years) should be screened

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NEUROLOGY

Which Treatment for Which Tumor? By Laura Freeman

‘Brain tumor’ may be the two most frightening words a patient will ever hear a surgeon speak. After the shock, there will be questions—most will ask what can be done. In finding the answer likely to lead to the best outcome, there are no simple templates for treatments that fit everyone. “The important thing is to look at the patient sitting in front of you,” neurosurgeon Joshua Menendez MD of Neurosurgical Associates said. “Each case has its own unique considerations. “The location and size of the tumor, the patient’s age and other morbidities, and the type of tumor and how aggressive it is are all factors in Joshua Menendez MD in surgery. developing a treatment plan. Depending on the circumstances, the recommendation ing the tumor with open surgery could most likely to benefit the patient may be take all day, plus a hospital stay and time open surgery, radiosurgery, a combinafor recovery. For older patients with other tion of both and perhaps follow-up with health issues, radiosurgery is likely to be a other therapies.” better choice. However, for younger paThe location of the tumor can influtients in good health, there could be adence the choice of treatments. A tumor vantages in traditional surgery. When the near the brain stem is likely to be higher risk for both traditional surgery and radiosurgery than one near the right frontal lobe, which would be more accessible for either. However, location isn’t always the only factor. “The nonmalignant tumors we often see rising out of nerve tissue near the brain stem are an example of how we might approach the same type of tumor differently in different patients,” Menendez said. “These tumors don’t spread cancer cells to other areas of the body, but as long as the tissue is there it continues to grow, compressing surrounding structures of the brain and causing damage. “We can do radiosurgery in half an hour and then send the patient home with very little time needed for recovery. Treat-

tumor is removed, it’s gone. Younger people with more years of life expectancy can live those years without as much worry about whether a trace of tissue could have survived and might start growing again.” The size of a brain tumor can affect whether or not radiosurgery is an option. “As of now, we typically don’t use radiosurgery for tumors over three centimeters. As tumors get larger, targeting them without damaging surrounding tissue becomes more difficult. However, neurosurgeons in some research centers are pushing the envelope in using radiosurgery for larger tumors. As their techniques are refined and developed, we hope to be able to offer this choice to more patients,” Menendez said. The nature of the tumor itself is one of the most important factors in deciding how to treat it. Some tumors respond to radiation better than others. More aggressive tumors, particularly glioblastomas, need to be targeted with every weapon in the treatment arsenal to make a difference in the patient’s survival.

“Glioblastomas are so tenacious, and they don’t have the more defined borders you see in other types of tumors. Even with surgery, it’s difficult to know if there is more. We tend to combine surgery with radiosurgery and possibly chemotherapy. Research is making progress toward gene therapies using viral vectors to target and destroy malignancies. We’re hoping this will give us a more effective way to treat aggressive brain tumors in the not-sodistant future,” Menendez said. Radiosurgery itself has come a long way since the early days of the gamma knife. “Instead of being immobilized with all that heavy, uncomfortable head gear we had to use in the past, patients now wear a lighter mask to assure precision placement. The equipment uses 3D computer tracking with an automatic shutoff if there is any variation in alignment. This protects healthy surrounding cells while making sure the therapeutic dosage is going where it is needed.” Radiosurgery may be completed in one session or delivered in fractionated doses in multiple sessions depending on the treatment plan. “We work closely with radiation oncologists to plan treatment, and with an entire team in the St. Vincent’s lab as we perform the procedure,” Menendez said. “With advances in radiotherapy, open surgery and new therapies, we have come a long way in what we can do to fight brain tumors.”

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NEUROLOGY

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lived. In an aging society where the risk of Alzheimer’s doubles every five years after age 60, the financial and social impact on the nation are becoming overwhelming. To counter this threat, federal resources have been mobilized in a campaign to fight Alzheimer’s on multiple fronts. Home base for that effort in Alabama is UAB’s Alzheimer’s Disease Center, allied with the Center for Neurodegeneration and Experimental Therapeutics (CNET). Director Erik Roberson, MD, PhD, oversees research into the neurobiology of how Alzheimer’s develops and progresses. He works closely with Clinical Core Director David Geldmacher, MD, who leads care and research teams working to improve strategies for managing Alzheimer’s. Several clinical trials are underway, testing new interventions aimed at easing symptoms and slowing progression of the disease. To assist caregivers, a new training program is now available using telemedicine. A key observational study now recruiting will follow subjects who aren’t yet showing symptoms of Alzheimer’s to learn more about how the disease develops, identify new targets for intervention and learn how the disease is different in the south. “Most of what we know about Alzheimer’s is based on research conducted outside the south, and a particular problem is that very few African Americans have been included in previous studies,” Roberson said. “The south has high rates of diabetes, obesity, and cardiovascular disorders including hypertension—all of which have a strong association with risk for Alzheimer’s Disease.” Geldmacher said, “African Americans are about twice as likely to develop Alzheimer’s Disease, and they seem to respond to risk factors differently. So far, around 30 genes have been linked to the risk for developing the disease. The strongest link is to APOE4, but this gene doesn’t seem to have as great an effect in African Americans. We don’t know if other genes are protective or if different factors are involved. We don’t understand why because we haven’t had enough African Americans involved in studies.” The APOE4 gene is more common in some areas of Africa, like Nigeria, but rates of Alzheimer’s are lower. This could be because obesity and diabetes rates are lower and nutrition and exercise habits are different. The UAB study will look at how these factors and others may influence the causes of the disease. “Our goal is to recruit about 50 percent African Americans in our study so we can make a meaningful comparison of how risk factors are expressed in different gene pools,” Geldmacher said. “In the past, Alzheimer’s was something we diagnosed after symptoms occurred. By then, too many brain cells were damaged for us to do much to intervene. Now advances in imaging and molecular medicine allow us to see earlier changes that can begin as much as 15 years before cognitive symp-

© UAB DIGITAL MEDIA

The New War, continued from page 1

Erik Roberson, MD, PhD, Director of UAB’s Alzheimer’s Disease Center

toms are obvious. If we can identify ways to influence epigenetic changes and targets for pharmaceutical and other interventions, we may be able to stop or slow the damage before it happens.” Participants in the study will have imaging studies, blood and genetic testing, and optional spinal fluid collection, which will be followed by an annual evaluation to detect changes. “With imaging, we can see the accumulation of amyloid plaques and tau tangles,” Roberson said. “The extent of these changes and where they show up in the brain tends to correlate closely with the degree and type of symptoms patients experience as the disease progresses.” Much of Roberson’s research is focused on learning more about the tau protein and its role in the development of tau tangles and interaction with amyloid plaques. “Early in the disease, the presence of tau protein seems to cause hyperexcitability of brain cells which can result in subclinical seizures. If we can reduce the level of tau protein, we may be able to reduce the hyperexcitablity and prevent the damage it seems to do,” Roberson said. Risk assessment is another clinical service available through the Alzheimer’s Disease Center. “People who have a family history of Alzheimer’s or other concerns can come to the clinic for a risk assessment based on genetics and their health history, and they can have imaging studies to determine whether any changes are visible,” Geldmacher said. “For many, this offers the peace of mind of knowing there are no signs of the disease. If changes are present, though we have no definitive therapies yet, we can begin early work to control other health issues that seem to influence risk, such as blood sugar, obesity and hypertension. “The risk assessment, unfortunately, isn’t usually covered by insurance, which brings into play another disparity on who gets Alzheimer’s. Those who can’t afford an assessment are also less likely to understand the role a healthy lifestyle plays in minimizing risks. “We’re hoping that what we learn about the disease over the next few years will lead to new ways we can help everyone who is at risk.”


Periacetabular Osteotomy for Hip Dysplasia Can Prevent Joint Replacement By Ann B. DeBellis

the acetabulum, or hip socket, should be perfectly concentric so they match up well. In indiAbnormal development viduals with hip dysplasia, the in the hip joint in adolescents acetabulum doesn’t develop and young adults is more fully, which makes it too shalcommon than was once low to contain and support the thought. The condition can femoral head. The abnormallead to hip dysplasia and hip ity causes misalignment in the impingement and usually rehip joint and can cause the quires surgery to correct the labrum to bear the force norproblem. mally distributed throughout Michael K. Ryan, MD, the hip. Injury to the labrum an orthopaedic surgeon and ligaments can increase at The Hip Center at Anpain and damage or weaken drews Sports Medicine in the cartilage. Birmingham, is one of only “That’s where the hip a few hip preservation surpreservation surgery we pergeons who surgically treats form comes into play,” Ryan these hip abnormalities with says. “We evaluate young paa surgical technique called tients who develop hip pain periacetabular osteotomy with a goal of not only treat(PAO). ing their pain but also delaying “Hip dysplasia is a delong-term problems related to velopmental abnormality of Michael K. Ryan, MD performs a periacetabular osteotomy to correct hip dysplasia in a arthritis.” the hip socket that results in a young patient. Hip dysplasia can be shallow acetabulum, while a caused by various factors, insocket that is over covered, or cluding family history, certain restrictive brum in the hip, which can eventually lead too-deep, can cause impingement,” Ryan swaddling practices, and breech birth. to arthritis at an early age.” says. “Both bony abnormalities change the “Pediatricians examine all newborns, but In a healthy hip joint, the ball, or femload-bearing mechanics of the hip joint, it can difficult to diagnose subtle dysplaoral head, should be perfectly round and leading to damage of the cartilage and la-

sia at that time unless there a palpable subluxation or a frank dislocation,” Ryan says. “Additionally, routine hip ultrasound screenings are not performed on newborns in the United States unless there is concern for dysplasia. “In addition to the genetic component of these conditions and how the socket is formed, a general theory is that these issues also can occur in children who play a lot of sports. With constant side-toside movement required in many sports, we are seeing the development of hip impingement as these young athletes age. It isn’t 100 percent proven at this point, but it is one of the theories.” The PAO is the main surgery used to correct acetabular dysplasia in adolescents and adults with fused growth plates. The three- to four-hour procedure corrects the bony deformity to relieve symptoms and normalize the load across the joint by reorienting the hip socket in a more optimal and normal position. “We cut the bone around the acetabulum and reposition the hip socket,” Ryan says. “To do this, we expose the hip joint from the front of the hip by making a bikini-line incision which allows us to access the main bony struts that hold the (CONTINUED ON PAGE 12)

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The Alabama Data Breach Notification Act of 2018 By: Beth Pitman, JD, CHPC On June 1, 2018, any person or business that acquires or uses personally identifiable information of an Alabama resident, or contracts to maintain, store, process or access such information, may

be subject to The Alabama Data Breach Notification Act of 2018. On March 28, Alabama, following unanimous vote of the house and senate, became the 50th state to enact legislation to protect the data of its residents. The time taken to structure the legislation resulted in a stringent Act that

addresses current cybersecurity threats, such as hacking events that circumvent encryption technologies. For a healthcare provider or vendor, the Act is comparable to HIPAA and provides a HIPAA safeharbor for HIPAA compliant organizations.

Beth Pittman, JD, CHPC is Of Counsel with Waller, Lansden, Dortch & Davis LLP where she practices Health Law.

Provision

Alabama

HIPAA

Who is regulated: Covered Entity

person, sole proprietorship, partnership, government entity, corporation, nonprofit, trust, estate, cooperative association or other business entity that acquires or uses sensitive personally identifying information

Health plan, healthcare clearinghouse or healthcare provider transmitting HIPAA transaction

Who is regulated: Third Party Agent vs. Business Associate

entity that has contracted to maintain, store, process, or otherwise access sensitive personally identifying information when providing services to covered entity

Person, other than workforce, , that creates, receives, maintains or transmits PHI for covered entity

Who is protected

Alabama residents

Individual whose PHI is created, received, maintained or transmitted

What is protected

Sensitive personally identifiable information: first name or initial and last name plus non-truncated SSI, tax ID, state or government issued ID, financial account information with access information, and any information regarding an individual’s medical history, condition, treatment or diagnosis; health insurance policy number or ID number and unique insurer ID; name or email plus password or security question and answer to enable access to a covered entity account.

PHI: individually identifiable health information, including demographics, created or received that relates to the past, present, or future health condition, treatment or payment

Electronic or digital, including tapes or storage devices

Electronic, paper or other

What is a Breach

Unauthorized acquisition with limited exceptions including good faith of covered entity employee and law enforcement

Acquisition, access, use or disclosure of PHI not permitted by the Privacy Rule which compromises the security or privacy of PHI; some limited exceptions

Breach Risk Assessment

Information was actually acquired or reasonably believed to be acquired and the breach is reasonably likely to cause substantial harm to individuals; consider if the information in the physical control of another (lost/stolen device); downloaded or copied; unauthorized use (accounts opened/identity theft reported) or information made public

Consider if there is a low probability of risk to PHI: (1) nature and extent of PHI; (2) unauthorized person who used or to whom disclosure was made; (3) was it actually acquired or viewed; (4) extent of mitigation

Encryption Safeharbor

Yes but not if the encryption key or code is compromised

Yes; but HHS guidance notes that encryption is not a safeharbor when unauthorized access circumvents the encryption level

How is it protected? HIPAA Safeharbor

Compliance with HIPAA and notice for ≥1000

Security Measures

Security officer, risk assessment and identification, and adoption and assessment of safeguards to address risks

HIPAA Security Rule

Security Risk Assessment

Identify internal and external risks

HIPAA Security Rule

Contracts

contracts with service providers requiring appropriate safeguards; CE may contract with 3rd Party regarding breach notice obligations

BAAs

Management Reports

Informing management and board of overall security measures

None but OIG guidance recommends similar action

Disposal

Reasonable measures to dispose of records in custody or control

HIPAA Security Rule

Notice

Individuals; if ≥ 1000, notice to Attorney General and consumer reporting agencies; substitute notice allowed

Individuals; if ≥ 500, notice to HHS and media; substitute notice allowed

Covered Entity Timing

As expeditiously as possible if at CE; within 45 if at 3rd Party

Within 60 days; HHS considers this the outer limit and possibly inadequate in some circumstances

Business Associate Timing

Notice to Covered Entity as expeditiously as possible after determination of breach or reason to believe breach occurred but no later than 10 days

Within 60 days; HHS considers this the outer limit and inadequate in some circumstances

Penalty/Fine

Unlawful trade practice; civil penalties; no criminal penalty (max. $500,000/breach); $5000/day for delayed notice

Civil and criminal fines and penalties

Covered entity and 3rd party liability

Covered entity and business associate liability

Attorney General representative action

U.S. Attorney General restitution to victims

No private right of action

No private right of action

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MAY 2018 • 7


WOMEN’S HEALTH

New Development Improves Surgical Treatment of Sacroiliac Joint Dysfunction By Dale Short

Look in a medical textbook for an illustration of the pelvis, near the tailbone, and along each side you’ll find a complexlooking structure of connecting bones and joints. Near the center there’s a connection between the sacrum and iliac bones known (not surprisingly) as the sacroiliac (SI) joint. It’s a familiar term because it’s such a frequent source of problems. One recent study shows that nearly one-third of patients’ hip pain is SI-related. Fortunately, SI treatment has come

a long way since the days when metal plates were attached to limit motion. Gregory Gullung, MD of Grandview Medical Center is streamlining one new development that uses a surgical tool Gregory Gullung, MD known as SICure. “SICure is a screw that, when you put it through the joint, harvests some of the bone as it goes,” Gullung says. “It has a hollow center, and teeth that cut some of the bone and pull it across the joint so the

joint will fuse. There have been different devices over time, such as little pegs and regular-looking screws, but this is a new design of screw that we can utilize. “This is much less invasive. The width of the screw head is about half a centimeter, so an incision that size is all it takes.” Both men and women suffer from SI joint dysfunction. The causes for men are often trauma, falling, or arthritis of the lower back. The disorder is more common in women, however, and one of the most frequent causes is pregnancy, especially multiple births.

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“When you’re having a baby, your body releases hormones that relax the joints, and sometimes the joints don’t stiffen back up like they should and end up as a permanent issue,” Gullung says. “SI dysfunction is a little more common among women who have had one or more children through vaginal delivery, but it can also occur through C-section. “Some hip pain after delivery is normal, but by six to 10 weeks the pain should be getting better. If it’s not, there may be some sort of dysfunction occurring.” SI dysfunction can be easy to misdiagnose. There are more than a dozen possible tests. “It’s very frustrating,” Gullung says. “Tests can point to it, but the symptoms can be caused by other issues as well, so each test’s ability to predict is about 60 percent. If three of the tests are positive, that’s a generally accepted answer for pointing to SI dysfunction. “But the most accepted test is to inject the joint and numb it up. If the patient really feels better, anywhere from a 50 percent to 75 percent reduction in pain, one can reasonably confirm the SI joint as the source of pain. We recently had a patient, a lady we injected, and she had no pain after the procedure. We did the fusion on her and she felt fantastic. That’s obviously the best-case scenario.” Another tool of the surgery in addition to the connecting screw is a triangular, porous plasma-coated implant that is bored into a hole, so that the bone will grow across the implant and fuse to it. “In any procedure without a selfharvesting option, you have to put some bone graft in somewhere to help it heal,” Gullung says. “That can be from the patient, synthetic, a cadaver, whatever. It’s more a fixation than a true fusion, and there are different ways you can help that bone growth. The whole purpose is to stop motion in that joint. “Stopping the motion doesn’t interfere with activity because there’s not a lot of motion in that joint to begin with. It’s not meant to be a very mobile joint. It’s the increased mobility where the dysfunction can occur, and when it does become hypermobile, it’s a problem. “Fortunately once the joint is fused you really wouldn’t notice any limitation in your ability to stand, bend, or twist. In fact, once most people are fused they say that can move with more freedom because it doesn’t hurt.” “Non-surgical treatment, such as physical therapy, can help in the short term but unfortunately the long-term data shows that people continue to have increased pain with the conservative treatment. Surgical fixation is the only treatment that’s been shown to really cut down on pain, which can also help get people off narcotics, and as we see from the current news, getting them off opiates is a good thing.”


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MAY 2018 • 9


WOMEN’S HEALTH

Kangaroo Mother Care Effective in Preventing Hypothermia Hypothermia in newborns is common worldwide and the incidence of is substantially higher in developing countries. Even in the United States, many babies require hospitalization because of hypothermia. A team of physicians, nurses and medical students from UAB are working in collaboration with their counterparts from Zambia at the University Teaching Hospital to find a low-cost way to protect newborns from hypothermia and improve their chance of survival. One such way is through kangaroo mother care (KMC), a technique that provides warmth to an infant through direct skin-to-skin contact. KMC, also known as skin-to-skin care, was initially developed in the 1970s to care for preterm infants in countries where incubators were either unavailable or unreliable.

UAB team from left: Rebecca Newton; Anna Choe; Maran Ramani, MD; Meggin Major

The direct skin-to-skin contact with the parent helps ensure physiological and psychological warmth and bonding and the parent’s stable body temperature helps to regulate the neonate’s tempera-

ture more smoothly than an incubator. Researchers from UAB and Zambia looked at the effectiveness of Kangaroo Mother Care right after birth when the babies are most at risk of hypothermia. A study published in the Archives of Disease in Childhood showed practicing shorter durations of KMC during the first few hours after birth does not prevent moderate hypothermia in the infant. However, the study showed babies who received longer durations of KMC more than 80 percent of the time were protected against hypothermia in the first few hours after birth.

“Kangaroo Mother Care is commonly practiced in many cultures, promoting breastfeeding and mother-baby bonding, but it has not been tested right after birth as a way to prevent hypothermia,” said Manimaran Ramani, MD, lead author and assistant professor in the UAB Division of Neonatology. “It is possible that kangaroo mother care will be beneficial in preventing hypothermia in infants born in resource-limited facilities, like in Zambia, if it is practiced for a longer duration of time.” The team found that infants who received Kangaroo Mother Care more than 50 percent of the time during their hospital stay did not have the risk of hypothermia at discharge. To reduce the neonatal hypothermia, the World Health Organization recommends a set of interlinked procedures called the “warm chain,” or thermoregulation protocol, to be implemented with every newborn from birth until the first few hours to days after birth. The warm chain procedures include warm delivery rooms, immediate drying, as much uninterrupted skin-to-skin contact as possible, early breastfeeding, delayed bathing and (CONTINUED ON PAGE 17)

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MAY 2018 • 11


Increasing Number of Women Diagnosed with Lung Cancer, continued from page 1 annually with a low-dose CT scan. “That should be part of their routine cancer screening, just like a colonoscopy every 10 years or a mammogram every year for patients who fall into that category,” Gilley said. “Women are at least equally at risk for lung disease as men. In fact, there is some evidence that estrogen can make women more prone to lung disease in general. “Sometimes lung disease can present without symptoms. However, coughing up blood, losing weight, fever, and night sweats are all common symptoms of lung disease.” Gilley suggests that physicians screen women for lung disease with greater care. Women should be asked not only if they smoke themselves, but whether their spouse or others who spend significant time with them are heavy smokers now,

or were in the past. While there are no specific guidelines for secondhand smoke, it’s an important factor. “If they live in a heavy smoke environment, they are at increased risk for lung disease,” she said. In recent years, several diagnostic devices have been developed that improve the odds of finding cancer. Navigational bronchoscopy is an advanced imaging technique that uses GPSlike technology, enabling pulmonologists to find and biopsy suspicious masses that can’t be viewed via traditional bronchoscopy. The patient must first have a high resolution CT scan. “We put those images into a computer program and it figures out which brochial tubes are closest to the nodule,” Gilley said. The resulting map enables the physician to biopsy nodules and potentially save the patient surgery if they are not cancerous.

g n i t t e g e l b Trou s t n e i t a p r u yo ? b a l p e e l s a into

Endobronchial ultrasound-guided biopsies of lymph nodes and lung masses are minimally invasive procedures that provide relatively new diagnostic benefits. “It’s a special bronchoscope with an ultrasound probe on the end of it,” Gilley said. “We can identify the target lymph node or mass with the ultrasound, and the needle comes out next to it. We can actually see the needle going into the mass we are trying to biopsy. It used to be a blind procedure, and we had to know from the anatomy where to stick the needle, but that can obviously be problematic. Now we can stage the cancer before we send the patient to surgery. It helps us decide more accurately which patients are candidates for surgery and which are not.” But Gilley points out that having these improved procedures are most helpful when patients are identified through

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screening earlier in the disease process. “The number of women diagnosed with lung cancer is increasing, because they started smoking later than men,” she said. “Women who started smoking in the 1960s and 70s are just now getting to the age to develop these diseases.”

Periacetabular Osteotomy for Hip Dysplasia, continued from page 5

hip socket in place. We use special tools to cut the struts, freeing the hip socket from the rest of the pelvis, but keeping the joint intact. “That allows us to rotate the acetabulum into the correct position, which is then held in place with metal screws. Rotating the acetabulum allows us to put it in a more optimal position for load-bearing. The force of the body is distributed more evenly across the joint which protects the cartilage from early wear.” As with any surgical procedure, there are some risks involved. “The biggest initial surgical risk with PAO is bleeding, because we are cutting bone, and a tourniquet cannot be used during the surgery,” Ryan says. “There is a small possibility of infection and blood clots like we see in knee and hip replacements. Most of these risks are relatively low, because most of the patients are young, have few medical co-morbidities, and are mobilized quickly due to the ability to bear partial weight on the hip immediately. There is also a small risk of nonunion which means the bone doesn’t heal where it was cut. In the long-term, the risk of developing arthritis persists, but a successful PAO performed in patients diagnosed early enough can delay arthritis for 10 to 30 years or more following surgery. That could be the difference between a hip replacement at 35 versus 55 or older.” Whether a total hip replacement will be needed later depends on many variables including the degree of damage present in the joint when the PAO surgery was performed. However, periacetabular osteotomy has been successful in relieving pain and delaying the need for an artificial hip joint. “Right now, the PAO is the gold standard for treatment of adult hip dysplasia, because correcting the mechanical deformity has been proven to positively alter the long-term health of the hip joint,” Ryan says. “Treating only the cartilage and labrum using hip arthroscopy cannot adequately correct the bony deformity, but recent advances have allowed us to combine hip arthroscopy and the PAO to treat all facets of hip dysplasia.”

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Staying Focused on Practice Business Strategy By Joni Wyatt, MHA, MHIA, CPHIMS, FHIMSS

I recently attended a conference in Las Vegas where I caught up with colleagues who specialize in healthcare operations and business strategy. However, like many destinations in Las Vegas, to get to the conference center, you must walk through the Casino. They plan this. They want us to maybe get distracted by the blackjack table or the slot machines. Sure, there are signs and people who give directions, but there are also flashing lights, noises and other distractions. Walking through the Casino is when it dawned on me how much our industry is like Vegas. We all have goals and destinations we are trying to reach, but in order to get there, we have to walk through a sea of distraction. We have webinars, conferences, and workshops to foster communication about the “next new big thing,” yet we are still side-tracked by the urgency of daily operations and the fires that come with it. Much like the best poker players in Vegas, we all need a strategy. Business Strategy is defined in a lot of ways, but the most basic being “a plan of action designed to achieve a particular set of goals.” Strategy should be developed

based on the ultimate vision of where you want your practice to be and prioritizing tasks and objectives to get you there. This is typically where many practices falter because few of them have a clearly defined strategy. This is not intended to be a jab at our office administrators and physician owners. The daily fires are real and essential, while the idea of strategy seems like a luxury. Strategy has resolved itself to being in the “if I have extra time” bucket for many smaller practices. But strategy can be your map through the sea of distraction. The 4 Disciplines of Execution, by Steven Covey specifies that the more goals you try to juggle, the fewer you will achieve with excellence. A defined strategy helps you focus only on the top priorities and attain desired outcomes.In 2011, Berg Consulting Group wrote a blog about the importance of strategy, breaking it down to three simple points.

Understanding your Industry and how your company fits within it. With the fast pace of change in healthcare, a full understanding our industry is not as easy as it used to be. Charting your course of action in response to new requirements, payment programs, regulations, and

incentives is critical. Consider the return on investment and the ultimate impact to your practice before putting an action plan in place. As with most business decisions, a cost benefit analysis must be performed. Be strategic in determining if the “next new big thing” applies to you and how.

Adapting and Growing in a Changing World Beyond identifying whether the “next new big thing” applies to you now, it is important to understand that it may in the future. A common mistake is to make a final determination about how your practice will be impacted today, but then failing to pay attention to how the situation continues to evolve. None of us can say for certain what will happen- but new trends in the marketplace are often easy to spot. We all know that if CMS implements a new rule, then the other payers often follow. Additionally, ACHE, HFMA, HIMSS, MGMA and other organizational meetings provide ongoing exposure to what those trends may be. Creating a Direction for the Whole organization No matter how large or small an organizational goal may be, your staff must understand their purpose and how they

are supporting the intended vision of the practice. If the physicians, the practice leadership and the staff are working toward the same destination, then resources are effectively used and redundant activities are minimized. Communication allows an organization to move forward quickly and leads to a more engaged staff. The process of creating a shared vision and business strategy can be overwhelming. It also requires time and engagement from others at all levels within the practice who may not have an interest. Considering the three points discussed above, it is often easier to create strategy around specified topics as they become relevant. The strategies that you create will help guide you through daily distractions and ensure that your efforts are on the goals and tasks that mean the most to your practice. The odds in Vegas will always favor the Casino. Strategy and vision moves the odds more in favor of your practice. By implementing this process, you will increase the odds that every hand is a full house. Joni Wyatt is a Healthcare Advisor with Kassouf & Co.

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NEUROLOGY

Alzheimer’s Association Sees Increase in Federal Support Patients, Researchers, Caregivers All Score Wins By CINDY SANDERS

In late March, President Donald Trump signed the massive $1.3 trillion omnibus spending bill into law to fund the federal government. Part of the spending package included a $414 million increase for Alzheimer’s and dementia research funding at the National Institutes of Health (NIH). Rachel Conant, senior director of Federal Affairs at the Alzheimer’s Association, leads the organization’s efforts to elevate Alzheimer’s disease as a priority for the federal government. She also serves as senior political director of the Alzheimer’s Impact Movement Rachel Conant (AIM), which is the national association’s advocacy arm. “The Alzheimer’s epidemic has a profound impact on families,” she said, adding her own family had been touched by the disease. “The Alzheimer’s epidemic has a profound implication for state and federal budgets,” Conant continued. “Nearly one

those costs could rise to as much as $1.1 trillion by 2050. The current cost represents nearly a $20 billion increase over last year.

in every five Medicare dollars is spent on Alzheimer’s or related dementias.”

Alzheimer’s Stats Just days before the spending bill was signed, the Alzheimer’s Association released a new report outlining the toll of the disease. “The 2018 Alzheimer’s Disease Facts and Figures” found increases in prevalence,

deaths and cost of care. An estimated 5.7 million Americans are living with Alzheimer’s dementia in 2018, nearly two-thirds of Americans with Alzheimer’s are women, 10 percent of those 65 and older have the disease, and the incidence rates are even higher in older African-Americans and Hispanics. Alzheimer’s cases are expected to spike alongside the nation’s aging population with an estimated 14 million living with the disease by 2050. Currently, someone in the United States develops Alzheimer’s every 65 seconds. The Alzheimer’s Association predicts by mid-century, someone will develop the disease every 33 seconds. Although deaths from other major diseases have decreased, recorded deaths from Alzheimer’s disease increased 123 percent between 2000 and 2015. The sixth leading cause of death, the new report stated Alzheimer’s is the only one among the top 10 causes of death that cannot be prevented, cured, or significantly slowed. In addition to the human toll, the financial cost is staggering. The 2018 Alzheimer’s Association report cited a $277 billion cost to the nation for Alzheimer’s and other dementias with a projection that

Plan of Action Conant noted that in 2011, landmark legislation laying the groundwork to create a national Alzheimer’s strategy was signed into law. The National Alzheimer’s Project Act (NAPA) created an advisory council to make recommendations to the Secretary of Health and Human Services in three key areas: research, clinical care, and long-term services and support. “That was the first time we really saw the federal government put an emphasis on Alzheimer’s funding and research,” Conant said. She added with this latest $414 million NIH increase earmarked for Alzheimer’s and dementia research, federal funding has now risen to $1.8 billion. A great deal of work is being done to better understand the underlying mechanism of Alzheimer’s and related dementias, and there are a number of promising drug trials underway that hope to stop or slow down disease progression. “We’re really excited about the focus not only on treatment but on prevention,” said Conant. “We just announced the 2018 launch of the Pointer Study, which is a two-year clinical trial to look at multifactorial and lifestyle interventions to prevent cognitive decline and dementia,” she continued. The intervention methods will include exercise, nutritional counseling, cognitive and social stimulation, and improved self-management of health conditions. For more information, go online to alz.org/us-pointer. Kevin & Avonte’s Law Also included in the omnibus bill was funding for Kevin and Avonte’s Law, bipartisan legislation to protect seniors with dementia and children with developmental disabilities who are prone to wander. (CONTINUED ON PAGE 20)

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Non-invasive Procedure for Relieving Spinal Stenosis The only surgical course for those suffering from moderate lumbar spinal stenosis used to be open back surgery. But two years ago, a new option entered the physician’s arsenal. “The success rate has been overwhelmingly positive,” says Brad Goodman, MD, a physiatrist with Alabama Ortho Spine and Sports in Birmingham. Goodman was the first physician in the U.S. to perform the Superion Indirect De- Brad Goodman, MD compression System (IDS) procedure and still remains the only one performing it in Alabama. Lumbar spinal stenosis (LSS) usually results with aging. The spinal canal narrows, infringing on the nerves causing pain, numbness, tingling and/or weakness in the back and legs. The distress intensifies with standing and walking and dramatically improves when sitting or bending over. The trademark stance for someone seeking relief from LSS makes them look like they are hunched over pushing a shopping cart.

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Though not a cure-all for all the leg and back pain caused by LSS, the impact of this procedure has been notable. Of the 60 patients treated by Goodman using the Superion IDS, 80 percent were functioning at a much higher level, including around 50 percent reduction in pain. Less than five have gone on to have traditional surgery so far In the clinical trial in 2,000 patients worldwide, results showed leg pain improvement equal to or better than found in the traditional surgical options. Four years after their surgery, 90 percent of those trial patients reported continued satisfaction. “What’s really important is that these people have a problem with which the only solution used to be major back surgery,” Goodman says. “But they found relief with something far less invasive.” The Superion IDS process requires only an inch-long incision and is handled as an out-patient procedure. “It’s even less invasive than other minimally invasive procedures, like laparoscopy,” Goodman says. A small tube is then inserted between the spinous processes. Then the implant is deployed. “It looks like a little bullet, and it has wings that are opened with a screw-

driver once it is in place,” Goodman says. The process takes less than an hour and requires no bone or tissue loss. The titanium implant works like a little jack or shoehorn, so when the patient stands erect, it blocks that level of the spine from being able to fully extend backward. “By blocking extensions, it puts that level in a little bit of flexion which is what happens when a patient seeking relief sits or bends forward. It decompresses the back,” Goodman says. Recovery is much like with an epidural block. Patients are given very light sedation for the procedure and are sent home an hour or two later with a few staples to be removed a week later. “Generally speaking, patients are pretty much able to do basic activities the next day,” Goodman says. Some patients feel so well that they have actually caused a small fracture in their back from being so active. “Because they feel so good afterwards,” Goodman says. The fracture can negate the implant’s positive effect and leave the patient back where they started. Research has not yet explored whether or not the Superion IDS method can be performed again in these conditions. Small fractures of the spinous pro-

cesses can also occur during placement. “This procedure is done in mostly older people, so their bones can be more brittle and soft,” Goodman says. “But these fractures are a rare issue. They occur in less than five percent of the procedures. “The result can displace the implant. But that doesn’t necessarily affect the outcome. Most of those patients will still find relief. The ones who don’t, aren’t doing any worse.” The ideal patient for the Superion IDS has a significant amount of stenosis, been treated with non-surgical options for at least six months, and not had back surgery at that same lumbar level of the spine. “Four levels are potentially treatable with this procedure, but it is only approved for up to two levels,” Goodman says. “That doesn’t mean it wouldn’t work for more, but it hasn’t gotten the approval at this time.” Goodman points out that there is no downside to this procedure, relativity speaking, because Superion IDS patients can still opt for the more invasive decompression or spinal fusion surgeries. “The procedure doesn’t burn any bridges,” he says. “It doesn’t work in reverse, though. You can’t go back from open back surgery. In that case, the anatomy you need to put this device in has been removed.”

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Can I Waive a Patient’s Co-Pay? By Kelli Fleming

I am occasionally asked by providers whether or not they can waive a co-pay for a particular patient. There are many reasons providers wish to waive co-pays: financial hardship, professional courtesy, employee discounts, etc. All of these reasons are well justified and appropriately motivated. Further, all of these reasons would be appropriate for a client discount in almost any other industry (e.g., retail) except healthcare, which is one of the most, if not the most, highly regulated industries. Consequently, appropriate motivation is not always sufficient for giving “patient discounts” due to applicable legal restrictions. This article will focus on waiving co-pays for reasons related to financial hardship. Federal regulations prevent the routine waiver of co-pays for Medicare and Medicaid patients. Similarly, other thirdparty payors may also contractually prohibit routinely waiving co-pays. Federal regulations, however, do allow the nonroutine waiver of co-pays in situations of financial hardship as long as certain conditions are satisfied. The wavier may not be offered as part of any advertisement or solicitation, and the provider may only waive the co-pay after determining in

good faith that the patient is in financial need. When looking at financial need, providers can examine a variety of factors, including cost of living, patient’s income and assets, patient’s family size, and the scope and extent of medical bills. There is some flexibility given to the provider in determining what constitutes a financial hardship. However, providers cannot consider the ability of the patient to generate business or referrals when making the determination. Eligibility for co-pay waivers should also not be based on race, age, creed, sex, religion, ancestry, marital status, disability, national origin, or any other legally protected category. Thus, it is recommended that providers adopt a Financial Hardship Policy and utilize a Financial Hardship Application. The Financial Hardship Policy should set forth the guidelines used to determine financial need (e.g., patients earning below 150 percent of the federal poverty level are eligible for assistance) and should help ensure that such guidelines are applied uniformly. The Financial Hardship Application is designed to document the patient’s financial condition and to gather supporting information (e.g., federal income tax return, recent paychecks, bank statements, inability to work letter, etc.). Based on the information provided by

the patient in the Financial Hardship Application, as well as appropriate verification by the provider, the provider is in a position to make an informed, supported decision regarding financial need. The determination by the provider should be documented, and the determination, as well as the patient’s financial situation, should be reviewed periodically---in other words, as the financial condition changes or as time passes, the provider should re-evaluate whether continuing to waive co-pays is appropriate. The Financial Hardship Application, the verification information, and evidence of the ultimate decision by the provider should be retained in the patient’s file for at least six (6) years. Thus, the answer to the question “Can I waive a patient’s co-pay?” is “It depends.” If the provider complies with the steps mentioned above and if the patient has a demonstrated financial hardship, then, yes, you can. If not, the reasoning behind the co-pay waiver and whether or not federal requirements are met will need to be further examined. Kelli Fleming is an attorney with Burr & Forman LLP and practices exclusively in the firm’s Health Care Practice Group.

Kangaroo Mother Care Effective in Preventing Hypothermia, continued from page 10

weighing, appropriate bundling, mother and baby together, warm transportation, warm resuscitation, and improved training and awareness. “Not all elements recommended in the WHO thermoregulation protocol are practiced routinely in many birth facilities around the world,” Ramani said. “Kangaroo Mother Care is a low-cost intervention that could save the lives of infants by providing natural warmth from the mother if used consistently during the first few hours after birth.” There are several factors that could impair the mothers’ ability to provide continuous KMC, including post-partum tiredness, sickness, hygiene care, routine postpartum checkups, essential newborn care and frequent diaper changes. Other factors that are hard to control and play a role in the infants’ body temperature include unregulated delivery room and postnatal ward temperatures in the resource-limited birth facilities. Visiting physicians from UAB continue to search for alternative options to help prevent hypothermia of infants in Zambia.

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Searching for Sustainable Solutions to the Physician Shortage Adequate GME Funding Continues to be a Concern By CINDY SANDERS

Complex problems rarely have simple solutions. Certainly that is the case with the looming physician shortage facing the United States. New research published last month by the Association of American Medical Colleges (AAMC) shows increasing shortages looming for both primary and specialty care. The new data outlined in the 2018 update of “The Complexities of Physician Supply and Demand: Projections from 2016-2030” provides a forecast based on a number of supply and demand scenarios, including an aging population on the demand side and heavier reliance on other physician extenders on the supply side. Recognizing it is impossible to accurately predict exactly how market forces will play out over the coming years, each supply scenario is paired with a demand scenario to create a projected shortfall range. Part of AAMC’s commitment to annually updating physician workforce projections, the latest report increased the forecasted physician shortfall to between 42,600 and 121,300 by 2030. This is up from last year’s report, which projected a

physician shortfall of 40,800 to 104,900 by that same year. The shifting demographics of the U.S. population continue to be a key driver of demand. “Our data shows by 2030, the U.S. population aged 65 and older will grow by 50 percent,” said AAMC’s Chief Public Policy Officer Karen Fisher. She added the supply side of the equation is impacted by several factors including the hours physicians are willing to work, the number of providers nearing retirement, Karen Fisher and the quantity of young physicians completing training to fill in those gaps.

Schools Step Up Allopathic and osteopathic medical schools have both seen increases in enrollment over the last several years as academic centers have pledged to help alleviate projected workforce shortages. According to AAMC data, there were 21,338 new enrollees in allopathic medical

schools for the 2017-2018 academic year, a 1.5 percent increase over the previous year. Total enrollment for 2017-18 was 89,904 students compared to 81,936 in the 201213 year, a nearly 10 percent increase over the last five years and closer to a 20 percent increase over enrollment a decade ago. The American Association of Colleges of Osteopathic Medicine (AACOM) saw first-year matriculation jump with a nearly 7 percent increase in fall 2017 enrollment over the prior year. Preliminary figures from AACOM placed 2017 total enrollment at 28,981, an all-time high for the 34 accredited colleges of osteopathic medicine in the United States.

ple, if a resident trained at a facility where Medicare made up 30 percent of the patient population, then the federal program would pay 30 percent of the physician’s GME cost. However, continued Fisher, “In 1997, Medicare placed a cap on that support … so for over 20 years, Medicare’s support has been capped at the number of residents in 1996.” For every resident above the hospital’s cap, she said, the facility has had to absorb that extra cost. “It’s like they are taking a cut every year by virtue of that cap,” Fisher added. For the most part, she continued, there have been slots available for graduates because hospitals have borne the additional training costs. In some cases, states have stepped in to help with additional funding, as well. However, Fisher said sustaining the current setup is an ongoing concern. “When clinical revenues get tight, we’re very concerned about the ability of teaching hospitals to continue to train residents above the cap,” she said. “It’s important that we continue to receive stable, predictable financing to offset the significant costs associated with training new physicians.”

GME Bottleneck While growing medical school enrollment is a positive step, Fisher and colleagues point out increasing the number of students won’t translate into more physicians and surgeons if there aren’t adequate training slots for graduates. “The Medicare program has been a key financer of graduate medical education,” said Fisher, who added Medicare historically funded GME on a proportionate share of a resident’s training. For exam-

(CONTINUED ON PAGE 18)

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Searching for Sustainable Solutions, continued from page 17

AAMC, along with AACOM, strongly supports legislation that would moderate the chilling effect the current cap has on physician training. “We’re asking for 3,000 residency positions each year for five years for a total of 15,000 residency positions,” noted Fisher. The bipartisan Resident Physician Shortage Reduction Act of 2017 (HR 2267, S 1301) was introduced last May but didn’t make it out of committee. However, Fisher said there might be another chance to gain some traction if Congress takes up infrastructure this year. “I think the physician workforce is an important infrastructure need for the health of our country,” she pointed out.

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Other Options AAMC officials have repeatedly stressed the need for a multi-pronged approach to addressing the physician shortage. While enrollment and GME are huge components to the solution, there are other factors being addressed, as well. “Overall, our modeling certainly looks at the role and growth of nurse practitioners, physician assistants and telehealth,” she said of utilizing teams and technology to extend the delivery system. AAMC also supports non-GME incentives and programs, including Conrad 30, the National Health Service Corps, loan forgiveness programs and Title VII/ VIII, which are used to recruit a diverse workforce and encourage physicians to practice in shortage specialties and underserved communities. Fisher said foreign-born physicians are another potential part of the solution and noted those trained outside of America must undergo a rigorous assessment before being allowed to practice in the United States. “They are an important source of physicians in this country,” she said. “Many of them tend to practice in rural and underserved areas,” she added of filling gaps in care. Additionally, AAMC has been a champion of increasing the physician workforce in a manner that embraces diversity and cultural competency to mirror the nation’s changing demographics and to work towards eliminating health disparities. Fisher noted the AAMC also has released several statements calling for healthcare workers with DACA status to be able to continue their education, training and research. Similarly, the organization has expressed concerns over executive actions on immigration and travel impacting researchers and clinicians. In an issue brief from March 17, 2018, the organization noted, “Because disease knows no geographic boundaries, it is essential that we continue to foster, rather than impede, scientific cooperation with clinicians and researchers of all nationalities as we strive to keep our country safe from all threats.” Fisher concluded, “We certainly support national security, but we believe this is an issue of national health security.”


The Art of Interviewing Applicants By Jane Ehrhardt

“If they have an email address of [email protected] on their resume, I’m not going to call,” says Jennifer Neal, administrator with Pulmonary and Sleep Associates in Birmingham. “Obviously you’re not thinking.” Red flags like these make trimming down the initial pile of resumes for a staff position at a healthcare facility easier. “If they only say the hire date on their resume, that tells me a lot,” says Tina Davis, practice administrator with Surgical Associates of North Alabama in Decatur. Davis, who oversees a staff of 14 and five physicians, says a recent hiring problem has been the lack of work ethic among the younger hires. “They’re more interested in their phone or their social life. They don’t have the initiative to do things on their own, to see what needs to be done and just do it.” To fill that skills gap, she began pairing younger new staffers with a mentor. “Someone on staff who has the experience to work with them and say here’s what to do and why and how,” Davis says. “But also to point out when you see this, go do that. To jump in and help without being asked.” Not only has it helped with task training and teaching initiative, but with melding them into the staff. “It gives the new person someone they can relate to right off the bat,” Davis says, which helps with retention and staff morale.

Social media may cause distractions for staff on the job, but it can be revealing when hiring. “Avoid making assumptions in prescreening,” Neal says. Bias and lack of context can create false scenarios in a hirer’s mind and lose out on a potentially good candidate. References can be equally biased. “Normally they give favorable reviews. But the reference may say enough between the lines that indicates they’re probably not a good employee,” says Greg Hulsey, CEO at Maynor and Mitchell Eye Center and Eye Surgery Center of North Alabama in Huntsville. Asking the referGreg Hulsey ence if the person is

eligible for rehire can be the most telling. “People won’t always answer that question, but sometimes they say no, and that’s enough of a red flag,” Hulsey says. Everyone agrees the most effective tool in the interview is the behavioral-based question. “I want to know specific examples of situations they have been in on the job and how they responded,” he says. “Not how they think they would respond to something.” The circumstances of the situation need not be in healthcare to be relevant. Hulsey had a candidate who had worked a bakery describe handling a disgruntled customer who destroyed their birthday cake while ranting at the counter. “The candidate talked about maintaining her composure, and working with the customer to get her a resolution on what she wanted,” Hulsey says. “That gave me a lot of insight

into someone who won’t panic in a stressful situation. I hired her, and she still is in a management position and doing well.” Hulsey also likes to involve a peer or a doctor in the interview process. “It not only gives a sense of buy-in from the staff or physician in the new hire,” he says, “but also involving a second person can give you insight into something you may have overlooked. “If you want to have your doctors involved in your interview process, it’s important you sit in on it or that you give them questions ahead of time. Then if they deviate in any way, you cut them off.” Physicians not trained in interviewing can inadvertently ask inappropriate and unlawful questions, such as where someone goes to church. The biggest hiring errors tend to derive from desperation. “Never hire someone simply to get a body in a position,” Hulsey says. “If you make a desperate hire and that person doesn’t work out, you will have to go through the same cycle again, which incurs costs for advertising and training the new employee.” Neal says that once she had been looking for months to fill a nursing position. One candidate interviewed really well. “She was fantastic. She’d just moved here and was a go-getter. Everything I needed, she had,” Neal says. They hired her. “But something had bothered me that I couldn’t put a finger on.” (CONTINUED ON PAGE 20)

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Alzheimer’s Association Sees Increase in Federal Support, continued form page 14 Conant said AIM has spent several years working on the bill, which reauthorizes the Missing Americans Alert Program through fiscal year 2022 and expands the program to include those with developmental disabilities. Introduced by Reps. Chris Smith (RNJ) and Maxine Waters (D-Calif.) in the House and Sens. Chuck Grassley (R-Iowa) and Amy Klobuchar (D-Minn.) in the Senate, the new law provides up to $2 million in grants each year to state and local agencies for programs to prevent wandering or locate missing individuals.

RAISE-ing Caregivers Up Yet another legislative win for the Alzheimer’s Association and AIM came earlier this year with passage of the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act. “From the Alzheimer’s perspective, we know there are more than 15 million caregivers providing unpaid care to individuals,” said Conant. The 2018 Facts and Figures report estimated these individuals provide 18.4 billion hours of care valued at over $232 billion. Research has shown caregivers of people with dementia report higher levels of stress, depression and worse

health outcomes than those caring for individuals without dementia. In 2017, these additional stressors led to Alzheimer’s caregivers incurring an extra $10.9 billion in health costs. Sens. Susan Collins (R-Maine) and Tammy Baldwin (D-Wis.) and Reps. Gregg Harper (R-Miss.) and Kathy Castor (D-Fla.) introduced the bipartisan legislation. The new law directs the Department of Health and Human Services to develop a national strategy to provide education and training, long-term services and supports, and financial stability and security for caregivers. Conant said her organization worked

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Providers & Care Planning Conant said the Health Outcomes, Planning and Education (HOPE) for Alzheimer’s Act that passed in November 2016 provides a funding mechanism for providers to be reimbursed for assessing and discussing a diagnosis of Alzheimer’s disease and available treatment and support options to improve or maintain quality of life. “Beginning in 2017 for the first time, people living with Alzheimer’s now have access to care planning with a medical professional, and it’s paid for by Medicare,” she said, adding the Alzheimer’s Association has a downloadable care planning toolkit for providers. For more information, go online to alz.org/careplanning. Moving Forward “The goal is to prevent or effectively treat Alzheimer’s by 2025,” said Conant. “We’re excited about our progress, but we know we have a long way to go.”

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closely with AARP to push for passage of RAISE, which was modeled off of NAPA. “It will require a plan to be updated annually,” Conant said. “It’s also going to create a National Family Caregiving Council to provide recommendations to the (HHS) Secretary.”

NEW

Six weeks later, the new nurse revealed she was pregnant and had the department of human resources visiting her for past issues with her children she had left behind in another state with an ex-husband. It took the advice of lawyers to be free from the desperate hire. “I should have trusted my gut, but I needed someone so bad, I hired her,” Neal says. As an alternative for administrators looking for help in hiring, Neal suggests using healthcare consultant firms. “Healthcare consultants that offer lots of different services—like billing and practice management—know what the criteria is for working in a healthcare office,” she says. “I have had good experiences with them.” The healthcare consultants handle advertising, drug screening, background checks and at least the first round of interviews. “The candidate doesn’t come to you before they’ve passed a series of steps, so it makes everything easier when you don’t have time,” Neal says. No matter the hirer’s experience, bad hires will occur and administrators should not give up on a good hiring process. “I don’t think there’s a process that’s foolproof,” Hulsey says. ”Sometimes you do all the things right and it still doesn’t work out.”


The Literary Examiner BY TERRI SCHLICHENMEYER

Sleep by Nick Littlehales c.2018, Lifelong Books; $15.99; 177 pages It’s 3:00 a.m., and you’re still awake. Bedbugs are the least of your worries. The TV is off, the lights are off, but your brain isn’t. What did that client mean when he said…? Do your managers really understand your mission? How can you boost profits? And without the new book, Sleep by Nick Littlehales, how can you finally get some shut-eye? So you missed a few zzz’s last night. No big deal, you’ll make it up, right? Wrong, says sleep coach Nick Littlehales. Nick Littlehales Lost sleep is lost forever, and research now indicates that poor sleep habits can lead to type 2 diabetes, obesity, burn-out, and family issues. Part of the problem, some say, is with cell phones and blue light, which affects us, biologically. Littlehales avers that light from electronic devices can disrupt sleep

and it’s true that we’re sleeping less than our forebears did sixty years ago, but blue light isn’t entirely to blame. Instead, we’re losing sleep because we’re more stressed, and focused on hours, rather than cycles. In the past, we referred to people as “larks” and “owls,” depending on their natural wake-sleep patterns, but Littlehales says your chronotype is what matters today. Whether you’re an “AMer” or a “PMer” depends on your personal 24-hour body clock. AMers, for instance, get their deepest sleep between 2;00 and 3;00 a.m., while PMers run a few hours behind. Knowing your chronotype will help you get your best sleep by determining when to start your bedtime slow-down process and when you should rise. And by the way, that up-shower-brush-donut-out-thedoor routine isn’t good for you. Furthermore, every adult should

know how to nap, surreptitiously and quickly; how to lie in bed for optimal sleep; what to do to if you wake in the middle of the night; how to snooze without a pillow; and how to make a sleep kit. And buying a bed? Eh, you’ve been doing it all wrong. No one should be surprised that science has entered your bedroom, laid on your mattress, and looked at your blankies. And yet, there are some surprises inside Sleep. First, you may scoff at the idea of a sleep coach, but author (and sleep coach) Nick Littlehales has spent much of his life on mattresses in sales and sports. What he espouses for elite athletes he works with, he says, can extend to the enhancement of performance in business – which is good news, but there are things missing here.

Littlehales advises parents and comforts sleep-tilnoon teens. He offers do-able changes and make-sense fixes, but he does not adequately touch upon issues related to aging. Older readers may, therefore, feel left out; those who are over business books with sports focus should also take note. Even so, managers may find that this book’s advice is worth a try, despite that it may mean a major paradigm shift in thinking and protocol and it might feel weird, at first. If you’re still tired of being tired, get your jammies and try getting some Sleep. Terri Schlichenmeyer is a professional book reviewer who has been reading since she was 3 years old and she never goes anywhere without a book.

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RESEARCH NOTES

Drinking Sugary Drinks may be Associated with Greater Risk of Death Adults who are 45 years old or older and who consume large amounts of sugary beverages, including soft drinks, fruit drinks and fruit juices, may have a higher risk of dying from heart disease or other causes, compared to those who drink fewer sugary drinks, according to new research. The researchers found that people who drink 24 ounces or more of sugary beverages each day have twice the risk of death from heart disease than those who drink less than one ounce of sugary drinks per day. The study also found an increased risk of death from all causes, including other cardiovascular conditions. Study co-author Suzanne Judd, PhD, associate professor of biostatistics at the UAB School of Public Health, says the research is important for both consumers and health care providers. “Health care providers should talk to their Judd, patients about intake of Suzanne PhD sugary and sweetened drinks and foods,” Judd said. “Reminding them to limit sweetened drinks and foods to no more than 400 total calories

per day is ideal. If their patients aren’t sure what types of drinks and foods to limit, providers should refer them to a nutritionist to get help with their diets.” Researchers used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, which is based at the UAB School of Public Health. The researchers focused on foods and beverages with added sugars. Sugar-sweetened beverages included sodas and fruit drinks. Sugar-sweetened foods included desserts, candy and sweetened breakfast foods, as well as foods to which calorie-containing sweeteners such as sugars or syrups had been added.

Big-Data Helps Define the Burden of Sarcoidosis Physician-scientists from UAB using big-data recently summarized in the Journal of the American Heart Association the prevalence of cardiovascular manifestations, rates of defibrillator placement (ICD) and predictors of in-hospital mortality in sarcoidosis — a disorder that affects multiple organs. Sarcoidosis is a systemic illness with a strong propensity to involve the cardiovascular system. It is the growth of tiny collections of inflammatory cells — granulomas — in different parts of the

body, most commonly the lungs, lymph nodes, eyes and skin. Utilizing the largest in-patient database — the National Inpatient Sample — a team of researchers identified more than half-million sarcoidosis hospitalizations without any history of ischemic heart disease from 2005 through 2014 in the United States. “We conducted a retrospective study to determine trends of hospitalizations and outcomes in sarcoidosis during 2005 to 2014,” said UAB’s Nirav Patel, MD. “We examined rates of ICD, cardiac resynchronization therapy, permanent pacemaker placement, and factors associated with in-hos- Nirav Patel, MD pital mortality. We also examined racial disparities in outcomes in sarcoidosis hospitalizations in a propensity matched subgroup. “In previously conducted studies, there was a lack of assessment of the prevalence of cardiovascular manifestations, and trends of ICD implantation in sarcoidosis hospitalizations. Sarcoidosis with naturally accompanying cardiovascular manifestations has more complications, and a greater risk of sudden death. Thus, there is a considerable interest in identifying sarcoidosis with naturally accompanying cardiovascular

manifestations.” Researchers have found the rate of hospitalization for sarcoidosis has increased, and in-hospital mortality associated with sarcoidosis decreased from 2005 to 2014. Heart failure and arrhythmias were the most prevalent cardiovascular manifestations in sarcoidosis, followed by pulmonary hypertension, non-ischemic cardiomyopathy and conduction disorder. Conversely, increasing hospitalizations with sarcoidosis, rates of ICD implantations were low — less than one percent — and have not shown any upward trend from 2005 through 2014. Additionally, African-Americans with sarcoidosis had higher in-hospital mortality and cardiac arrest compared with Caucasians. “We hope to inform clinicians that the co-occurrence of cardiovascular manifestations in sarcoidosis could be a leading cause of death,” said Pankaj Arora MD, assistant professor in the UAB Division of Cardiovascular Disease. “Our investigation highlights that aggressive primary and secondary prevention of co-morbid cardiovascular and pulmonary conditions is critical for patients with sarcoidosis.”

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Celebrating 50 years of collaboration, partnership, and transplant success.

Eric Willis, 2016 Transplant Recipient Since 1968, physicians have entrusted UAB’s Comprehensive Transplant Institute with their patients. Patients like Eric, who was referred to the experts at UAB despite being from out of state. We worked directly with his doctor throughout the process, and just like so many other times over the past 50 years, it was a successful transplant that ultimately led to a celebration for Eric, his referring physician, and all of us at UAB. To join the celebration and learn more about our latest research, results, or patient referrals, visit UABMedicine.org/ReferTransplant.

Celebrating 50 years of Transplant Success UABMEDICINE.ORG/REFERTRANSPLANT

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Rare Eye Cancer has Affected Some Women who Attended Auburn in the 1980s By Elizabeth A. Steele, OD, FAAO

A rare cancer of the eye known as uveal melanoma has affected a specific demographic, mainly women, who attended Auburn University in the late 1980’s and early 1990’s. Uveal melanoma is the most common cancer in the eye, but overall its incidence is extremely low, known to affect only 4.3 per 1 million people in the US. While these cancers are uncommon, they can lead to unfortunate outcomes including total removal of the eye, and even aggressive cancers spreading throughout the body, making it crucial to catch them early. No one yet knows why this disease has occurred in this group of people. However the rate of incidence is too high for it to be a coincidence. Given the uniqueness of the presentation, and the implication that there could be a link to location and potential environmental factors, it has garnered the attention of experts in uveal cancers across the country. A special conference was held in early 2018 in Philadelphia, specifically to collaborate regarding these patients. The uvea is the pigmented part of the eye, made up of three different structures: the iris, or colored part of the eye, the ciliary body which produces the fluid inside the eye, and the choroid, responsible for much of the blood supply to the back of the eye. Examining these structures requires a detailed eye exam using a microscope and

pupil dilation. The iris is the least common of the three structures to be affected by melanoma, and iris melanomas are the least likely to metastasize. People thought to be most at risk are Caucasian, fair-skinned, tan easily and have light-colored eyes. Choroidal melanomas are the most common type of uveal melanoma. These growths initially present as a benign nevus that can be examined during a dilated eye exam (as seen in the image below). And while malignancy is not common, its consequences can be severe. As with a freckle on the skin, these in the eye should be monitored carefully for growth, change of any kind, and other characteristics that indicate potential cancer. Specific to choroidal melanomas, the most common site of metastasis is the liver, and these cases are almost always fatal. It is easy to assume that your eyes are healthy if your vision is normal. But many diseases can occur in the eye without initially impacting vision. In early and even late stages of these cancers, vision may be totally unaffected. Patients may have no symptoms whatsoever, highlighting the need for regular, dilated eye exams. A detailed eye health exam is more than what most people realize – there are many different components, and various instruments are needed. Additional special testing may be required in many cases. For example, when an optometrist or ophthalmologist notices an iris or choroidal

growth, specific imaging technology such as ultrasound and optical coherence tomography (OCT) may be necessary to determine risk and the need for follow-up. An online eye exam, on the other hand, consists of one test – refraction. Refraction is the procedure we do to determine the glasses prescription for a patient – it does not address eye health or examine the eye at all. Not to mention, online refractions have so far been found to be less accurate and more likely to lead to unsatisfied patients. The American Optometric Association recommends that healthy, asymptomatic adults receive an eye exam every two years. Those with symptoms, risks such as family history of eye disease, or systemic disease that put the eyes at risk, should seek care more frequently. If you or someone you know attended Auburn University during that time, it is especially important to get your eyes checked right away. For more information and to keep up with the affected individuals, you can go to the following Facebook Page: https://www.facebook.com/search/ top/?q=auburn%20ocular%20melanoma%20page Elizabeth A. Steele, OD, FAAO practices with UAB Eye Care.

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Swanson Named National Optometric Educator of the Year Mark Swanson, OD, MSPH, FAAO, professor in the UAB School of Optometry, has been named the American Optometric Association’s 2018 Educator of the Year. A faculty member in the School of Optometry since 1986, Swanson has written and/or Mark Swanson, co-written more than 45 OD, MSPH, FAAO papers in his 30-year tenure and most recently was awarded the UAB President’s Teaching Award for Optometry. An accomplished researcher, he has participated in more than a dozen clinical investigations and FDA trials. Beyond the School of Optometry classrooms, Swanson has presented more than 200 continuing education classes to optometrists. Swanson is an active member of the Alabama Optometric Association and the American Academy of Optometry and contributes his time and services locally to organizations including Camp Seale Harris’ Vision Service Project for diabetic children, Cahaba Valley Health Care and Project OASIS, a statewide vision rehabilitation program for the elderly.

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David Cox, MD, MSCAI Named 2018-19 President of SCAI David A. Cox, MD, MSCAI, director of the cardiac catheterization laboratory at Brookwood Baptist Health and practicing at CVA, has assumed office as 2018-19 president of the Society for Cardiovascular Angiography and Interventions (SCAI). SCAI introduced David A. Cox, MD, MSCAI a new slate of officers during its 2018 Scientific Sessions in April. Cox will oversee the development and execution of SCAI’s newly cemented four key strategic initiatives: community and membership; quality and research; education and; marketing and communications. He will also focus on aligning external partner relationships to help better deliver on the Society’s mission. “SCAI is focused on a new strategic plan put forth by our Board of Trustees and our Executive Director, Francesca Dea,” Cox said. “It is an honor to serve as president of SCAI during these exciting times, and I look forward to contributing as SCAI tackles the new challenges ahead and demonstrates its worth to all members, new and old.” Cox graduated from the University of Chicago Pritzker School of Medicine

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and completed his residency training at UAB. After serving four years in the National Health Service Corps, he returned to UAB for his general cardiology and interventional fellowships. Prior to his position at CVA and Brookwood Baptist Health, Cox practiced in a large cardiology group in Charlotte, NC for over a decade, where he led his interventionalists to highenroller positions in many clinical trials and served as a national primary investigator for two interventional cardiology devices. In 2006, he joined a hospitalbased cardiology practice in Allentown, PA, where he served as director of clinical research for cardiology and associate director, cardiac catheterization laboratory. A devoted member for more than two decades, he served as the SCAI budget and finance chair and treasurer for five years, after co-chairing the SCAI Education Committee.

Brookwood Receives Award for Stroke Care Brookwood Baptist Medical Center, part of the Advanced Neuroscience Network (ANN), earned the American Heart Association/American Stroke Association’s “Get With The Guidelines®Stroke” Gold Plus Quality Achievement Award with Target: StrokeSM Honor Roll-Elite. The award recognizes the hospital’s commitment to providing the most appropriate stroke treatment according to nationally recognized, research-based guidelines based on the latest scientific evidence. Hospitals must achieve 85 percent or higher adherence to all “Get With The Guidelines-Stroke” achievement indicators for two or more consecutive 12-month periods and achieve 75 percent or higher compliance with five of eight Get With The Guidelines-Stroke Quality measures to receive the Gold Plus Quality Achievement Award.

To qualify for the Target: Stroke Honor Roll-Elite, hospitals must meet quality measures developed to reduce the time between the patient’s arrival at the hospital and treatment with the clotbuster tissue plasminogen activator, or tPA, the only drug approved by the U.S. Food and Drug Administration to treat ischemic stroke. Brookwood Baptist’s achievement of the Target: Stroke Honor Roll-Elite means the stroke team

treated 75 percent or more of acute ischemic stroke patients with IV tPA within 60 minutes of their arrival to the hospital. To earn the Stroke Gold Plus Quality Achievement Award, Brookwood Baptist’s Primary Stroke Center met specific quality achievement measures for the diagnosis and treatment of stroke patients at a set level for a designated period.

Ashley Martin, PA-C speaks to the conference.

Urology Centers CME Conference Urology Centers of Alabama hosted their annual CME conference in March at the Grand Bohemian Hotel in Mountain Brook. This year’s focus was “Urology Fundamentals: There’s more to Urology than just Catheters!” Topics included a Patient’s Journey through the UCA comprehensive prostate cancer center, urological issues facing women, cutting edge minimally invasive therapies, male infertility, and other male sexual health issues. Taylor Bragg, MD, Brian Christine, MD, Jason Biddy and Marcie Prescott served as the conference planning committee. The event was attended by over 115 physicians, mid-level providers and nurses and was kicked off with a reception for physicians, attendees, and exhibitors on the Friday evening prior to the conference. “This conference was a great opportunity for us to educate PCP’s regarding a broad range of topics affecting patients,” Taylor Bragg, MD said. “We strive for collaboration between UCA and the PCP’s and this is an excellent opportunity for us to discuss the most up to date Urologic treatments. We are already planning the agenda for next year’s conference.” “We enjoy hosting this conference as it allows the UCA team to provide information of value to the PC physicians in diagnosing and treating common urologic problems,” Brian Christine, MD said. “We wanted to help Primary Care practitioners understand when to refer and to enlighten our audience as to current trends in Urology, and how we are leading the way.”

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Infirmary Health Becomes Affiliate of the UAB Health System Infirmary Health in Mobile has become an affiliate of the UAB Health System. “The affiliation links two outstanding health care organizations,” said Will Ferniany, PhD, CEO of the UAB Health System. “This affiliation will extend the clinical expertise and research capabilities of UAB to southwest Alabama,” said Mark Nix, president and CEO of Infirmary Health. The Infirmary Health System is a four-hospital system headquartered in Mobile. Representing more than 700 physicians and 5,000 employees, it includes Mobile Infirmary, Thomas Hospital, North Baldwin Infirmary and Atmore Community Hospital. The two health systems will collaborate in a number of areas, include the burgeoning field of telemedicine. Other areas of collaboration may include oncology, and in the handling of complex cases in fields such as neurology, neurosurgery and neonatology. “Additionally, we will work together on economies of scale to aid in controlling health care costs,” Nix said. “We are already in conversations to expand the presence of UAB specialty physicians in Infirmary Health facilities to cover underserved medical specialties throughout our communities.” UAB may also work with Infirmary to create exposure to potential medical residency rotations or additional residency positions for existing programs. The affiliation will also link UAB and community physicians for increased opportunities for collaboration regarding quality patient care. “We were committed to identifying a clinical partner in the Mobile Bay region,” Ferniany said. “UAB does certain procedures — in cancer and transplantation, for example — that are not available anywhere else in Alabama. This affiliation will improve access for patients in Mobile to those procedures at UAB when necessary, while continuing to get the bulk of their medical care at home.” The arrangement could also show benefit in supply chain and revenue cycle management, along with recruitment and incentive programs for medical students and residents.

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Colleen Tobe-Donohue, DO Joins Grandview Medical Staff Colleen Tobe-Donohue, DO has joined the medical staff of Grandview Medical Center. She is board certified in Family Medicine by the American Board of Family Medicine. Donohue is in practice with Grandview Colleen TobeMedical Group and will Donohue open the network’s newest location in Vestavia Hills. Donohue received her undergraduate degree from Samford University and her Doctorate of Osteopathic Medicine degree from Pikeville University School of Osteopathic Medicine in Pikeville, Kentucky. She completed her residency with St. Vincent’s East Family Residency Program, and has been in private practice in the Birmingham area since 2012. Donohue is a member of the American Academy of Family Physicians and the American Osteopathic Association.

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Brookwood is First in State to Provide Live Webcam for Parents of NICU Infants Brookwood Baptist Medical Center has implemented a video-only webcam system designed for families to see their hospitalized baby whenever they wish. The system, called NICVIEW, is distributed by the Natus Medical Incorporated. A bedside camera transmits live visual images of the baby through a secure system that families can access with their unique code and display on any internet-accessible device. The cameras run on the hospital’s network and do not interfere with the technology otherwise in use in the unit. NICU staff is trained on the use of the system and have the option of turning off the camera when requested by the family. “We recognize how stressful it is for parents to have a hospitalized infant,” said Keith Parrott, CEO of Brookwood Baptist Medical Center. “The addition of this technology to our Level III NICU underscores our goal of providing the highest level of patient care.”

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MAY 2018 • 27


Connected care. Superior outcomes. HealthSouth Corporation and Encompass Home Health & Hospice have combined our post-acute strengths into Encompass Health. As part of a nationwide network, we are redefining expectations for how providers work together to create better patient experiences and deliver unparalleled outcomes. As a coordinated care team, we set the standard for the future of rehabilitation. E NCOMPA SSHE ALTH .COM/MONTGOME RYRE HAB

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