1. Healthcare

February 2015
8
Options for
Extracorporeal
Membrane
Oxygenation
Duke’s successful
program is one of the
largest in the country
Micropractices:
Simplifying Patient Care
Part 2
4
Posterior Approach
to Adrenals
Proves Superior
6
Brachytherapy 13
Improves Cervical
Cancer Care
Clinical Practice Today
Duke Medicine Marketing
and Communications
Editor
Mary Jane Gore, MA
Publisher
Med-IQ
Editorial Management
Laura Espinoza
Lisa R. Rinehart, MS, ELS
Writers
Frank Celia
Meredith Kleeman
Emily Paulsen
Shelly K. Schwartz
Eric Seaborg
in Clinical Practice Today
4
Micropractices: Simplifying Patient Care
6
Posterior Approach to Adrenals Proves Superior
We strive to transform medicine and
health locally and globally through
innovative scientific research, rapid
translation of breakthrough discoveries,
educating future clinical and scientific
leaders, advocating and practicing
evidence-based medicine to improve
community health, and leading efforts
to eliminate health inequalities.
Preventing Unintentional Fraud
8
Options for Extracorporeal
Membrane Oxygenation
10
Keep Patients Coming Back
11
Slowing the Progression of Diabetic
Kidney Disease
12
Clinical Practice Today from Duke Medicine
Early detection, appropriate lifestyle changes, and
pharmacologic treatment can lead to a cure
Brachytherapy Improves Cervical Cancer Care
14
Closing the Gap on Unpaid Patient Balances
15
New Treatment for Wet Macular Degeneration
©2015 Duke Medicine. All rights reserved.
2
Gout Is Curable With Proper Intervention
13
Materials may not be reprinted without
written consent from the publisher.
If you wish to be removed from the mailing
list, please email [email protected] or
call 866-858-7434.
Increase patient satisfaction with these key strategies
A new study is evaluating a telehealth approach for the
prevention of kidney disease
Duke University Hospital, Durham, NC
Duke Regional Hospital, Durham, NC
Duke Raleigh Hospital, Raleigh, NC
Duke University, 3100 Tower Blvd., Suite 1008
Durham, NC 27707-2575
Keep your practice safe by watching out for these
common areas of health care fraud
Duke’s successful program is one of the largest in
the country
To refer patients, call 800-MED-DUKE.
For more details on the services we
offer your patients, please visit
DukeMedicine.org.
A new surgical technique leads to enhanced
postoperative outcomes
7
About Duke Medicine
U.S. News & World Report consistently
ranks Duke University Hospital in
its Honor Roll of top hospitals in the
United States.
This concluding article in our 2-part series offers
strategies for establishing a micropractice
Gynecologic brachytherapy confers higher survival rates
than standard treatment alone
Reduce your incidence of unpaid balances by implementing
these helpful tips
Approximately two-thirds of patients with treatmentresistant disease can benefit from this new procedure
To learn more or
to refer a patient,
call 800-MED-DUKE
News Briefs
New Guideline for Hip
Fractures in the Elderly
A new guideline on diagnosing and treating hip
fractures in patients aged 65 years and older
emphasizes the importance of reducing post­
operative delirium, a common side effect of
hip-fracture surgery. Patients who experience
this side effect are less likely to return to their
pre-injury level of function and have an increased
risk of mortality.
Recently released by the American Academy of
Orthopaedic Surgeons, “the guideline provides
evidence that supports the best care for this
growing segment of patients,” says Steven A.
Olson, MD, FACS, a professor in Duke Medicine’s
Department of Orthopaedic Surgery who served
on the work group that developed the clinical
practice guideline.
The guideline recommends using preoperative
regional analgesia to reduce pain and performing
hip-fracture surgery within 48 hours of hospital
admission. Olson says the guideline was
necessary because hip fractures are costly and
increasing among older patients as the prevalence of
osteoporosis rises. (Image above shows an x-ray
of an elderly patient with a hip fracture.)
Ten Oncologists Join
Duke in Wake County
Ten oncologists, most from Cancer Centers of
North Carolina, joined Duke Cancer Institute’s
Wake County team this fall: medical oncologists
Neeraj Agrawal, MD, William Berry, MD, Elizabeth
Campbell, MD, Maggie Deutsch, MD, Amit Mehta,
MD, and Steve Tremont, MD; gynecologic oncologist Monica Jones, MD; and radiation oncologists
February 2015
John Reilly, MD, Lewis Rosenberg, MD, and Scott
Sailer, MD. They will practice at Duke Cancer Center
locations in Wake County, including Raleigh and
Cary. For appointments, call 919-862-5400.
New Drugs Target
Midlife Symptoms
Several new hormone-replacement agents are
coming onto the market, says Alison Weidner,
vice chair for clinical affairs in OB/GYN at Duke.
“Now there are more targeted therapies for a
constellation of menopausal symptoms, such as
forms of estrogen replacement that can stimulate
the vagina to thicken its walls without affecting
breast tissue,” Weidner says.
Some of the new formulations include an
anti-anxiety drug that mitigates hot flashes; an
oral non-estrogen pill that relieves painful intercourse; and conjugated estrogens/bazedoxifene
that reduce the risk of uterine cancer and mitigate
hot flashes and vaginal dryness.
Updates on the new pharmacology for midlife
women and other topics will be discussed in
depth at the Midlife Matters Conference on April
11, 2015, in Raleigh. For more information about
this CME-certified course, call 877-707-2904 or
visit www.dcri.org/events/stronger-together.
3
PART 2
Micropractices:
Simplifying
Patient Care
By Emily Paulsen
In this concluding article of our 2-part series, we explore factors that should be considered
when establishing a micropractice. Part 1 (see the Dec. 2014 issue) examined the conditions
that led to the micropractice model; part 2 will help you determine whether this approach
might work for you.
When staffing challenges and productivity
pressures feel overwhelming, it’s easy to start
daydreaming about going solo to focus on the
foundation of medical practice: the patientphysician relationship. By cutting overhead,
some doctors have been able to establish “micropractices,” which consist of little more than the
doctor, the patient, and a computer.
Many doctors who have gone this route report
closer patient relationships, more time for family,
and renewed joy in their profession. But even
those who have met success in the micropractice
model readily admit that it’s not for everyone
or every situation.
“It takes a special type of physician for this,
someone with a lot of confidence, energy, and
vision,” says Mary Pat Whaley, a practice management consultant who specializes in setting up
solo and two-physician practices. It also helps
4
Clinical Practice Today from Duke Medicine
to be a tech-savvy, “take charge” person who is
comfortable with some degree of risk.
“To practice this way takes a leap of faith,” admits
John Brady, president of Ideal Medical Practice,
a nonprofit organization that provides technical
support for physicians exploring or practicing
in this model. Brady took the leap in 2003 and
remains happy with his Virginia-based solo
practice, The Village Doctor.
Doing the Math
Determining whether this practice model will
work takes some strategizing and calculating.
The right personality is only part of the equation.
Location, specialty, and local economic climate
are also factors. “We have to understand where
they are going to practice, what their specialty is,
and whether the community will support them,”
says Whaley.
Primary care may be better suited to the
micropractice model than specialty care and
procedure-based care, which may require a
larger referral base and patient population. But
Whaley warns against making such generalizations. Determined physicians can find ways to
make solo practices work even when the odds
are against them. For example, some physicians
move to less-expensive areas, whereas others
avoid high rents by starting a “house-calls only”
practice or renting space from another practice.
Some areas greatly need niche specialties such as
pediatric endocrinology or fibromyalgia management. Whaley remembers a surgeon who set up
a micropractice and performs his surgeries at a
hospital. He sees patients before and after the
procedure in an examination room that he rents
from other practices 1 day a week.
The local economic climate—including the
cost of living and income potential—plays an
important role. By reviewing personal expenses
(eg, mortgage or rent, food, transportation, child
care), physicians can determine their minimum
income require­ments. Then they can research
local reimbursement rates, malpractice premiums,
and rental costs to figure out how the numbers
add up. Both Brady and Whaley recommend
setting aside at least 5 to 6 months’ worth of
living expenses to cushion the financial blow of
starting a new practice. A physician who is right
out of residency and carrying a lot of student debt
probably isn’t a good candidate for this model.
Low Overhead Setups
When working with a client, Whaley makes
projections for 2 or 3 different practice setups
to see which plays out best. The strict onephysician, one-computer micropractice model
may offer the lowest overhead and quickest
financial return, but most of Whaley’s clients go
with a trimmed-down traditional practice of one
physician and one assistant or join forces with
February 2015
another physician. Some clients are interested
in making the practice a family affair: a nonphysician spouse runs the administrative side of
the office and the physician focuses on patients.
The key is to come up with a plan that keeps
overhead low. Brady recommends questioning
just about everything in a typical practice to
determine what’s absolutely necessary to the
physician-patient relationship.
Processing insurance and interacting with insurance companies could take 3 hours or more of a
physician’s time each week and can significantly
cut into direct patient care and annual revenue.
Direct pay, cash only, and other self-payment
structures may save time and money but can
reduce the potential patient population and make
it difficult to ramp up a practice, Brady says. (He
opted to streamline his processes and continue
accepting insurance.)
Technology plays an outsized role in this type
of practice. Brady thinks of his electronic health
record (EHR) as an electronic employee that helps
with scheduling, billing, and patient communications. Most EHR packages are now certified for
Meaningful Use, and the emergence of cloudbased technology has significantly lowered the
price for small practices. “You can get a reasonably
priced or free EHR that will work fine for a small
practice,” Brady notes.
Although many physicians turn to a consultant
to crunch the numbers, Brady encourages doctors
to hammer out a business plan on their own.
“You need to know the ins and outs before going
in,” he cautions. Brady provides his own business
plan on his Web site (www.thevillagedoctor.com)
and invites physicians to use it as a starting
point for their own practice. He also refers
people to Ideal Medical Practice’s Web site
(www.impcenter.org), which offers technical
and moral support throughout the process.
5
Posterior Approach
to Adrenals
Proves Superior
Posterior retroperitoneoscopic adrenalectomy
(PRA) is a recently developed surgical strategy for
removing adrenal-gland masses through the back,
and it is proving helpful to many patients. Now,
a clinical trial published in the Annals of Surgery
has shown that this novel, minimally invasive
approach has demonstrated outcomes that are
superior to lateral transperitoneal laparoscopic
adrenalectomy and open transperitoneal surgery.
Patient outcomes were found to be better with
the PRA approach, which conferred a shorter
operation, less blood loss, less postoperative pain,
and a quicker recovery.
Sanziana Roman, MD, a Duke endocrine surgeon,
says she is now seeing more referrals for this
uncommon procedure. Roman, who is among
the first to perform this procedure in the United
States (US), says that most adrenal patients with
benign neoplasms can be considered for PRA. “It is
well tolerated and reduces pain and recovery time
for patients because the surgeons do not cut as
far into the body.” PRA is helpful for patients with
tumors on both adrenal glands, which happens
in up to 10% of cases. This approach also benefits
patients who have previously had extensive
abdominal surgery.
Referrals for PRA are rising as the number of
6
Clinical Practice Today from Duke Medicine
adrenal incidentalomas rises, says Julie Ann Sosa,
MD, who heads endocrine surgery at Duke.
Experts must evaluate unknown adrenal masses
to rule out a pheochromocytoma, a usually benign
tumor that can release dangerously high catecholamine levels during biopsy or surgery, and to rule
out hypercortisolism and hyperaldosteronism.
Adrenal masses can require close monitoring.
If an adrenal mass measures more than 4 cm,
produces hormones, or grows rapidly, a patient
will probably need surgery. PRA is not generally
used for malignant adrenal masses.
Adrenal masses represent just one type of neoplasia
treated by the newly formed Duke endocrine
neoplasia group made up of endocrinologists,
endocrine surgeons, radiologists, pathologists,
oncologists, geneticists, and other specialists. The
team works together to diagnose and treat thyroid
nodules, thyroid cancer, goiters, overactive parathyroid
glands, adrenal tumors, neuroendocrine tumors
of the pancreas, and genetic endocrine dis­­orders,
including multiple endocrine neoplasia types 1
and 2, says endocrinologist Jennifer Perkins, MD.
To refer a patient, call 800-MED-DUKE. (Image
above depicts an adrenal gland tumor.)
Preventing
Unintentional Fraud
By Frank Celia
One of the hallmarks of the Affordable Care
Act era is a heightened focus on billing, audits,
and false claims. With this increased focus on
oversight, clinicians may be surprised to discover
that they run a risk of being accused of financial
improprieties, even in the absence of fraudulent
intent. Here are a few trending issues that could
expose clinicians to the perception of impropriety,
potentially warranting extra caution.
Laboratory Reimbursement. Some laboratories
pay practices to package, collect, or otherwise
process specimens, and—in certain cases—to
gather specimen-related patient data. Last
summer, the Office of Inspector General (OIG)
issued a fraud alert warning that such arrangements may violate the anti-kickback statute
(ie, the Stark law). “The government is saying
this amounts to paying for referrals,” says Alice
G. Gosfield, JD, a Philadelphia-based health care
attorney. Although reimbursements that stay
within “fair market value” are allowed, prevailing
fees for such services are so low that it’s probably
best to avoid these arrangements altogether.
a rigorous audit within a month or two (under
new rules, federal overpayments automatically
become “false claims” after 60 days). In addition,
using the “cut and paste” function during transcription can put practices at legal risk. Many EHR
programs allow this function to be shut off, which
is an approach recommended by Rachel V. Rose,
JD, MBA, a Houston-based attorney.
PODs. Last summer, the Department of Justice
brought false-claim charges against a physicianowned distributorship (POD) in California.
Because these types of companies sell medical
devices, the OIG has called them “inherently
suspect” under the anti-kickback statute.
Additional crackdowns on PODs could also open
the door to patient and government lawsuits
against hospitals that buy from them.
Waiving Co-Pays. Allowing patients to forgo
insurance co-pays is riskier than ever. Payers
want to ensure that these fees get collected
because they discourage patient overutilization.
If you decide to waive co-pays, it should be
EHR Snafus. As more practices transition to
EHRs, a few bugs have started to emerge. For
starters, some EHR software programs tend
to overbill. If you have a new system, conduct
February 2015
done on a case-by-case basis, not routinely.
Additionally, make sure to document that the
fees were waived because of the patient’s
financial needs.
7
A Duke extracorporeal membrane oxygenation machine.
Options for Extracorporeal
Membrane Oxygenation
By Eric Seaborg
Duke’s successful program is one of the largest in the country
Patients hospitalized with certain heart and
lung issues no longer need to struggle with
the challenges of remaining bedridden with a
ventilator—not even those with conditions severe
enough to warrant a transplant. Duke’s extracorporeal membrane oxygenation (ECMO) program
offers patients with such issues the ability to stay
ambulatory, which provides a variety of benefits.
8
physical therapy or walk around the unit,” says
Mani Daneshmand, MD, a cardiovascular and
thoracic surgeon. “We had one patient who was
practically jogging through the unit on ECMO.”
Essentially a portable version of a heart-lung
machine, ECMO provides many advantages over
ventilators, which require a breathing tube and
operate with a high level of pressure that can
damage the lungs. ECMO patients can be awake
and active while the machine takes over the functions of the lungs or both the heart and lungs.
This level of portability also means that patients
can be transported safely to Duke from hospitals that offer ventilator-style treatment only.
Daneshmand cites the case of a patient who
could not get off the heart-lung machine after
heart surgery. The patient’s heart surgeon said
that nothing more could be done. “We put the
patient on ECMO, then transported and took the
patient to the operating room,” Daneshmand
says. The patient was back at home less than
1 month later.
The 20-pound machine can be placed on a cart
to accompany a mobile patient. “Patients can do
The Duke ECMO team can transport patients from
anywhere in North Carolina, southern Virginia, and
Clinical Practice Today from Duke Medicine
northern South Carolina via Life Flight ground
transport, and some patients have also arrived by
air. During transport, the patient receives comprehensive medical support from a 7-person team
that includes a surgeon, a perfusionist, nurses,
and an emergency medical technician.
Daneshmand says that part of Duke’s success can
be attributed to surgeons who develop their own
unique approaches, particularly regarding placement
of cannulas. For instance, in veno-venous ECMO,
the machine returns oxygenated blood to a vein
to relieve work done by the lungs. Veno-arterial
ECMO returns the oxygenated blood to an artery at
a physiologic pressure to
provide both breathing and
hemodynamic support.
Duke has a 91%
survival-to-discharge
rate for adults who use
respiratory services only
compared with an ELSO
benchmark rate of 56%.
As with any complex
procedure, high volume
and collective experience
are key ingredients to
success. Duke has one
of the largest ECMO
programs in the country,
treating more than 75
patients a year who
have a wide variety of
conditions. The program has been designated
as a Center of Excellence by the Extracorporeal
Life Support Organization (ELSO), which sets
quality benchmarks that the Duke ECMO program
has exceeded.
One particularly noteworthy example is Duke’s
91% survival-to-discharge rate for adults who
use respiratory services only compared with an
ELSO benchmark of 56%. Duke’s overall ECMO
outcomes are also well above the averages for
other ELSO member institutions (Fig 1).
Fig. 1. Survival-to-Discharge Rate for All
ECMO Patients.
66%
71%
62%
48%
Neonatal & Pediatric
ELSO Average
Adult
Duke
ECMO = extracorporeal membrane oxygenation; ELSO = Extracorporeal
Life Support Organization.
Inclusive of all neonatal, pediatric, and adult ECMO patients. Data
from 2008-2012.
February 2015
Some institutions return
this blood into the femoral
artery, and some open the
patient’s breastbone to
insert a cannula into the
aorta. Typically, both methods make it difficult to
impossible for a patient to be ambulatory.
“At Duke, we make a small incision in the right chest
and put all the cannulas in directly through that
small incision,” Daneshmand explains. “That does a
couple of things. One, it nicely unloads the heart
and lungs and gives them time to recover. Two, it
puts the blood directly back into the aorta, following
the body’s natural flow. Putting it into the femoral
artery means the blood has to flow backward.”
“The big selling point of our ECMO program is that
we have a lot of experience. We can ambulate
these patients to prevent their physical debilitation
and offer them many options,” Daneshmand adds.
“If they don’t recover their heart or lung function,
we can transplant them. We can put in mechanical circulatory support, like a left-ventricular assist
device (LVAD). We have options that are not
available at many other institutions.”
Duke surgeons have considerable experience with
these options: the lung transplant program is the
largest in the country, performing more transplants
than any other center in 2013; the LVAD program is
the third largest; and the heart transplant center
is the fifth largest.
9
Keep Patients
Coming Back
By Meredith Kleeman
Customer loyalty is essential in any business, and
thriving medical practices recognize that patient
satisfaction is vital to their success. Here are some
strategies to enhance the patient experience and
keep your valued patients coming back.
Deliver Superb Customer Service. Customer
service is a crucial component in keeping patients
happy, and every interaction
during the visit affects the
patient experience. “It’s not just
about the doctors, it’s about
the office,” says Lisa B. Nadler,
MD, a physician at Duke Triangle
Family Practice. “Everybody’s
involved in determining patient
satisfaction. If you have good
[people] throughout the office, then [patients are]
more likely to come back.”
Communicate Honestly. Indeterminable wait
times are a common frustration among patients.
Help ease their frustration by sharing expected
wait times. For instance, Nadler’s practice sets
up a simple display board in the lobby that lists
physician names and expected wait times. “This
makes it easier for [patients] to know what to
expect,” Nadler says.
Thriving medical
practices recognize
that patient
satisfaction is vital
to their success.
Evaluate Patient Satisfaction. Patient satisfaction
surveys are a great way to determine what patients
like (and dislike) about your practice. You can develop
and administer your own survey or use the survey
feature available in some practice management
software. Make sure to actually read the surveys,
and try to schedule recurring meetings to discuss
the results with staff and brainstorm strategies for
implementing some of your patients’ suggestions.
10
Clinical Practice Today from Duke Medicine
Set Realistic Expectations.
Another common complaint
among patients is how long
it takes to get in touch with
front-desk staff. “Setting
realistic expectations for people
is key,” Nadler says. Consider
adding an anticipated returncall time frame to the office’s outgoing voice
message or implementing an advanced-notice
policy for medication refills.
Provide Options. Inform unhappy patients that
they are welcome to see another physician at
the practice or refer them to a different practice.
“Patients are going to move around until they find
someone who they feel comfortable with, and
that’s good!” Nadler explains. “If they don’t feel
comfortable with the person, then they’re not
going to get the kind of care that they [need].”
Slowing the
Progression of
Diabetic Kidney
Disease
Approximately 37 million people in the US and
Caribbean have type 2 diabetes, and 592 million
people worldwide are projected to have diabetes
in 2035. Those who develop kidney disease experience some of the most significant morbidity and
mortality risks related to the condition, says Uptal
Patel, MD, who directs nephrology research at the
Duke Clinical Research Institute.
As the incidence of diabetic kidney disease rises,
Thomas Coffman, MD, chief of the Duke Division
of Nephrology, recommends referring patients
to specialists for nephrology care whenever
necessary. Indications for referring a patient to
a nephrologist include, but are not limited to,
the following circumstances:
 Estimated glomerular filtration rate (eGFR) < 30
mL/min/1.73 m2 or progressive decline in eGFR
 Acute kidney injury
 Persistent albuminuria or proteinuria
 Hematuria
 Hypertension refractory to multiple medications
 Serum electrolyte abnormality
 Recurrent kidney stones or hereditary disease.
As principal investigator of a new study, Patel
is trying to replicate the positive results of a
successful Danish trial focused on reducing
diabetes-related complications with a novel
February 2015
telehealth-based approach. Duke is recruiting
300 patients from 5 of its clinics in the
STOP-DKD trial (Simultaneous Risk Factor
Control Using Telehealth to Slow Progression
of Diabetic Kidney Disease) to study the
progression of kidney disease and uncontrolled
hypertension. The treatment group will receive
a telehealth intervention that covers medication management and risk-factor modification
through a combination of self-monitoring and
behavioral therapies to slow disease progression
(or kidney-function decline).
“Of all of the diseases that can lead to kidney
disease, diabetes is the biggest problem
worldwide, and I believe that it can be better
prevented,” says Patel.
The STOP-DKD trial is one of several ongoing
research trials in the Duke Division of Nephrology,
many of which are supported by the Duke O’Brien
Center for Kidney Research (DOCK). Coffman
says, “even basic research is focused on clinical
problems, including diabetic kidney disease.” For
example, Duke is studying links between cardiovascular risk and kidney disease, says Coffman, who
won the 2014 Excellence Award for Hypertension
Research from the American Heart Association.
(Image above shows a self-test for glucose.)
11
Gout Is Curable
With Proper
Intervention
Although gout can progress into a debilitating
and continually painful condition, the disease can
be curable if patients are properly treated from
the onset of signs and symptoms.
“Many doctors do not think of gout as a chronic,
debilitating process,” says Robert Keenan, MD, a
rheumatologist who directs the Duke Gout and
Crystal Arthropathy Clinic. “They may consider it
a disease of flare-ups with no inflammation and
normal function in between, but damage continues
until a patient may become unable to walk.”
During intercritical gout periods when
patients are not experiencing
flaring, crystals are still present,
and inflammatory cells are
continuously releasing
cytokines and proteases
at low levels, which
To refer a patient
cause joint damage and
for treatment or trials,
disability.
call 800-MED-DUKE
Timely Detection
and Treatment
Gout responds to the right
treatment at the right time delivered in the right way, Keenan says. He
explains that catching the disease as early as
12
Clinical Practice Today from Duke Medicine
possible and managing it appropriately can
lead to a cure.
Most patients can be managed with dietary
changes at first (eg, a low-purine diet in which
patients avoid organ meats, shrimp, and beer)
combined with pharmacologic therapy. Diet
measures alone are often ineffective long term.
Patients with gout symptoms and pain should be
referred for specialty care if uric acid levels cannot
be lowered to below 6 mg/dL (normal is between
3.5 and 7.2 mg/dL) or if uric acid levels are below
6 mg/dL but patients still have flaring.
Pharmacologic Options
The Duke Division of Rheumatology and
Immunology has been a leader in gout treatment, as illustrated by the approval of Krystexxa
(pegloticase). In 1993, Michael S. Hershfield, MD,
began developing the compound, an orphan drug,
for late-stage gout. Clinical trials were conducted
at Duke, and the Food and Drug Administration
approved the drug in 2010 for intractable cases.
New trials are available at Duke and will begin Feb.
2015. Duke may also participate in phase 1 and phase
2 trials for potential new gout treatments. (Image
above depicts the foot of a patient with gout.)
Brachytherapy
Improves Cervical
Cancer Care
Compared with traditional treatment alone,
gynecologic brachytherapy has been shown to
extend survival for patients with cervical cancers.
This technique involves brief exposure to intracavity or interstitial high-dose radiation.
Although the standard for treating cervical cancer
is external-beam radiation therapy (EBRT), “there
are fewer side effects with brachytherapy, so
studying the optimal usage for brachytherapy is
important for best practice,” says Junzo Chino,
MD, a gynecologic brachytherapy specialist at
Duke, one of the few places in North Carolina that
offers such services.
A 2013 population-based analysis, published in
the International Journal of Radiation Oncology
(Red Journal) in September, found that
brachytherapy use was associated with improved
cause-specific survival and overall survival in
patients with cervical cancer. In a matched cohort,
brachytherapy was associated with higher 4-year
cause-specific survival (CSS, 64.3% vs. 51.5%;
P < 0.001) and overall survival (OS, 58.2% vs.
46.2%; P < 0.001) compared with EBRT alone.
The study examined results for 7,359 patients
with stages IB2-IVA cervical cancer.
Interestingly, the researchers observed a decline
February 2015
in the use of brachytherapy: it was implemented
in 83% of cases in 1988 but just 58% of cases in
2009, hitting a low in 2003 of 43%. The authors
concluded that because brachytherapy use independently led to higher survival rates, the therapy
“should be implemented in all feasible cases.”
Given that recommendation, it is fitting that gynecologic brachytherapy practice is now becoming
more formalized with the publication of new guidelines. The American Brachytherapy Society has
released three guidelines for locally advanced carcinoma of the cervix as well as guidelines for adjuvant
vaginal-cuff brachytherapy after hysterectomy
and interstitial brachytherapy for vaginal cancer.
Chino stresses that brachytherapy and EBRT could
each be used against various cancers, depending
on the region and stage. For example, if the
location of the intrauterine channel is insufficient
to cover the area of disease to be treated, doctors
can insert interstitial catheters to direct the dose
and create customized implants for patients.
The careful use of imaging such as an ultrasound,
MRI, and computed tomography is currently being
evaluated in clinical trials at Duke to spare normal,
sensitive tissue, such as bladder. (Image above
depicts carcinoma of the cervix.)
13
Closing the Gap
on Unpaid
Patient Balances
By Shelly K. Schwartz
As much as you may enjoy helping patients,
you can’t afford to do it for free. “With the rise
in high-deductible plans and self-pay patients,
practices are having to operate a lot differently
than they used to,” says Tamra Swindoll, president
of Catalyst Consulting in Austin, Texas.
Personal Communication
The best-performing practices, says Swindoll,
contact patients who don’t respond to reminder
notices of overdue bills. “In this day of technology
and automated payment systems, sometimes you
still can’t replace the good old live conversation,”
she notes, adding that a call can shed light on
what would have otherwise been assumed.
Payment Options
Practices must also make every effort to collect
what they can at the point of care, recommends
Jamie Claypool, a medical practice consultant
with J. Claypool Associates in Spicewood, Texas.
“Give patients as many payment options as
possible, including credit card, check, and thirdparty financing through groups like CareCredit.”
Written Documentation
Claypool also says that all medical practices should
ask patients to sign a written collection policy that
14
Clinical Practice Today from Duke Medicine
clearly delineates what they can expect from
your office and what you expect from them (eg,
confirmation of eligibility prior to appointments or
a 25% up-front deposit for surgeries). Your patients,
in turn, must agree to pay their balances on time.
The written policy should also indicate when an
unpaid bill will be sent to a collection agency.
Estimated Costs
At the same time, says Claypool, provide patients
with estimates ahead of time for how much their
office visit or procedure will cost. “Good eligibility
information from the start gives patients the
opportunity to accept or deny care based on their
ability to pay,” explains Carol Gibbons, another
consultant with Catalyst Consulting.
Standard Fees
In cases where co-pays and deductibles cannot be
determined ahead of time, Claypool suggests that
practices collect a standard visit fee. “If you don’t
know how much to collect, at least get something,”
she says. “Co-pays and deductibles are higher now,
so have a standard amount that you charge for all
visits and settle up later with a refund if necessary.”
Ultimately, practices that hope to minimize unpaid
balances should set expectations that out-of-pocket
fees will be collected at every visit.
New Treatment
for Wet Macular
Degeneration
A new therapeutic approach is available for
treatment-resistant wet macular degeneration,
a form of advanced age-related macular degeneration that affects people older than 50 years.
The disease starts as dry macular degeneration
in which abnormal deposits called “drusen” form
under the retina. Patients experience gradual
vision loss; significant vision loss may take 25 years.
Some patients develop a more-severe form called
wet macular degeneration in which an abnormal
blood vessel grows underneath the macula, leading
to plasma leakage, bleeding, and scarring. With
early diagnosis, wet macular degeneration can be
treated with ocular injections of medications that
block vascular endothelial growth factor (VEGF),
and sudden, severe vision loss can be avoided.
“Long-term treatment with anti-VEGF medications
is effective for disease control,” says Duke ophthalmologist, immunologist, and retina expert Scott
Cousins, MD, who serves as director of the Duke
Center for Macular Diseases. “However, between
25% and 40% of patients have an incomplete
response and remain at risk of vision loss.”
Retina specialists at the Duke Eye Center have
initiated a pilot clinical study for patients who
February 2015
don’t respond to anti-VEGF therapy. This approach
involves adding Visudyne (verteporfin; manufactured by Bausch + Lomb) photodynamic therapy
(PDT) to standard treatment. Duke pioneered the
use of PDT and developed retinal imaging technology called indocyanine green angiography (ICG)
as a biomarker of disease type to identify patients
who may be candidates for PDT.
PDT, which was previously approved for treating
wet macular degeneration, involves infusing a
light-activatable medication (Visudyne) into a
peripheral blood vein. The doctor then applies
a “cold” laser (to avoid thermal damage) to the
abnormal blood vessel in the back of the eye to
activate the medication and block blood flow
to that vessel.
“Because the ICG biomarker also tells us about
the exact size and location of the blood vessel,
we can use it to selectively target the vessel
while limiting any effects on normal blood
flow,” says Prithu Mettu, MD, an ophthalmologist
and retina specialist at Duke who is co-leading
the study with Cousins. About two-thirds of
treatment-resistant patients who receive PDT
benefit from it, Cousins says. (Image above shows
an angiogram of a patient with age-related
macular degeneration.)
15
Duke Medicine
DUMC 3687
Durham, NC 27710
Non-profit Org.
U.S. Postage
PA I D
Durham, NC
Permit No. 60
800-MED-DUKE
Readership Survey—5 minutes could win you $500!
We hope you have been enjoying your complimentary subscription to Clinical Practice Today from Duke Medicine.
Do you have comments, suggestions, or ideas? If so, we’d love to hear from you!
This survey should take about 5 minutes. Please answer the questions and submit your completed survey to us
via fax at 866-419-5789, mailed in an envelope to 5523 Research Park Drive, Suite 210, Baltimore, MD 21228, or
online at ClinicalPracticeToday.com/survey. Upon receipt of the completed survey, you will be entered into a drawing
to win a $500 American Express gift card. Entry deadline: February 27, 2015. The winner will be notified via email.
1)_ On a scale of 1 to 5 (1 = strongly
disagree; 5 = strongly agree), please
rate your agreement with the
following statements:
__ I enjoy reading Clinical Practice Today
2)_ As a result of reading Clinical Practice
Today, what actions have you taken?
(Select all that apply.)
__ I have shared an article with colleagues
__ I have implemented recommended
practice changes
__ I have called a phone number for more
information
__ I have visited DukeMedicine.org
__ I have made a referral to a Duke
Medicine doctor
__ I have recommended Duke Medicine
services to a colleague or patient
__ O ther: _________________________
__ Managing uncompensated care
__ Medicare reimbursement and reform
updates
__ Physician-patient communication
__ Diabetes and endocrinology
__ Ear, nose, and throat
__ Gastroenterology and GI surgery
__ Geriatrics
__ Gynecology
__ Nephrology
__ Neurology and neurosurgery
__ Clinical trials
__ Ophthalmology
__ New and updated national guidelines
__ Orthopaedics
__ Research updates
__ Pulmonology
__ Technology in medicine
__ Rheumatology
__ Translational science
__ Urology
__ Q&As or profiles of thought leaders
__ Other: _________________________
4)_ Would you recommend Duke Medicine
to your patients?
__ Yes
__ No
__ Unsure
6) _Please name up to five hospitals that
you believe provide the best care in
________________ (your specialty)
for patients who have the most
challenging conditions or who need
particularly difficult procedures.
(Do not consider location or cost.)
5) _Have you referred patients to any Duke
Medicine services in the past year?
__ Yes
__ No
__ Unsure
If yes to Q5, which service(s)? (Select all
that apply.)
__ Cancer
__ Cardiology and heart surgery
a.______________________________
b.______________________________
c.______________________________
d.______________________________
e.______________________________
Name______________________________________________ Email__________________________________________
TEAR ALONG DOT TED LINE
__ The information in Clinical Practice
Today helps me in the management of
my practice and patients
__ Clinical Practice Today has increased my
interest in using Duke Medicine for my
patients’ care
hich topics would you be interested in
3)_ W
reading about in future issues of Clinical
Practice Today? (Select all that apply.)
__ Reducing operating expenses