August 2014
Clinical Practice Today
from Duke Medicine
CASE STUDY
Thoracic Aortic Surgery:
Improving Outcomes
8
Surgical experience and
volume are key for optimal
patient outcomes
Concierge Medicine: Exploring
Traditional and Newer Models
4
Part 2
11
Repairing Vaginal and Uterine Prolapse
Caring for Your Blood and
12
Marrow Transplant Patients
Clinical Practice Today
Duke Medicine Marketing
and Communications
Editor
Mary Jane Gore, MA
Publisher
Med-IQ
in Clinical Practice Today
Concierge Medicine:
Exploring Traditional and Newer Models
Editorial Management
Laura Espinoza
Lisa R. Rinehart, MS, ELS
The second article in this 2-part series delves into
the ins and outs of direct primary care Writers
Frank Celia
Meredith Kleeman
Emily Paulsen
Shelly K. Schwartz
New therapies can help patients better control
their seizures About Duke Medicine
U.S. News & World Report consistently
ranks Duke University Medical Center
in its Honor Roll of top hospitals in the
United States.
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.
To refer patients, call 800-MED-DUKE.
For more details on the services we
offer your patients, please visit
DukeMedicine.org.
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
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.
©2014 Duke Medicine. All rights reserved.
Page 4
Advances in Epilepsy Care
Present More Therapeutic Options
Page 6
Reducing Turnover in Your Practice
A welcoming and productive working environment
can minimize staff turnover Page 7
CASE STUDY
Thoracic Aortic Surgery: Improving Outcomes
Duke’s Thoracic Aortic Surgery Program has
significantly decreased operative mortality rates Page 8
Building Better Relationships With Hospitalists
Clear and open communication with hospital-based
physicians can help improve patient care Page 10
Repairing Vaginal and Uterine Prolapse
Extensive experience and innovation result in
successful prolapse procedures Page 11
Caring for Your Blood and
Marrow Transplant Patients
These recommendations can help your patients
remain healthy for as long as possible Page 12
Streamlining Appointment Setting and Reminding
Automated systems can reach more patients
and save money Page 14
When to Refer for Scoliosis
The orthopaedic team at Duke can help evaluate
patients with scoliosis Page 15
To learn more or
to refer a patient,
call 800-MED-DUKE
News Briefs
Imaging for
Alzheimer’s Risk
Murali Doraiswamy, MD, professor of psychiatry
and geriatrics at Duke Medicine, and team recently
showed that PET scans using the radioactive
dye florbetapir (Amyvid) to image amyloid brain
plaques can predict Alzheimer’s disease (AD) risk.
The researchers published data in Molecular
Psychiatry on 121 people who were cognitively
normal or had mild cognitive impairment (MCI);
they were followed for 36 months. Amyloidpositive subjects with MCI were more than 3 times
as likely to be diagnosed with AD dementia at
follow-up, but amyloid-negative subjects in both
groups had minimal cognitive decline.
The Duke team recently used this technique to save
the life of a young, competitive athlete with acute
respiratory distress syndrome (ARDS); her lungs
had been normal before ARDS. Her status didn’t
improve with standard ECMO. Doctors brought her
out of an induced coma, but she panicked because
of her inability to breathe on her own. After 10
days on ECMO, she was able to walk on her own
and had strengthened enough for the transplant.
(Image above shows donor lung in ice water.)
“We recommend a scan be performed if a diagnosis
is unclear in a patient with progressive cognitive
decline. A negative scan suggests that the
cause of cognitive decline is unlikely to be AD,”
Doraiswamy says.
Infections Need More
Accurate Treatment
ECMO and an Athlete’s
Double-Lung Transplant
Patients with chronic lung disease who are
awaiting lung transplantation on extracorporeal
membrane oxygenation (ECMO) often have poor
outcomes. In 2010, Duke started an ambulatory
ECMO program as an effective bridge to lung
transplantation so patients can exercise before
surgery. Outcomes dramatically improved as a
result. Duke performed transplants in 13 patients
with a 100% survival-to-discharge rate, says Ira
Cheifetz, MD, who pioneered the program and
directs the Duke Pediatric Critical Care Program.
August 2014
A Duke study recently provided the most complete
picture of bloodstream infections (BSIs) in United
States (US) community hospitals to date. Over time,
the types of BSIs have changed. Staphylococcus
aureus is now the most common cause of infection,
but 1 in every 3 BSI patients receives inappropriate
empiric antimicrobial therapy.
“Based on our data, it would be valuable to set
a physician performance metric for appropriate
empiric antimicrobial therapy,” says Deverick
Anderson, MD, MPH, an infectious disease
specialist at Duke who was the lead author of
the study, published in PLoS One in May 2014.
Electronic data about risk factors and daily activities
could be entered into a system that notifies
ordering physicians, the study suggested.
3
PART 2
Concierge Medicine:
Exploring Traditional
and Newer Models
by Frank Celia
In this second installment of our 2-part series, we explore a new model of concierge
medicine that’s quietly gaining traction. Part 1 (see the June 2014 issue) focused on the
traditional concierge style. This second article focuses on direct primary care.
Imagine never working with another third-party
payer again: no more payer-related paperwork,
coding, or billing. Now imagine keeping your
current revenue while reducing your overhead to
10% of your gross profit. Finally, imagine spending
30 minutes with every patient.
4
Expanded Scope
Does it sound too good to be true? Not according
to proponents of “direct primary care,” or DPC,
a subspecies of retainer-based medicine that
might offer doctors these benefits and more.
Sometimes referred to as “concierge medicine for
the masses,” DPC is gaining footholds in certain
markets, especially rural ones.
Like other forms of “concierge care,” DPC models
ask patients to pay a flat monthly or annual fee.
DPC contributions tend to be much lower, however,
than for standard concierge models—around $40
to $60 per month for adults and often less for
children. DPC patients receive an enhanced array of
services, such as 24/7 physician access, extended
visits, email communication, and, in some cases,
house calls. Excluded from these offerings are the
“luxury” services that are often associated with
traditional concierge care: therapeutic massages,
a spa-like atmosphere, and so on.
Approximately 500,000 patients across the country
are being cared for under DPC models, according to a
2013 study by the California HealthCare Foundation.
Some of these DPC practices have succeeded in
cutting costs, improving outcomes, and offering
patients and physicians a more rewarding experience.
In one sense, DPC practices are no-frills, meatand-potatoes operations, but in other ways, they
greatly expand upon primary care’s traditional
role. For instance, many DPC practices provide
wholesale pharmaceuticals, laboratory testing,
x-rays, ECGs, and minor procedures.
What is unclear, however, is whether this approach
can be scaled to a national level amid diverse markets
and patient populations.
Its refusal of third-party insurance, Medicare,
or Medicaid is perhaps DPC’s single-most distinguishing characteristic. This policy is unusual
Clinical Practice Today from Duke Medicine
because the vast majority of retainer-based
primary care practices augment patient fees with
some form of third-party payer income. But DPC
devotees claim that relying solely on patient fees is
the very lynchpin of their success.
“The ‘sure thing’ boat never gets far from shore,”
says Josh Umbehr, MD, who has run a DPC
practice in Wichita, KS, for 3 years. In other words,
retainer-based practices that hedge their bets
by accepting insurance never achieve the vast
reductions in overhead that DPC offers, he says.
His practice charges $600 per year for an adult,
and each doctor is expected to care for 600
patients, which equates to $360,000 in gross
revenue for each physician. “At first we estimated
overhead of $120,000 per doctor, but that goes
down as you add more doctors. We now have
3 doctors, and our total overhead is somewhere
around $180,000 to $200,000 on gross revenues
of $1.08 million per year. We’re getting close to
10% overhead…and most medical practices run
at 60% to 70% overhead—and that’s going to get
worse when ICD-10 arrives.”
DPC patients can visit as often as they like and
drop out and rejoin at any time, penalty free,
regardless of preexisting conditions. Umbehr
offers both wholesale drugs and laboratory
testing at a cost and can handle many cases that
would normally warrant a trip to the emergency
room. All this with negligible paperwork, zero
insurance hassles, and no interaction with the
Centers for Medicare & Medicaid Services.
Most patients retain some form of insurance for
catastrophic conditions, such as cancer or heart
failure, which remain the domain of specialists.
But by removing primary care from the insurance
world, DPC achieves enormous cost savings, both
in paperwork and in downstream services like
emergency and specialty care. True believers hail
DPC not just as a discrete solution for certain
August 2014
markets, but as a broad solution that can help
curb rising health care costs and administrative
requirements on a national level.
“The country needs this,” says Umbehr, who
has helped convince a few local insurers and
employers to switch to DPC. “We often lower
health insurance premiums by $1,000 a month.”
Mainstream Barriers
Not everyone agrees. The most frequent criticism
leveled against a more widespread adoption of
DPC is that it would create doctor shortages. If
primary care physicians reduce patient panel sizes
by two-thirds or more, won’t many patients be left
without health care? DPC advocates believe that
the decreased need for emergency and specialty
care physicians could create manpower efficiencies
to bridge the gap, but how this would work in
real-world scenarios remains uncertain.
Medicare patients pose another big challenge.
After a lifetime of paying into a system, the
idea of having extra, unanticipated expenses for
primary care would understandably frustrate many
seniors. In addition, many of these patients are on
limited incomes and simply do not have the extra
money for DPC’s out-of-pocket monthly fees.
But even if these major roadblocks can be overcome, it remains unclear whether DPC can flourish
on a macro level as it has on a micro one. “I’ve
studied the direct-pay model, and it has done
extremely well in certain rural communities,”
says Wayne H. Lipton, CEO of Concierge Choice
Physicians in Rockville Centre, NY. “If it saves
enough on paperwork, direct-pay can work. But
there are all kinds of challenges.”
In the end, however, physician competence is
more important than the model in which the
physician practices, notes Lipton. “It’s good care
that saves money, regardless of what model it’s
practiced under.”
5
Advances in Epilepsy
Care Present More
Therapeutic Options
Advances in epilepsy treatment have created
therapies that didn’t exist as little as 1 year ago.
Patients who have a fairly certain diagnosis of
epilepsy and have tried 3 or 4 medications but are
still seizing should be referred to epileptologists.
About 1 out of every 3 patients who have seizures
don’t respond to medication, says Saurabh
R. Sinha, MD, PhD, director of Duke’s Epilepsy
Monitoring Unit. “If a patient tries 4 medications
and they all fail, the chance of the next medication working is less than 5%,” he says.
Patients whose diagnoses are less certain should
also be referred to epilepsy centers. In many of
these patients, multiple seizure medications have
failed. “We perform testing and find that nearly
one-third of these patients don’t have epilepsy,
but they may have cardiac or psychological issues,
for example,” Sinha says.
Patients are evaluated for all possible treatments
after medication and testing histories have
been taken. If a single area in the brain is found
to be the source of seizures and the location is
not performing critical functions, a craniotomy
is commonly performed as noninvasively as
possible. Extensive testing is needed to make sure
that the area can be removed safely.
6
Clinical Practice Today from Duke Medicine
If a single spot cannot be pinpointed noninvasively,
electrodes may be implanted to locate the seizure
focus. For patients who cannot have surgery, a
vagus nerve stimulator, similar to a pacemaker,
implanted in the neck, may help prevent seizures.
Two new antiseizure therapies are now available
at Duke:
 MRI-guided stereotactic laser thermal ablation
(manufactured by Visualase) is a minimally
invasive surgery in which a 3-mm hole is made in
the skull and a fiber optic wire is inserted with MRI
guidance. The fiber optic is then heated in multiple
locations to ablate the region in question.
 “Responsive neurostimulator,” or RNS (manufactured by NeuroPace), is a device that uses
implanted electrodes to record brain waves. It
delivers a preemptive shock to a specific brain
region at the first sign of seizure activity. The
device is for patients whose seizure focus is
in an area that is too critical to be removed or
those with more than 2 seizure foci.
Each potential surgical case is discussed by a team
of 6 epileptologists, 2 neurosurgeons, a neuropsychologist, and other staff, which ensures that
every patient is evaluated from multiple perspectives. (Image above depicts removal of brain mass
causing seizures.)
Reducing Turnover
in Your Practice
By Shelly K. Schwartz
Performance reviews and opportunities for growth
play key roles in motivating your staff to succeed. But
practices that take the time to develop their team
also gain a direct financial benefit: lower turnover.
Indeed, employees who work in a positive and
productive environment are far less likely to leave.
If your office is experiencing financial difficulty
or conducting meetings with a potential partner,
speak with your team as early as you can. The
truth is better than the fear of the unknown,
which can result in the loss of your best and
brightest.
Owen Dahl, a practice management consultant
in The Woodlands, TX, says most medical practices
spend between 70% and 200% of a departing
worker’s annual salary to recruit and train a replacement. That speaks nothing of the burden the
process creates for your staff while a new colleague
learns the ropes. Here are some simple suggestions
that can help enhance staff retention.
Create Training Opportunities. Employees should
be given opportunities to develop their skills
through continuing education. “More than anything
else, staff need to feel that they have a chance to
develop professionally,” says Claypool, noting that
cross training your team to perform multiple jobs
within your office also creates scheduling flexibility
when someone calls out sick.
Establish a Collaborative Environment. One of the
most effective retention-boosting strategies is collaboration, says Jamie Claypool, a practice management
consultant in Spicewood, TX. “Employees take
more ownership of major changes or decisions
when they are involved in the process,” she says.
Solicit input from your billing staff on the selection
of new software for their department, for example,
and include staff members who will be working
with new recruits in the interviewing process.
Avoid Micromanaging. Once they’re trained,
however, get out of the way. “Do not micromanage
your staff,” advises Claypool, emphasizing that
excessive oversight is among the most common
reasons for high turnover. “You should expect a
level of professionalism from everyone on your
staff. If they are trained well, you do not have to be
there to continuously oversee them.”
Talk to Staff in Challenging Times. Communicate
with your staff, especially in times of turmoil.
August 2014
Excessive turnover, and the costs incurred as a
result, can be dramatically reduced by maintaining
an open dialogue with staff members and encouraging them to take an active role in your practice.
7
CASE STUDY
Thoracic
Aortic Surgery:
Improving
Outcomes
Angiogram showing aneurysm in the aorta (red, at top) just above heart (pink).
Surgical experience and volume are key for optimal patient outcomes
More thoracic aortic repairs are being performed
due to an aging population as well as the more
frequent use of CT and MRI imaging, which leads
to more instances of disease recognition. New
aortic-repair procedures that often use complex
endovascular techniques are emerging.
(STS ACSD). This study developed the first-ever risk
models for patients undergoing proximal (aortic
root, ascending aorta, and aortic arch) thoracic
aortic surgery, which clinicians may find useful
when counseling patients about risks and benefits
prior to elective and non-elective surgery.
Refer Early and Assess Risk
High Surgical Volume =
Better Outcomes
Patients with newly recognized thoracic aortic
disease should be referred to a specialist early
because those undergoing elective repair
procedures have better outcomes than those
undergoing required surgery, according to a
study of more than 45,000 patients who received
proximal aortic replacement. The findings were
published in the Sept. 2012 issue of Journal of
the American College of Cardiology by researchers
from Duke University who used the Society of
Thoracic Surgeons Adult Cardiac Surgery Database
8
Clinical Practice Today from Duke Medicine
Many hospitals perform thoracic aortic surgery,
but often do so in low numbers, according to
STS ACSD data.
A separate study from the STS ACSD that examined outcomes for elective aortic-root surgery in
North America showed that hospitals with higher
volumes have better outcomes. Findings, published
in the Jan. 2013 issue of Journal of Thoracic and
Cardiovascular Surgery, showed that patients who
had surgeries at hospitals performing fewer than
30 to 40 such procedures annually had a greater
risk-adjusted mortality than similar patients in the
highest-volume hospitals.
Duke was one of only 22 centers in North America
that fell into the highest-volume category for
aortic-root surgery. Additional studies demonstrated that this volume-outcome relationship
also exists for other types of aortic surgeries such
as descending thoracic and thoracoabdominal
repair, as well as Type A dissection repair.
Minimizing Risk Associated
With Aortic Dissections
Aortic dissections are tears that allow blood to
flow between the layers of the aortic wall. Type A
(involving the ascending aorta) and Type B (involving
the descending aorta)
aortic dissections require
extensive experience
to achieve the best
outcomes. Patients
who undergo surgery at
Duke benefit from that
experience; operative mortality rates for acute Type
A dissection repair have been dramatically reduced
since Duke launched its Thoracic Aortic Surgery
Program (TASP).
Type B aortic dissection and has one of the largest
programs with experience in these conditions.
More Experience and Options
Benefit Patients
Because of its ability to offer both conventional
open and endovascular repairs, as well as its
extensive experience repairing all segments of
the aorta, Duke’s thoracic aorta surgery team
takes both a patient’s pathology and physiology
into consideration when making precise treatment decisions. Furthermore, team members
have published numerous evidence-based papers
on surgical outcomes, risk models, and frailty
assessment, outlining under which conditions
patients may need a particular procedure.
Hybrid surgeries combining open and endovascular
techniques to minimize
surgical risk are becoming
more common, and
Duke’s experts can
evaluate your patients
to determine whether
they are candidates for
an endovascular, open, or hybrid repair.
We had an 8-fold reduction
in observed-to-expected
in-hospital mortality rates
with the TASP team.
According to the International Registry of Acute
Aortic Dissection risk model, the expected
operative mortality rate is 18.2%. After TASP was
implemented at Duke, operative mortality rates
fell to 2.8%. “We found an 8-fold reduction in
observed-to-expected 30-day in-hospital mortality
rates once the TASP team was established,” says
G. Chad Hughes, MD, a thoracic aortic surgeon
who leads the team. “This improvement in survival
has persisted over long-term follow-up as well,
with a 30% increase in overall survival at 5 years.”
Duke published outcomes for the endovascular
management of acute and chronic complicated
August 2014
Duke also takes special care to avoid complications.
Neurologist Aatif Husain, MD, and his staff of
experienced technologists conduct
neurophysiologic intraoperative
monitoring (NIOM) to reduce
the risk of damage to the
brain and spinal cord
To learn more or
during aortic repair. As
Husain notes, “NIOM
to refer a patient,
has been shown to
please call
reduce neurologic
800-MED-DUKE
morbidity in these types
of surgeries. The NIOM
team at Duke, with the
aortic surgery and anesthesia
teams, has developed monitoring
paradigms for safer surgeries.”
9
Building Better
Relationships With
Hospitalists
By Emily Paulsen
A natural disconnect may exist between
hospitalists and community physicians. Indeed,
physical separation, busy schedules, and complex
cases all conspire to make communication
between these two groups difficult.
According to Win Whitcomb, MD, co-founder and
past president of the Society of Hospital Medicine,
systems such as value-based payment or shared
electronic health records can help, but there’s no
substitute for good old-fashioned relationship
building. Here are some tips that may prove useful.
Set the Stage. Many patients are still unfamiliar
with the hospitalist concept. Whitcomb
recommends that community-based physicians
talk with patients—particularly those with a high
risk of hospitalization—ahead of time about how
hospitalists and community-based physicians work
as a team. “There’s already a trust relationship
between physician and patient,” says Whitcomb.
“The trick is to transfer that trust to the hospitalist.”
A telephone check-in with hospitalized patients
can reassure them that you’re still in the loop.
Keep Contact Info Up-to-Date. It sounds obvious,
but Whitcomb says hospitalists do not always have
up-to-date contact information for communitybased physicians, including preferred office and
cell phone numbers, secure email addresses, and
current fax numbers.
10
Clinical Practice Today from Duke Medicine
Provide Hospitalists With Your Contact
Requirements and Preferences. This step can be
especially important for consulting specialists.
When is an in-hospital consultation necessary
and when will a next-business-day phone call
suffice? Also, although many physicians prefer
telephone communication, email or fax may
work better for routine matters. Whitcomb
suggests developing a list of guidelines and
distributing it or posting it on the hospitalist
bulletin board.
Communicate Verbally for Challenging Situations.
Clear communication is especially important
when managing patients with complex illnesses
or high readmission risks or when disagreeing
about treatment approaches. Pick up the phone
or stop by the hospital to speak with the hospitalist
in person.
Create Opportunities for Interaction. “It’s really
important to get to know each other,” notes
Whitcomb. Make a point to stop by during rounds
or regular hospitalist staff meetings.
Attending a staff social or lunch-and-learn
conducted by a hospitalist may seem like a
luxury in an already busy schedule, but the
face-to-face conversations that occur at these
events can improve communication—and
patient care.
Repairing Vaginal
and Uterine Prolapse
Nonsurgical treatments for pelvic prolapse include
Kegel exercises or internal devices (pessaries) to
strengthen vaginal muscles. If surgery is needed,
3 minimally invasive approaches are available:
 A vaginal repair without mesh
 A vaginal repair with mesh
 An abdominal robotic sacrocolpopexy
All 3 procedures are indicated to treat even advanced
pelvic organ prolapse, which allows surgeons to
tailor their approach to the particular needs of their
patients. In addition, a urethral sling can be added
to any of these procedures to treat urinary stress
incontinence. Surgeons must be appropriately trained
in these procedures so they can anticipate and
respond quickly to complications that might arise.
“The success rates are favorable, and complications
are low with any of these options,” says Anthony Visco,
MD, past president of the American Urogynecologic
Society and current Duke urogynecologist.
Duke’s Expertise
Duke pioneered the open sacrocolpopexy
procedure and continues to innovate as an early
developer of the robotic version.
urogynecologists are fellowship trained and have
received training in robotic sacrocolpopexy.
Advances in Mesh-Based Repair
The abdominal robotic sacrocolpopexy is a
minimally invasive surgical advance that helps
patients quickly return to normal function. Five
small laparoscopic incisions are made to attach
mesh to the front and back walls of the vagina,
and then the mesh is attached to a ligament
overlying the sacrum, providing a high level of
support. It is frequently performed as an out­‑
patient procedure, with less pain, little blood
loss (< 25 mL), and a low risk of infection.
In addition, mesh products have improved in
recent years. For instance, they now include weave
patterns designed to provide support and minimize
complications. They are placed with direct suturing
for improved delivery and are being studied to
demonstrate superiority to older mesh devices.
“We receive a fair number of patients with
recurrent prolapse after a previous procedure,
and they are sometimes seen here shortly after
the initial procedure,” Visco says.
Duke is currently offering a randomized trial to
study vaginal repair with or without mesh, and
related trials are also underway.
Duke’s fellowship program was one of the first
accredited programs in the nation and has
consistently graduated fellows since 1994. Duke
To refer a patient or learn about trials, call
800-MED-DUKE. (Image above depicts uterus
rotated to show prolapse.)
August 2014
11
Caring for Your
Blood and Marrow
Transplant Patients
The number of adult patients who have had
blood and marrow transplants (BMT) is steadily
rising. Referring physicians providing care for this
growing population should consider the following
recommendations to keep their patients as
healthy as possible.
Care After BMT
Physicians must monitor their patients to be
sure that their blood counts
remain within a healthy
range. Some may experience
briefer periods of remission
than others.
Another medical condition that doctors should
be aware of is chronic graft-versus-host disease,
which can occur if a patient has received a donor
transplant. Sun exposure can activate the disease,
so patients must be vigilant about their exposure
to sunlight and wear an SPF 30 (or higher)
sunscreen.
Physicians should be alert to laboratory results
or symptoms that may indicate patients are
coming out of remission.
“It’s generally possible
to match a patient
to a potentially
beneficial treatment.”
12
Once patients return home
after a transplant, they must
remain alert to the risk of infection, particularly
viral infections. One of the best things patients
can do is avoid crowds and continue good
hand-hygiene practices.
“There are two big issues
when referring patients
who are no longer in
remission,” Chao says.
“One is to contact specialists
as early as possible so they
can help to manage the patient’s case as early
as possible. The other is to begin looking for the
right donor even before a patient really needs
the donor.”
“It takes about 1 year for the immune system to
fully mature after a transplant, so it is best to stay
away from large groups or people who are ill or
have been exposed to pathogens,” says Nelson
Chao, MD, MBA, chief of the Duke Division of
Hematologic Malignancy and Cellular Therapy.
The more aggressive the disease, the earlier
a donor needs to be established, because the
chances of relapsing are relatively high. Chao
notes that patients with low-grade lymphomas
may be able to wait longer for a donor because
the pace of the disease is slower.
Clinical Practice Today from Duke Medicine
Physicians in the Duke Hematologic Malignancies
and Cellular Therapy Division encourage referring
physicians to contact them to discuss their
patients’ cases so they can get them help as soon
as possible.
Donation and Matching
Duke uses 4 types of donors:
 Matched related
 Matched unrelated
 Partially matched (haplo) related
 Umbilical cord blood
Similarly, it offers 3 preparatory regimen types:
 Ablative
 Reduced intensity
 Nonmyeloablative
“There are many possibilities, given the donor
type crossed with the preparatory regimen
options, so it’s generally possible to match a
patient to a potentially beneficial treatment,”
Chao says.
The science for partially matched donations has
improved. Complications that previously arose
from partial matches have been partially or
fully solved in most cases, and such treatments
have become more effective, Chao explains.
He says that if a patient is Caucasian, there is
usually a 75% chance or higher of being matched;
African American, a 25% chance; Asian or Native
American, less than a 25% chance. Cord blood
requires less-stringent matching and therefore
further increases the potential to find a match.
The ideal donors are younger, rather than older,
because their bone marrow is more effective.
Donors are evaluated for indicators that show
heart, lung, and kidney health to be sure that
they can donate safely.
Duke’s adult BMT team, which includes the
pioneers who performed the first umbilical cord
August 2014
Active Clinical Trials
53
42
41
25
ABMT
Hematologic Malignancies
Open
Actively Accruing
ABMT = adult blood and marrow transplants
blood transplant, offers a combination of effective clinical care and academic research to provide
patient-centered delivery and tailored care.
Patients may be enrolled in more than 1 clinical
trial to continue their access to treatments;
some patients may ultimately be enrolled in
3 or 4 trials to obtain the best individualized
treatment possible.
“We strive to deliver the most
optimal care and latest
regimen choices to
patients,” Chao says.
“There is a strong
dedication to
Call 800-MED-DUKE
care for both patients
for an appointment;
and their families that
919-668-1002
is a reflection of the
to reach a physician
specialists, nurses,
for consultation
and support staff, who
are highly committed to
the psychosocial side of care
and to care delivered in a
team approach. If you are interested
in sending a patient here
or have questions, call whenever you wish.
We are accessible.” (Image on the previous page
shows erythropoiesis in the bone marrow.)
13
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Streamlining
Appointment Setting
and Reminding
By Meredith Kleeman
Patients today are savvier than ever—they expect
doctors to deliver both high-quality care and
excellent customer service. Meeting these two
expectations, however, doesn’t have to require
more time and money.
Customized technology tools can strengthen
the doctor-patient bond, and—at the same
time—make life a little easier for front office
staff. One type of tool that is particularly useful
in this regard is the automated reminder or recall
system, which can send text messages or emails
and make phone calls in the evening when staff is
gone for the day, but when patients may be more
likely to answer.
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automated systems that work with their existing
scheduling software.
Before implementing an automated system,
look at current staff costs versus the recall
system’s estimated monthly cost, compare
the number of phone calls staff is making per
month with the total the automated system
would make, and determine the current missed
appointment rate.
It’s also wise to research several automated
systems and find out how automated the
software really is, when the software would
make the calls, what its connection rate is, and
whether it can provide monthly reports or data.
These systems can save practices money and
reach a greater number of patients, explains
David Zetter, a practice management consultant
based in Mechanicsburg, PA. “Using staff to
[make reminder calls] is time consuming and very
expensive,” he says, and recommends eliminating
that process altogether.
“If you make the change and you don’t have
data, there’s no way of knowing whether it’s
benefitting you,” says Zetter. After deploying an
automated system, Zetter’s health care clients
typically see their no-show rates reduced to
nearly 2%.
Zetter suggests finding an automated
system that’s customizable. He cautions that
many of the automated services in practice
management software are ungainly or outdated
and recommends finding a program that uses
voice actors instead of recordings to deliver
personalized scripts. Doctors should also look for
As for waiting-list calls, staff calls trump most
technology solutions. “The only solution I’ve seen
that works really well is [when] you’ve got a staff
member looking at the holes in a physician’s
schedule, and—right away—checking the
appointment list and making that phone call to
the patient,” notes Zetter.
Clinical Practice Today from Duke Medicine
When to
Refer for Scoliosis
Scoliosis affects about 5% of the population.
New data from clinical trials show that providing
children with individualized treatment for scoliosis
can be effective.
“It’s important to note that the vast majority of
scoliosis findings do not warrant intervention,”
says Benjamin Alman, MD, a pediatric orthopaedist
and chair of the Duke Department of Orthopaedic
Surgery. “If you suspect a case is worsening,
orthopaedists can assist with evaluation.”
Alman says surgery may be needed for those
with scoliosis of more than 50 degrees. The goal
is to prevent progression to a 90-degree curve,
where compression could interfere with heart
and lung function.
It’s imperative to ascertain whether a scoliosis
case is truly idiopathic, Alman says. Tumors in
nerves, neurologic disorders, or muscular disorders such as muscular dystrophy can involve a
curve in the back. Scoliosis may also be related to
the growth of bones that are longer than normal.
The younger children are, the worse their scoliosis may become with more years of growth.
Although girls experience scoliosis more
often than boys, girls have a lower risk of poor
outcomes because they typically stop growing at
a younger age than boys.
Decisions about whether patients should be
braced are still debatable. The 2013 Bracing
in Adolescent Idiopathic Scoliosis Trial found
that the suggested 18-hour-a-day bracing time
significantly reduced the risk of curve progression
in patients with adolescent idiopathic scoliosis.
Primary study outcomes were skeletal maturity
without curve progression to 50 degrees or more
(treatment success) and curve progression to 50
degrees or more (treatment failure).
Seventy-two percent of subjects in the bracing
group had success after wearing a brace; benefits
increased with longer wear times. Notably,
however, 48% of patients in the observation group
and 41% of patients in the bracing group who wore
braces infrequently also met the success criteria.
To refer a patient for consultation or surgery,
call 800-MED-DUKE. (Image above shows marked
scoliosis.)
Because schools no longer screen for scoliosis, primary care providers often discover spinal
conditions that may warrant referral. A simple visual test can be performed to examine
patients’ spines when they bend over from the waist.
August 2014
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