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eRounds - Fall 2013

The Primary Care Physician: Quarterback for Care

The Affordable Care Act (ACA) tossed the ball to primary care physicians (PCPs), tasking them with the unprecedented responsibilities of keeping people well and more aggressively managing those with chronic diseases.

“We are moving from a reactive to a proactive model,” says David L. Longworth, MD, Chairman of the Medicine Institute. “Our focus has shifted to coordinating the care of higher-risk, resource-consuming patients to keep them out of emergency rooms and hospitals. We must also promote wellness, so healthy people do not develop chronic diseases such as diabetes, hypertension and obesity.”

Quarterback for Care

At the core of this new model is the patient-centered medical home (PCMH), a team-based model of care in which providers operate at top of license and manage individuals as well as a population of patients. In this model, the PCP serves as each patient’s personal caregiver and is supported by other team members. Within this team is an RN who helps coordinate and proactively manage the minority of complex medical patients with chronic diseases, including those with heart failure, diabetes, renal disease, hypertension and COPD. Also included are patients who have been recently hospitalized or seen in the emergency room. Although these patients may represent a relatively small percentage of a PCP’s total patient population, they tend to consume a disproportionate amount of time, energy and resources.

In football, the quarterback calls the shots but relies on a team to carry out his instructions. In the PCMH, the PCP is the quarterback who is supported by the care coordinator and others to deliver care to an entire population. Rather than leaving the responsibility for obtaining care solely in patients’ hands, the nurse care coordinator runs interference. If a patient has been recently hospitalized, or has been in and out of the emergency department, the nurse follows up and pulls the patient in to see the PCP. If the patient has a chronic disease, the nurse coordinator ensures that the patient makes and keeps appointments with the PCP.

Studies have shown this proactive approach reduces the utilization of costly services and lowers the cost of care. It also undoubtedly makes patients happier; quality of life polls continue to reinforce patients’ desire to stay out of the hospital.

Since the new law provides PCPs with a financial incentive to manage patient care proactively, the staff must understand the game plan and work as a team.

“It’s much easier to quarterback a team that is oriented toward a single goal than to run with the ball and try to reach the goal by yourself,” says Dr. Longworth.

New Prostate Cancer Treatment Based on Your Patients’ Genetics

Overtreatment of prostate cancer is one of the most significant issues in men’s health today. Limited available information leads more than 90 percent of low-risk patients to undergo immediate treatment, despite having less than a 3 percent chance of their low-risk disease progressing to become deadly. But now, a new genetic-based test can help determine which of your patients truly need treatment.

The Oncotype DX Prostate test

Developed at Cleveland Clinic, the Oncotype DX Prostate Cancer Test can more accurately determine how aggressive a patient’s cancer is — and whether surgery or radiation therapy is necessary.

“For slow-growing, low-risk prostate cancers, active surveillance may be a better option — when cancer is monitored with periodic clinic visits and prostate-specific antigen tests and repeat biopsies every year or two,” explains Glickman Urological & Kidney Institute Chairman Eric A. Klein, MD.

The new test helps identify more men who can opt for active surveillance — and men whose cancer is actually more aggressive than originally thought.

What the test measures

Oncotype DX measures the expression levels of 17 genes across four biological pathways to predict a man’s prostate cancer aggressiveness.

Its results create a Genomic Prostate Score (GPS), ranging from 0 to 100. This score, combined with other factors, helps further determine prostate cancer risk before starting treatment.

By adding the individualized biological information, Dr. Klein says, more men with low-risk disease can confidently choose active surveillance and be spared unnecessary treatment and possible life-altering side effects, such as incontinence and impotence.

How we developed the test

We conducted studies evaluating 700 patients at Cleveland Clinic with manufacturer Genomic Health. Working with our pathologists, Cristian Magi-Galluzzi, MD, and Sarah Falzarano, MD, we identified genes important in both low and high-grade tumors.

“In doing this, we tackled key challenges in assessing prostate cancer risk, including the problem of tumors being too varied to fully interpret their risk from one patient to another,” Dr. Klein says. “With Oncotype DX, we can improve risk assessment at diagnosis and choose the most appropriate treatment options.”

We were able to measure and analyze gene expression in prostate cancer tissue samples from radical prostatectomy and very small needle biopsy specimens, Dr. Klein says. “Our final analysis found the expression of 17 genes could be converted to a reproducible GPS to accurately predict disease aggressiveness of the entire prostate before considering treatment options.”

Study to validate our findings

University of California at San Francisco researchers validated our findings in another study of 395 patients, adding the biological information revealed by the GPS. They significantly increased the number of patients identified as having very low-risk disease, making them appropriate for active surveillance, from 5 to 10 percent to 26 percent.

Specifically, more than one-third of patients originally classified as low risk based on clinical measures were identified by GPS as very low risk and could confidently choose active surveillance.

Also, patients requiring more aggressive treatment were identified. About 10 percent of patients originally classified as very low or low risk by clinical factors were identified by the test as having more aggressive disease, which would more appropriately be considered for immediate treatment.

Our urologists can order the Oncotype DX for your patients, analyze the GPS report, meet with them to discuss the implications and help them decide on the best options. Call 855.REFER.123.

That Tiny, Tricky Thyroid

Thyroid disease doesn’t always cause symptoms, which can make it challenging to diagnose.

Here’s what you need to know about three common thyroid disorders.

Truth or bunk?

Thanks to unsubstantiated theories published on the Internet, it is increasingly common for patients with normal TSH and T4 levels to question whether they might be hypothyroid. “It does not make scientific sense!” says Dr. Nasr.

Most primary care physicians know how to recognize and treat symptomatic hypothyroidism, the most common thyroid disorder. But hyperthyroidism and thyroid nodules, as well as asymptomatic hypothyroidism, present challenges that leave more room for error.

“The diagnosis and treatment of these less-common diseases is less straightforward,” says Christian Nasr, MD, Medical Director of Cleveland Clinic’s Thyroid Center.

Hyperthyroidism: A disease with systemic impact

Patients with hyperthyroidism may experience a racing heart, excessive sweating and other symptoms of a metabolism in overdrive. Eye symptoms (pain and blurred vision) are also common. These symptoms may begin up to two years before hyperthyroidism begins, or up to two years after. Severe symptoms, such as bulging eyes, occur in only about 10 percent.

Referral to an endocrinologist ensures that these patients receive a comprehensive evaluation and care, including consults with cardiology or ophthalmology, when needed.

The diagnosis is made with a radioactive iodine uptake scan, which should be ordered before the patient is sent to an endocrinologist. Pregnant women and women of childbearing age are exceptions. “These patients may have gestational hyperthyroidism or a high-risk pregnancy and should be referred without testing,” says Dr. Nasr, who collaborates with Cleveland Clinic maternal-fetal medicine specialists to evaluate pregnant patients.

Hyperthyroidism may be treated with medication to slow thyroid output or elimination of the thyroid with radioactive iodine or surgery. Older patients may benefit from a betablocker to relieve palpitations and tachycardia and to protect the stressed heart.

Thyroid nodules: Cancerous or benign?

As many as one-third of women have one or more thyroid nodules, of which 5 to 15 percent are malignant.

Most nodules are painless. They may be discovered by palpating the neck during routine physical examination. However, most are diagnosed incidentally on imaging studies. Patients with large nodules may feel or see a lump in the neck. Some nodules can cause compressive symptoms, such as difficulty swallowing or breathing.

“Nodules most often do not affect thyroid function. Even in the presence of symptoms such as fatigue and weight gain, many patients with thyroid nodules are euthyroid,” says Thyroid Center Surgical Director Joyce Shin, MD.

A nodule’s size and characteristics determine the need for fine-needle aspiration biopsy. The thyroid is removed if the nodule is diagnosed as, or is suspected of being, malignant or causes compressive symptoms.

“It is helpful, but not necessary, to obtain a thyroid ultrasound before referring a patient, as this is performed in the office during the patient’s initial consultation. There is usually no need for other tests, such as a CT or thyroid uptake scan,” says Dr. Shin.

Asymptomatic hypothyroidism

Sometimes, hypothyroidism is a subclinical, biochemical finding. A TSH test is usually sufficient to detect hypothyroidism, but a T4 level is needed when pituitary disease is suspected. “TSH alone cannot be trusted, and a T3 test is unnecessary. A low T3 does not diagnose hypothyroidism,” says Dr. Nasr.

Call 855.REFER.123 to refer a patient to Cleveland Clinic’s Thyroid Center.

When in Doubt, Sit Them Out

A look at House Bill 143: Ohio’s return-to-play law

This spring, House Bill 143, Ohio’s return-to-play law for young athletes, went into effect to protect young athletes from serious and potentially permanent harm by promoting education and proper treatment of concussions. Here’s what you should know about this new law — and what it means for managing concussion patients in your practice.

The basic components

The law contains three elements:

  • Preseason education of athletes, parents and coaches on the signs and symptoms of concussions
  • Removal of young athletes suspected of having a concussion from a game or practice and not permitting return to play on the same day
  • A licensed healthcare professional must clear young athletes to return to play
Why Was H.B.143 Needed?

Richard Figler, MD, a sports health physician at Cleveland Clinic Sports Health and team physician for Solon High School and John Carroll University, says the law stems from several high-profile events across the nation in which mild traumatic brain injuries, or concussions, in young athletes may have been prevented if recognized and treated earlier.

Managing Concussion Patients

Concussion symptoms can be physical, cognitive and emotional and can impact sleep patterns. Dr. Figler says primary care physicians play a key role in appropriately identifying, diagnosing and managing cases.

“Individuals still manifesting signs and symptoms of concussion are not allowed to return to play,” he says. “We want the athlete to return to his or her normalcy before being allowed to return to play.”

The Acute Concussion Evaluation (ACE) form from the Centers for Disease Control and Prevention provides physicians with evidence-based protocols for initial evaluation and diagnosis of suspected mild traumatic brain injury. The ACE also can be used to track symptom recovery over time.

“From a primary care physician standpoint of managing concussions, what we found to be most effective is relative rest,” Dr. Figler says. “The main point to drive home with patients is don’t push through symptoms; that typically will delay overall recovery. When in doubt, sit them out.”

Evidence-Based Resources

Cleveland Clinic Concussion Center was formed to prevent concussions in athletes of all ages and skill levels, minimize their long-term effects when they do occur, and further research to improve tomorrow’s care. The center brings together a multidisciplinary team of sport and exercise medicine physicians, neurologists, neurosurgeons, neuropsychologists, certified athletic trainers, vestibular therapists, physical therapists, pediatricians, radiologists, neuro-ophthalmologists and researchers.

Together, they use an evidence-based approach to customize care for athletes, which includes baseline testing, accurate and prompt diagnoses, symptom management, recovery monitoring and help returning to play as soon as safely possible.

The Concussion Center is leading the way in mild traumatic brain injury care path development across multiple institutes — Orthopaedic & Rheumatologic, Pediatric, Neurological — and Emergency Services. Care paths are evidence-based care models, embedded in the electronic medical record to guide clinicians through the care process for a specific condition. The aim is to reduce harmful or needlessly expensive practice variation and ensure evidence-based care.

“If we can arm physicians with educational material and outcome data, or information that eventually could be transmitted to the clinician, that will help us improve continuity of care. And when used with an evidence-based protocol such as the Concussion Care Path, it holds the promise of taking much of the guesswork out of concussion management for athletes and helping guide therapy over time,” says Concussion Center Director Jay Alberts, PhD.

To refer a patient to the Cleveland Clinic Concussion Center, call 855.REFER.123.

Battling Obesity

New programs for expectant mothers, children and adolescents at Cleveland Clinic, we’re committed to halting the obesity epidemic that began in the 1980s and continues to sweep across our nation without signs of stopping. Here is a look at two innovative programs we offer — to help expectant mothers and children and adolescents in your practice.

Healthy Expectations
The risks of doing nothing

Risks to obese expectant mothers:

  • Preeclampsia
  • Gestational diabetes
  • Large babies
  • Complications following vaginal delivery or cesarean section

Risks to the child:

  • Stillbirth
  • Prematurity
  • Birth defects
  • Obesity in childhood
  • Diabetes

About one-third of women of reproductive age in the United States are obese. Not only is maternal obesity associated with adverse perinatal outcomes (see box below), but it is directly linked to childhood obesity. Maternal obesity also escalates healthcare expenses — from additional office visits and ultrasounds to additional days spent in the hospital due to complications.

The Ob/Gyn & Women’s Health Institute’s new maternal obesity program is specifically designed to help women optimize their weight before pregnancy and continue on a healthy path during pregnancy and after delivery.

“You wouldn’t run a long-distance race without training for it,” says Jeffrey Chapa, MD, Head of Maternal-Fetal Medicine at Cleveland Clinic. “It’s the same kind of thing with pregnancy. Pregnancy puts a significant strain on a woman’s body for nine months. Studies show that getting healthy beforehand can make a world of difference.”

Patients frequently feel there is nothing they can do about their weight, says Dr. Chapa. “My goal is to encourage women to say, ‘Look, I can try to do something to lower my risk of complications.’ ”

How does it work?

Patients are seen during a 60-minute shared medical appointment, led by obesity medicine physician Karen Cooper, DO, and a registered dietitian, with other women who face similar weight challenges before, during or after pregnancy. This helps patients hear answers to questions they may not have asked and learn more than they would have on their own.

Before pregnancy — Dr. Cooper will explain, in a group setting, how your patients can improve their health to increase fertility and reduce the risks of miscarriage. Our registered dietitian calculates each patient’s BMI and shows her how to eat right to achieve her weight loss goals.

During pregnancy — Our staff will explain how much weight patients should gain — and how weight affects pregnancy outcomes. Your patients’ BMI will be calculated and patients will receive practical meal-planning tips.

After pregnancy — If a new mother gained excessive weight during pregnancy, Dr. Cooper will evaluate her and determine which food choices and exercise plan she needs to achieve a healthier weight. Our registered dietitian will offer tips on making easy, healthy family meals. And the team will help your patients understand portion control and how to quickly decipher food labels to make healthy choices for themselves and their families.

While conversations about weight are tough ones to have with patients, Dr. Chapa says patients tend to be a bit more receptive when the end goal is the health of their child or child-to-be.

“It’s not to make people feel bad. It’s to say, ‘Look, these are the risks that are out there. Because if there was something else that would adversely affect the health of your child, wouldn’t you want to know about it? And it is so clear that excess weight impacts the health of your kid going forward.”

Your patients can schedule an appointment with our maternal obesity program by calling 216.444.6601.

Children's Health Essentials Kids Clinic
Health problems caused by childhood obesity

These problems were practically unheard of in kids just a few decades ago:

  • Type 2 diabetes
  • Hypertension
  • High cholesterol
  • Sleep apnea
  • Fatty liver disease
  • Polycystic ovarian syndrome

We all want kids to be healthy. Yet more than 30 percent of American children and teens are overweight or obese. The reason for concern has little to do with appearance and everything to do with health: This generation of children is likely to be the first to die sooner than their parents.

Behind the shorter life span are profound health problems that begin in childhood, says Cleveland Clinic Children’s pediatrician Sara Lappé, MD.

For obese and overweight kids and teens ages 2 through 20, Cleveland Clinic Children’s new Children's Health Essentials Kids Clinic offers help from a team including Dr. Lappé; pediatric GI specialist Naim Alkhouri, MD; Kari Gali, CNP; pediatric psychologist Eileen Kennedy, PhD; and Andrea Rumschlag, RD, CSP, LD.

How does it work?

During a one-and-a-half-hour evaluation, one of our medical experts will review the child’s medical, family and diet history. A physical exam will be performed, and lab tests will be ordered. The child’s health status will be explained to his or her parents, and a few goals will be set. The family will also meet with a registered dietitian, who will assess the child’s eating habits, discuss healthy alternatives and explain how to keep a food journal.

The families will have follow-ups monthly, both individually and with other families in a group session with the entire Children's Health Essentials Kids Clinic team. Any kids with weight-related medical complications are seen by Cleveland Clinic Children’s specialists, including:

  • Endocrinologists for diabetes, thyroid problems or PCOS
  • Sleep medicine specialists for sleep apnea
  • Pulmonologists for asthma or apnea
  • Nephrologists for hypertension
  • Cardiologists for high cholesterol or lipids

“A lot of families see overweight and obesity as an insurmountable problem,” says Dr. Lappé. “They feel overwhelmed by everything they need to change. But small changes really add up. Every parent can make these changes to get their kids — and the whole family — healthier.”

To prevent long-term medical problems, it’s best to get started young, Dr. Lappé notes. “Prevention is the best approach,” she says. “Obese kids create more fat cells than healthy-weight kids as they grow — up until early adolescence. Because of this, they have more difficulty losing weight when they are older.”

You can refer a child to the Children's Health Essentials Kids Clinic by calling 216.448.6000.