a focus on new technology - thepermanentejournal.org · a focus on new technology -...

www.kp.org/permanentejournal

A Focus on New Technology

25 Fantastic Voyage: Questions fromthe 21st Century

26 Advances in Imaging—The ChangingEnvironment for the Imaging Specialist

29 Genetic Services in the KP SouthernCalifornia Region: Delivering thePromises of Tomorrow Today

38 Kaiser Permanente Southern CaliforniaRegional Technology ManagementProcess: Evidence-Based MedicineOperationalized

42 Update on Interventional Neuroradiology

47 Implementation of a Teleradiology Systemto Improve After-Hours RadiologyServices in KP Southern California

Special Section—Spirit

57 Writing and Telling Our Clinical Storiesto Improve the Art of Medicine

Spring 2006 Volume 10 No. 1a peer-reviewed journal of medical science and social science in medicine

PermanenteJournalThe

Advisory BoardRichard Abrohams, MD; Internist and Geriatrician .................................................... TSPMG

Terry Bream, RN, MN; Manager, Nursing Administration ......................................... SCPMG

Brian Budenholzer, MD; Director, Clinical Enhancement and Development ................. GHC

Dan Cherkin, PhD; Senior Scientific Investigator ...................................................... GHCHS

Linda Fahey, NP; Regional Coordinator of Advanced Practice .................................. SCPMG

Tom Godfrey, MD; Director of Communications ............................................................. TPF

Carol Havens, MD; Director, Department of Continuing Medical Education ............... TPMG

Arthur Hayward, MD; Internist and Geriatrician, Chief, Continuing Care Services ....... NWP

Tom Janisse, MD, MBA; Chairperson ............................................................................ NWP

Michael Mustille, MD; Associate Executive Director, External Relations .......................... TPF

Arlene Sargent, EdD, RN; Director of Education and Research .................................... TPMG

Joanne Schottinger, MD; Asst to Assoc Medical Director, Technology Assessment ....... SCPMG

Eric Schuman, PA; Family Practice Clinician ................................................................ KFHP

Mark Snyder, MD; Executive Director, Research and Information Management ....... MAPMG

Paul Wallace, MD; Executive Director, Care Management Institute ................................. TPF

David Waters, MD; Department of Ophthalmology; Member, Board of Directors ........ HPMG

Eddie Wills, Jr, MD; Assistant Medical Director, Prof Development & Support Svcs ..... OPMG

Levin, MD; For-Shing Lui, MD; Tamara MacLean, FNP; Mibhali Maheta, MD; Harold Mancusi-Unearo, Jr, MD, FACS; Laure Mazzara, MD; Bonnie McDonnell, RNP; Laurie Miller, MD; JohnMitchell, MD; Mary Mockus, MD, PhD; Ronald Morgan, MD, PhD; Stanley NG, MD; ValerieOzsu, NP; Karen Pantazis, MD; Steve Petty, MD; Dennis Pocekay, MD; Judi Price, PA-C;Roshan Raja, MD; Rafiq Sheikh, MD, MRCP (UK); Larry Sheridan, MD; Andris Skuja, PhD;Jeffrey Smith, MD; Elizabeth Smith, RNP; Prasit Vassantachart, MD; Gail Wagner, MD; LaurieWalsh, NP; Kaho Wong, MD, PhDThe Southeast Permanente Medical Group, Inc (TSPMG): Richard Abrohams, MD; GayleArberg, CANP; Joshua Barzilay, MD; Luke Beno, MD; Angel Cobiella, MD, MBA; Rick Derby,MS, LPC; Kenneth Ellner, MD; Marshall Fogel, MD; James Hipkens, MD, PhD; JeffreyHoffman, MD; Stanley Jagielski, MD; Sharon Lehman, MD; Adrienne Mims, MD; Sam Moss,MD; Sean Murphy, MD; Milton Sarlin, MD; Sandy Schafer, MSN; Helen Selser, MD, MMM;Gregory Valentine, MD; Gail Vest, MSN, MBA; S Luke Webster, MD; Alonzo White, MD,MBA; Marcia Williams, MD; Eric Zurbrugg, MDSouthern California Permanente Medical Group (SCPMG): Antoine Abcar, MD; Sherif Aboseif,MD; Anna Maria Andia, MD; Maria Ansari, MD; David Apel, MD; Fariba Ariz, MD; Zarin Azar,MD; Paul Bernstein, MD, FACS; Matthew Berry, MD; Trish Beuoy, CNM; Raj Bhagat, MD;Solomon Bitew, MD; Robert Blum, MD; Harsimran Brara, MD; Gayne Brenneman, MD; IoneBrunt, CNM; Kenneth Burns, MD; Timothy Carpenter, DO; Connie Casillas, MD; KreightonChan, MD; Kevin Chang, MD; Winjing Chang, MD; Joseph Chen, MD, PhD; Hae-Kyung Cho,NP; Ashok Chopra, MD; Reema Chugh, MD; Naomi Cohen, NP; William Crawford, MD;Roberto Cueva, MD; Dale Daniel, MD; Dereck De Leon, MD; James Delaney, PAC; RichardDell, MD; Mark Dreskin, MD; Karen Durinzi, MD; Alan Evans, MD; Michael Farooq, MD;Shireen Fatemi, MD; F Ronald Feinstein, MD; Vincent Felitti, MD; Linda Fitts, MD; ValoraFlukers, RNP; Peter Fung, MD; Brendan Gaylis, MD; Yoav Gershon, MD; Cary Glass, MD;Andrew Golden, MD; Glenn Goldis, MD; Adam Guo, MD, PhD; Paul Gweon, MD; Joel Handler,MD; Paul Hartman, MD; Lubna Hasanain, MD, MPH; Yassamin Hazrati, MD; Lisa Heikoff, MD;Chris Helmstedter, MD; Lucretia Hemminger, RNP; Diane Hom, MD; Aram Hovanessian, MD;Adam Howard, MD; Steve Huang, MD; Robert Hye, MD; Gladys Inga-Surainder, MD; HoracioJinich, MD; Samir Johna, MD, FACS; Sara Jones-Gomberg, MD; Sharon Kalina, MD; CraigKalthoff, MSN, FNP; Michael Kanter, MD; Siamak Karimian, MD; MaryAnn Kazem, NP; AfshinKhatibi, MD; Gary Kodel, MD; Charles Koo, MD; John D Kovac, MD; Tracy Kritz, MD; JudyKuhlman, NP; Nam Lam, MD; Daniel Lang, MD; Michael Lee, MD; Hollis Lee, MD; DavidLerman, MD, JD; Margaret Lin, MD; James Lindeen, MD; K David Liu, MD, MSc; CarlaLizarraga, RNP, CDE; Felicio Lorenzo, MD; Marcus Magallanes, MD; Daniel Marcus, MD; JuanyMazaira, NP; Michael McBeth, MD; Kerry McCabe, CNM; Patrick Merrill, MD; Steven Minaglia,MD; Alexander Miric, MD; Natasha Mironov, CNM; Richard Moldawsky, MD; Mark Mueller,MD; Manuel Myers, MD; Michael Neri, MD; Lisa Nyberg, MD, MPH; Theresa O’Donnell,MD; Ronda Ochoa, CPNP; Naheed Olsen, MD; Christine Phan, MD; Willye Powell, MD;Holly Pressburg, NP; Diana Ramos, MD; Albert Ray, MD; William Reilly, MD; Eugene Rhee,MD; Bradley Richie, MD; Ronald Rosengart, MD; Marlene Rosenwald-Becker, NP; MarkRutkowski, MD; Michael Ryan, MD; Firoozeh Sahebi, MD; Charles Salemi, MD; LisaSanders, MD; Asma Saraj, MD; Ramin Sarshad, MD; Gail Sateri, RNP; Thomas Schares, MD,MBA; Robert Schechter, MD; Matthew Schneiderman, MD; Michael Schwartz, MD; TheodoreScott, NP; Pranav Shah, MD; Alexander Shar, MD; Sung Shin, MD; Ellen Song, NP; Steven Soto deMayor, PA; Ricardo Spielberger, MD; Vishwas Tadwalkar, MD, FACS; Christopher Tarnay, MD,FACOG; Mitsuo Tomita, MD; Timothy Tran, MD; Melanie Turner, NP; Jessie Uppal, MD; KaroleVelzy, RNP; Jim Wang, MD; Edward C Wang, MD; John Weaver, MD; Calvin Weisberger, MD;Penelope Westney, MD; Nicolas Wieder, DO; Pauline Woo, MD; Edward Yang, MD; HuiquanZhao, MD, PhD; Fred Ziel, MD

Review BoardColorado Permanente Medical Group, PC (CPMG): Tim Adair, PA; Paulanne Balch, MD; PaulBarrett, MD, MSPH; John Brozna, MD, PhD; Heather Burton, MD, MA; Theresa Capaci, PA;Michael Chen, MD; Kathleen Cramm, PsyD; Richard Erickson, MD; Kenneth Faber, MD;Deborah Fisher, MD; Timothy Garling, PA; William Georgitis, MD, RDC; James Hardee, MD;Gregory Kirk, MD; Jill Levy, MD; Evelyn Lifsey, LPC; Karen Lucas, MD; Randall McVean, MD;Clara Elizabeth Miller, PhD; Judy Mouchawar, MD, MSPH; Ted Palen, MD, PhD; AlfonsoPantoja, MD; Robert Podolak, MD; Nancy Rogers, MD; Andrew Schreffler, MD; Peter Schultze,MD; Healther Shull, MD; Marie Spollen, PsyD; Richard Spurlock, MD; Michael Tobin, PhD;Patrick Williams, MD; Charles Wilson, MD; William Wright, MDHawaii Permanente Medical Group, Inc (HPMG): Scott Beattie, PA; Rossini Botev, MD; LisaCamara, MD; Monique Canonico, DO; John Chen, MD; Anita Dekker-Jansen, MD; HobieFeagai, MSN; James Ford, MD, MBA; Robert Frankel, PA-C; Paul Glen, MD; Lisa Hui, PCP;Esther Ines, FNP; Randy Jensen, MSN; Paula King, NP; Brian Lee, MD; Michelle Marineau,MSN, RN; Chenoa Morris, PA; Kevin Murray, PA; Bill Pfeiffer, MD; Stein Rafto, MD; CarlosRios, MD; J Marc Rosen, MD; Christian Sunoo, MDMid-Atlantic Permanente Medical Group, PC (MAPMG): Akin Abisogun, MD, PhD; DelroyAnglin, MD; Jean Arlotti, NP; Michael Caplan, MD; Maurice Cates, MD; Gail Cavallo, NP;Soma Chakraborty, MD; Susan Chhabra, MD; Harish Dave, MD; Christopher Della Santina,MD; Tarun Dharia, MD; Andrew Dutka, MD; Brian Egan, MD; Carol Forster, MD; HaroldFruchter, PA-C; Daniel Glor, MD; Virgil Graham, MD; Alan Halle, MD; Ann Hellerstein, MD;Mahrukh Hussain, MD; Leon Hwang, MD; Mutombo Kankonde, MD; Saul Kaplan, MD;Stuart Katz, MD; Ronald Klayton, MD; Thomas Krisztinicz, MD; Robert Kritzler, MD; LonnieLee, MD, L AC; Hing-Chung Lee, MD; Jeff Lowenkron, MD; Paula McNinch, MS; AnthonyMorton, MD; Cathriya Penny, NP; Peter Pham, MD; Martin Portillo, MD, FACP; AshokPrahlad, MD; Daniel Schwartz, MD; Christopher Spevak, MD, MPH; Duane Taylor, MD; MarkTerris, MD; Devika Wijesekera, MD; Sue Wingate, RN, DNSC; Bradley Winston, MD; ECWynne, MD; Jing Zhang, MD, PhDNorthwest Permanente, PC, Physicians and Surgeons (NWP): Michael Alberts, MD, PhD;Keith Bachman, MD; Kendall Barker, MD; Marcia Bertalot, NP; David Black, MD, MPH;Candace Bonner, MD, MPH; Radhika Breaden, MD, MPH; Suzanne Brown, CRNA; HomerChin, MD; Les Christianson, DO; Vicki Cohen, CNM; Susan Cooksey, PhD; Paul DeBaldo Jr,NP; Lawrence Dworkin, MD; Charles Elder, MD, MPH; Kitty Evers, MD; Adrianne Feldstein,MD, MS; Norman Freeman, MD; Patricia Hanson, PsyD; Bettylou Koffel, MD; Richard Konkol,MD; Mike Kositch, MD; Louis Kosta, MD, FACS; John Lasater, MD, MPH; Theresa Laskiewicz,MD; Steve Lester, MD; Amy Lindholm, MS; Joseph MacKenzie, PA; Sherwin Moscow, MA;Jeanne Mowry, MD; Chuong Nguyen, MD; Luanne Nilsen, MD; Christopher Pearce, OD; JimPowell, MD; Jock Pribnow, MD, MPH; James Prihoda, MD; Anita Rao, MD; Jacob Reiss, MD;Ed Ruden, MD; Joan Sage, MD; Michael Salinsky, MD; Ronald Sandoval, PhD; AlistairScriven, MD; Susan Sharp, PhD; David Shenson, MD; Kelly Sievers, CRNA; PhD; JohnSobeck, MD; Kathy Stewart, MD; Stephen Stolzberg, MD; Ron Swan, MS LPC; Micah Thorp,DO; Kathyleen Tomlin, LPD-CADC; Kelly Tuttle, NP; Victoria VanDyke, CNM; David Watt,MD; Don Wissusik, MA, MS; David Zeps, MDOhio Permanente Medical Group, Inc (OPMG): Andrew Altman, MD; Joseph Armao, MD;Kurt Birusingh, MD; Stephen Cheng, MD; Lydia Cook, MD; Eliot Gutow, LISW; Mark Hardy,DPM; Mark Roth, MD; Sardul Singh, MD; J Michael Wertman, MDThe Permanente Medical Group, Inc (TPMG): Pamela Anderson, MD; Wayne Arioto, DO;Jonathan Blum, MD; Lucienne Bouvier, MD; Jeffrey Brown, MD; Sherry Butler, MD; ThomasDailey, MD; Lianna Edwards, FNP-C; Rita Enright, NP; Pascal Fuchshuber, MD, PhD;Gordon Garcia, MD; Jay Gehrig, MD; Jan Herr, MD; Raymond Hilsinger, Jr, MD; GavinJacobson, MD; Myles Lampenfeld, MD; Juan Larach, MD; Theodore Levin, MD; David

EditorsTom Janisse, MD, MBA Editor-In-Chief& Publisher

Vincent J Felitti, MD Book ReviewsLee Jacobs, MD Health Systems

Arthur Klatsky, MD Clinical Contributions& Abstracts

Helen Pettay Care Management Institute

Scott Rasgon, MD KP In The Community& Corridor ConsultJon Stewart Public Policy

KM Tan, MD Continuing Medical Education

ProductionMerry Parker Managing Editor & Publisher

Lynette Leisure Print & Web Designer

Amy Eakin Director of Publishing Operations

Max McMillen Assistant Editor & Writer

Sharon Sandgren Production Assistant

Editing provided by the MedicalEditing Service of TPMGPhysician Education andDevelopment DepartmentLila Schwartz Senior Editor

David W Brown Copyright LibrarianJuan Domingo Assistant Editor - Graphics

Jan Startt Assistant Editor - Copyright

Administrative Team

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Mission: The Permanente Journal iswritten and published by the cliniciansof the Permanente Medical Groups andKFHP to promote the delivery of superiorhealth care through the principles andbenefits of Permanente Medicine.


2 LETTERS TO THE EDITOR

3 PERMANENTE ABSTRACTS

7 HMO ABSTRACTS

81 ANNOUNCEMENTS

84 CROSSWORD

85 BOOK REVIEWS

87 INDEX

91 CME EVALUATION FORM

Spring 2006/ Volume 10 No. 1

On the cover:

“Totem” by Joseph MacKenzie,PA, is a photograph recognizingthe peoples of the Northwestcoast who still carve great cedarlogs into the figures that fill theirstories about the beginnings ofthe world. Mr MacKenzie printshis photographs in his homestudio using archival inks andwatercolor paper to add depthand richness to the colors. He isa member of The BroadwayGallery in Longview, WA, andparticipates in other localexhibition events.

Mr MacKenzie is in the Department of Gastroenter-ology on the Interstate campus in Portland, OR.More of his art can be seen on page 24.

CLINICAL CONTRIBUTIONS 9 Stereotactic Radiosurgery:

Indications and Results — Part 2.Joseph C T Chen, MD, PhD;Michael R Girvigian, MD

This second of two parts pre-sents indications for this in-creasingly important option inthe treatment of central nervoussystem disease and discussesresults reported in the medicalliterature.

16 Predictive Value of the RapidWhole Blood AgglutinationD-Dimer Assay (AGENSimpliRED) in CommunityOutpatients with SuspectedDeep Venous Thrombosis.Julieta E Hayag, MD; Prem PManchanda, MD

The efficacy of using d-dimerassay to diagnose suspecteddeep venous thrombosis is re-viewed in this retrospectivestudy that considered electronicmedical record results of d-dimer assay and compressionultrasonography.

The Permanente Journal500 NE Multnomah St, Suite 100Portland, Oregon 97232www.kp.org/permanentejournal

ISSN 1552-5767

The Permanente Journal/ Spring 2006/ Volume 10 No. 1

SOUL OF THE HEALER24 “Green Sea Turtle”

Joseph MacKenzie, PA

56 “The Monks”Ming Jing (Mike) Wang, MD

80 “Zan”Sevada Younesian, RN

21 Corridor Consult

Snoring Versus ObstructiveSleep Apnea: A Case Report.Paul Bernstein, MD, FACS;JoAnne Higa Ebba, MD

This case report examinesthe diagnosis and treatmentof obstructive sleep apnea.

CME

CCC UPDATE51 Institute for Culturally Competent

Care: Clinicians’ Needs Assessment2005. Gayle Hunt; Saleena Gupte,DrPH, MPH

This article describes the 2005survey and the learnings gleanedfrom it.

53 A Successful Partnership to HelpReduce Health Disparities at KaiserPermanente: The Institute forCulturally Competent Care and theKaiser Permanente School ofAnesthesia. Nilda Chong, MD, MPH,DrPH; Sassoon M Elisha, CRNA, MS,EdD; Maria Maglalang, RN, MN, NP;Karen Koh, MPH, DrPHi

This article describes the genesisevolution, and potential impact ofan ongoing partnership betweenthe KP school of Anesthesia andthe California State University sys-tem in incorporating a formal cul-tural competence program.

Subscriptions: The Permanente Journal is available by group orindividual subscriptions. For information about subscriptionscontact 503-813-2623 or e-mail: [email protected] Manuscripts: Manuscripts submitted to TPJ arereviewed by members of the editorial staff and selected for peerreview. For more information regarding manuscript submissions,read “Instructions for Authors” on our Web site at www.kp.org/permanentejournal or contact our editorial office.Submitting Artwork: Send us a high-quality color photograph ofyour art no smaller than 4”x5” and no larger than 8”x10”. Pleaseinclude a cover letter explaining Kaiser Permanente association,art background, medium, size, and a brief statement about theartwork (description, inspiration, etc). Electronic and e-mailsubmissions are accepted; 600 dpi resolution is required.Editorial Office: The Permanente Journal500 NE Multnomah St, Suite 100, Portland, Oregon 97232Phone: 503-813-4387; Fax: 503-813-2348E-mail: [email protected]/permanentejournalDistribution: If you have any questions regarding distributionof this journal, contact 503-813-2623or e-mail: [email protected] to find The Permanente Journal: A full-text versionof this journal is available on our Web site: www.kp.org/permanentejournal. In addition, copies of The Permanente Journalare available in Kaiser Permanente libraries programwide and allnational medical school libraries.


Book reviewspage 85SPECIAL SECTION—SPIRIT

57 Writing and Telling Our ClinicalStories to Improve the Art ofMedicine.Tom Janisse, MD

58 Restoring Our Humanity:Our Intention to Heal.Fred Griffin, MD

59 Does Anyone Have a Case?The Balint Group Experience.Cecilia Runkle, PhD; LauraMorgan, MD; Eric Lipsitt, MD

60 Finding Meaning in Medicine.Laura Morgan, MD

61 Things Happen in the Park.Steve Long, MD

62 For Carl.Barbara Gardner, MD

62 Life Lesson.Shawna L Swetech, RN

63 Mountain.Laura L Wozniak, LCSW

64 One of Our Stories.Tom Janisse, MD

65 Doctoring My Doctor.Tom Janisse, MD

25 Fantastic Voyage: Questionsfrom the 21st Century.Joanne Schottinger, MD

26 Advances in Imaging—TheChanging Environment forthe Imaging Specialist.John Rego, MD; KM Tan, MD

29 Genetic Services in the KPSouthern California Region:Delivering the Promisesof Tomorrow Today.Mónica Alvarado, MS; NancyShinno, MD; C Douglas Monroe,MS, RPh; Mehdi Jamehdor, MD,FACMG; Kermit Anderson, MA

38 Kaiser Permanente SouthernCalifornia Regional TechnologyManagement Process: Evidence-Based Medicine Operationalized.Joanne Schottinger, MD; RichardM Odell

42 Update on InterventionalNeuroradiology.Amon Y Liu, MD

47 Implementation of aTeleradiology System to ImproveAfter-Hours Radiology Servicesin Kaiser Permanente SouthernCalifornia.Bruce Horn; Danny Chang, MD;Julian Bendelstein, MD; Jo CarolHiatt, MD

SPECIAL FEATUREA Focus on New Technology

This issue of The Permanente Journal explores exciting new technolo-gies, devices, tests, and drugs and, at the same time, poses the questionsrising from the many challenges these new technologies create, and triesto answer the question: How do I keep up with such rapidly changingmedical advances?

66 Evanescence.Mason Turner-Tree, MD

67 Miracle.Vicky Van Dyke, CNM

70 1970.Les J Christianson, DO

71 Insight.Kurt Smidt-Jernstrom, MDiV, MA

72 Silence.Laura Morgan, MD

73 Harpooning the Vein.Shawna L Swetech, RN

74 The Wheezing Cherub, Her EarthGrandmama, and OUR LOSSES.Ed Ruden, MD

75 The Young Father’s ImperfectGift of Life.Ed Ruden, MD

75 Hypochondriacal Atopic DermAdolescent.Ed Ruden, MD

76 Poetic Moments.Cecilia Runkle, PhD

76 Disbelief.Kurt Smidt-Jernstrom, MDiV, MA

CME

CME

HEALTH POLICY IN FOCUS77 Pay-for-Performance:

At Last or Alas?Michael J Pentecost, MD

This first in a series on healthpolicy describes the pay-for-performance movement, itssuccesses and downfalls.

PERMANENTEIN THE NEWS82 News Roundup.

Barbara Caruso

A compilation of news,significant awards, andaccomplishments aboutPermanente physicians andthe Permanente MedicalGroups.

CME

2 The Permanente Journal/ Spring 2006/ Volume 10 No. 1

From Our Readers letters to the editor

Dear Editor,

In the Fall 2005 issue Roundtable Discussion: Transfer of Successful Practices, in thesection: On The Permanente Journal as a Connector, Arthur Huberman, MD, men-tioned: “TPJ may be most useful as an adjunct to help connect people, to raiseawareness of things that can be used. Some people just need to read something andthen they go do it, some people need to talk to others, and some people need to gosee it.” Tom Janisse, MD, responded, “Yes, and journal articles have also been usedas support devices for transfer when they are used as data or evidence and added inreference lists.”

I can add a personal experience supporting this. In getting our psychiatrists toembrace group visits for patients getting stabilized on meds—not just “clinics,” whichare corrals from which patients are picked off one at a time, but truly interactivegroups in which patients help each other identify acute changes and successes whilegetting settled into one of our chronic care pathways—one of the decisive validatorsI used was the TPJ series on group medical visits, which brought not just evidencebut prestige and authority into the recipe. (Thank you!) The other decisive factor wasthe promise of a clinician who does group work regularly as a coleader.

Betram Barth, LCSWKaiser PermanenteSacramento Medical CenterDepartment of Psychiatry

Let us hear fr om you.We encourage you to write, either to respond to

an article published in the Journal or to address aclinical issue of importance to you. You maysubmit letters by mail, fax, or e-mail.

Send your comments to:The Permanente JournalLetters to the Editor500 NE Multnomah St, Suite 100Portland, Oregon, 97232Fax: 503-813-2348E-mail: [email protected]

Be sure to include your full address, phone andfax numbers, and e-mail address. Submission of aletter constitutes permission for The PermanenteJournal to publish it in various editions and forms.Letters may be edited for style and length.

Soul of the HealerArt & Stories of The Permanente Journal$18.95 each

A full-color collection of the art: paintings, photographs, sculptures, etc, andwritings: poetry, short stories, and essays, of The Soul of the Healer section ofThe Permanente Journal. This soft-bound 150+ page book brings together inone volume the creative contributions of Permanente clinicians from the first

seven years of publication.

This Limited First Edition is now available. Place your order now—only $18.95 each.

To order, send an e-mail including your name, phone number, address and credit card information to AmyEakin at [email protected] or call 503-813-2623. Multiple copies may be ordered at a discount.

If you prefer, you may send a check or money order, payable to The Permanente Journal, to the attention ofAmy Eakin, The Permanente Journal/Soul Book, 500 NE Multnomah Street, Suite 100, Portland, OR 97232.

Now Available

3The Permanente Journal/ Spring 2006/ Volume 10 No. 1

Abstracts of Articles Authoredor Coauthored by Permanente Physicians

Selected by Daphne Plaut, MLS, Librarian, Center for Health Research

permanente abstracts

From Northern and Southern CaliforniaAlcohol drinking and risk ofhospitalization for heart failurewith and without associatedcoronary artery disease.Klatsky AL, Chartier D, Udaltsova N, et al. AmJ Cardiol 2005 Aug 1;96(3):346-51.

Myocardial damage from heavy alcohol in-take can cause the heart failure (HF) syn-drome, but the relation of lighter alcohol in-take to HF has rarely been studied. Weexamined the risk of HF hospitalizationamong 126,236 subjects who supplied dataabout alcohol during health examinationsfrom 1978 to 1985. Among 2594 subjects whowere subsequently hospitalized for HF,record review established an associationbetween coronary artery disease (CAD) andHF (CAD-HF) in 1559 patients. Among theremaining 1035 subjects who had HF (non-CAD-HF), we attempted determination ofpreponderant etiologic and contributory fac-tors. Analyses used Cox models that werecontrolled for seven covariates, with usualalcohol intake studied categorically com-pared with that in subjects who did not drinkalcohol. Heavier drinkers (≥3 drinks/day) butnot light to moderate drinkers had increasedrisk of non-CAD-HF; eg, relative risk for sub-jects who reported ≥6 drinks/day was 1.7(95% confidence interval 1.1 to 2.6). Thisassociation of non-CAD-HF with heavy drink-ing was limited to subsets with cardiomy-opathy or of unclear preponderant etiology.Alcohol drinking was inversely related to riskof CAD-HF (eg, at 1 to 2 drinks/day, relativerisk 0.6, 95% confidence interval 0.5 to 0.7),with consistency across subgroups of age,gender, ethnicity, education, smoking status,interval to diagnosis, and presence or ab-sence of baseline heart disease or systemichypertension. Moderate drinking was in-versely related to non-CAD-HF only in sub-

jects who had diabetes mellitus (n = 252). Inconclusion, heavy, but not light, alcohol drink-ing is associated with increased risk of non-CAD-HF and that apparent protection by al-cohol drinking against CAD-HF risk providesconfirmation of a protective effect of alcoholagainst CAD.Reprinted from American Journal of Cardiology,V96(3), Klatsky AL, Chartier D, Udaltsova N,Gronningen S, Brar S, Friedman GD, Lundstrom RJ,Alcohol drinking and risk of hospitalization for heartfailure with and without associated coronary arterydisease, 346-51, Copyright 2005, with permission fromExcerpta Medica, Inc.

CLINICAL IMPLICATION: Confusion about therole of lighter alcohol drinking in the heartfailure (HF) syndrome exists because heavyintake can cause heart muscle damagewhile light-moderate intake protectsagainst coronary artery disease (CAD). Inthis study of risk of HF hospitalization in alarge population, separate analyses weredone for 1559 persons with HF associatedwith CAD and 1035 persons with HF fromnon-CAD causes. Heavy, but not light, al-cohol drinking was associated with in-creased risk of non-CAD-HF, while alco-hol drinking appeared protective againstCAD-HF risk. Thus, prohibition of lightdrinking is not warranted in most patientsat HF risk. –AK

From Northern CaliforniaClinical outcomes and cost-effectiveness of strategies formanaging people at high risk fordiabetes.Eddy DM, Schlessinger L, Kahn R. Ann InternMed 2005 Aug 16;143(4):251-64.

BACKGROUND: Lifestyle modification can fore-stall diabetes in high-risk people, but the long-term cost-effectiveness is uncertain.

OBJECTIVE: To estimate the effects of thelifestyle modification program used in theDiabetes Prevention Program (DPP) on healthand economic outcomes.

DESIGN: Cost-effectiveness analysis using theArchimedes model.

DATA SOURCES: Published basic and epidemio-logic studies, clinical trials, and KaiserPermanente administrative data.

TARGET POPULATION: Adults at high risk for dia-betes (body mass index >24 kg/m2, fastingplasma glucose level of 5.2725 to 6.9375mmol/L [95 to 125 mg/dL], two-hour glucosetolerance test result of 7.77 to 11.0445 mmol/L[140 to 199 mg/dL]).

TIME HORIZON: 5 to 30 years.PERSPECTIVE: Patient, health plan, and societal.INTERVENTIONS: No prevention, DPP’s lifestyle

modification program, lifestyle modificationbegun after a person develops diabetes, andmetformin.

MEASUREMENTS: Diagnosis and complicationsof diabetes.

RESULTS OF BASE-CASE ANALYSIS: Compared withno prevention program, the DPP lifestyleprogram would reduce a high-risk person’s30-year chances of getting diabetes fromabout 72% to 61%, the chances of a seriouscomplication from about 38% to 30%, andthe chances of dying of a complication ofdiabetes from about 13.5% to 11.2%.Metformin would deliver about one thirdthe long-term health benefits achievable byimmediate lifestyle modification. Comparedwith not implementing any prevention pro-gram, the expected 30-year cost/quality-adjusted life-year (QALY) of the DPPlifestyle intervention from the health plan’sperspective would be about 143,000 dol-lars. From a societal perspective, the cost/QALY of the lifestyle intervention comparedwith doing nothing would be about 62,600dollars. Either using metformin or delaying


permanente abstractsAbstracts of Articles Authored or Coauthored by Permanente Physicians

the lifestyle intervention until after a persondevelops diabetes would be more cost-effec-tive, costing about $35,400 or $24,500 perQALY gained, respectively, compared withno program. Compared with delaying thelifestyle program until after diabetes is diag-nosed, the marginal cost-effectiveness of be-ginning the DPP lifestyle program immedi-ately would be about $201,800.

RESULTS OF SENSITIVITY ANALYSIS: Variability anduncertainty deriving from the structure ofthe model were tested by comparing themodel’s results with the results of real clini-cal trials of diabetes and its complications.The most critical element of uncertainty isthe effectiveness of the lifestyle program,as expressed by the 95% CI of the DPPstudy. The most important potentially con-trollable factor is the cost of the lifestyleprogram. Compared with no program,lifestyle modification for high-risk peoplecan be made cost-saving over 30 years ifthe annual cost of the intervention can bereduced to about $100.

LIMITATIONS: Results depend on the accuracyof the model.

CONCLUSIONS: Lifestyle modification is likelyto have important effects on the morbidityand mortality of diabetes and should be rec-ommended to all high-risk people. The pro-gram used in the DPP study may be too ex-pensive for health plans or a national programto implement. Less expensive methods areneeded to achieve the degree of weight lossseen in the DPP.

CLINICAL IMPLICATION: Lifestyle modificationwith weight loss and exercise are impor-tant ways to reduce the risk of developingdiabetes and its complications in high-riskpeople. They should be strongly encour-aged. The particular lifestyle modificationprogram implemented in the Diabetes Pre-vention Program was very expensive andis unlikely to be cost-effective in most set-tings. Less expensive ways to help peoplelose weight need to be found and imple-mented. –DE

From The NorthwestHigher medical care costs accom-pany impaired fasting glucose.Nichols GA, Brown JB. Diabetes Care 2005Sep;28(9):2223-9.

OBJECTIVE: The purpose of this study was toestimate medical costs associated with el-evated fasting plasma glucose (FPG) and todetermine whether costs differed for patientswho met the 2003 (≥ mg/dL) versus the 1997(≥110 mg/dL) American Diabetes Association(ADA) cut point for impaired fasting glucose.

RESEARCH DESIGN AND METHODS: We identified28,335 patients with two or more FPG testresults of at least 100 mg/dL between 1 Janu-ary 1994 and 31 December 2003. Those withevidence of diabetes before the second testwere excluded. We categorized patients intotwo stages of abnormal glucose (100-109 mg/dL and 110-125 mg/dL) and matched each ofthese subjects to a patient with a normal FPGtest (<100 mg/dL) on age, sex, and year ofFPG test. All subjects were followed until anFPG test qualified them for a higher stage,dispensing of an anti-hyperglycemic drug,health plan termination, or 31 December 2003.

RESULTS: Adjusted annual costs were $4357among patients with normal FPG, $4580among stage 1 patients, and $4960 amongstage 2 patients (p < 0.001, all comparisons).After removing patients with normal FPG testswhose condition progressed to a higher stageor diabetes, costs in the normal FPG stagewere $3799. Patients in both stages 1 and 2had more cardiovascular comorbidities thanpatients with normal FPG.

CONCLUSIONS: Our results demonstrate thatabnormal glucose metabolism is associatedwith higher medical care costs. Much of theexcess cost was attributable to concurrentcardiovascular disease. The 2003 ADA cutpoint identifies a group of patients withgreater costs and comorbidity thannormoglycemic patients but with lower costsand less comorbidity than patients with FPGabove the 1997 cut point.Copyright © 2005 American Diabetes Association fromDiabetes Care, Vol 28, 2005; 2223-9. Reprinted withpermission from The American Diabetes Association.

CLINICAL IMPLICATION: Our primary findingwas that medical costs among patients withelevated fasting glucose were higher thanamong patients with normal glucose. How-ever, the cost differential was not nearly asgreat as between those with and without dia-betes. Thus, successful diet and exercisemodifications that have been shown to de-lay or prevent diabetes should result in costsavings. We also identified a subset of pa-tients with apparently normal FPG who pro-gressed to IFG or diabetes. These patients,although their FPG was normal, were sub-stantially costlier than their counterparts whodid not progress to defined levels of abnor-mal glucose. –GN

From ColoradoComparison of syndromic surveil-lance and a sentinel providersystem in detecting an influenzaoutbreak—Denver, Colorado,2003.Ritzwoller DP, Kleinman K, Palen T, et al. MMWR MorbMortal Wkly Rep 2005 Aug 26;54 Suppl:151-6.

INTRODUCTION: Syndromic surveillance sys-tems can be useful in detecting naturally oc-curring illness.

OBJECTIVES: Syndromic surveillance perfor-mance was assessed to identify an early andsevere influenza A outbreak in Denver in 2003.

METHODS: During October 1, 2003-January31, 2004, syndromic surveillance signals gen-erated for detecting clusters of influenza-likeillness (ILI) were compared with ILI activityidentified through a sentinel provider systemand with reports of laboratory-confirmed in-fluenza. The syndromic surveillance and sen-tinel provider systems identified ILI activitybased on ambulatory-care visits to KaiserPermanente Colorado. The syndromic surveil-lance system counted a visit as ILI if the pro-vider recorded any in a list of 30 respiratorydiagnoses plus fever. The sentinel providersystem required the provider to select “influ-enza” or “ILI.”

RESULTS: Laboratory-confirmed influenzacases, syndromic surveillance ILI episodes,



and sentinel provider reports of patient visitsfor ILI all increased substantially during theweek ending November 8, 2003. A greaterabsolute increase in syndromic surveillanceepisodes was observed than in sentinel pro-vider reports, suggesting that sentinel clini-cians failed to code certain cases of influenza.During the week ending December 6, whenreports of laboratory-confirmed cases peaked,the number of sentinel provider reports ex-ceeded the number of syndromic surveillanceepisodes, possibly because clinicians diag-nosed influenza without documenting fever.

CONCLUSION: Syndromic surveillance per-formed as well as the sentinel provider sys-tem, particularly when clinicians were advisedto be alert to influenza, suggesting thatsyndromic surveillance can be useful for de-tecting clusters of respiratory illness in vari-ous settings.

From Northern CaliforniaComparison of glyburide andinsulin for the management ofgestational diabetes in a largemanaged care organization.Jacobson GF, Ramos GA, Ching JY, Kirby RS, Ferrara A,Field DR. Am J Obstet Gynecol 2005 Jul;193(1):118-24.

OBJECTIVE: This study was undertaken tocompare the use of glyburide with insulinfor the treatment of gestational diabetes mel-litus (GDM) unresponsive to diet therapy.

STUDY DESIGN: A retrospective study was per-formed among women with singleton preg-nancies who had GDM diagnosed, with fast-ing plasma glucose 140 mg/dL or less onglucose tolerance testing, between 12 and34 weeks who failed diet therapy from 1999to 2002. We identified 584 women and com-pared those treated with insulin between1999 and 2000 with women treated withglyburide between 2001 and 2002. Maternaland neonatal outcomes and complicationswere assessed. Statistical methods includedunivariate analyses and multivariable logis-tic regression.

RESULTS: In 1999 through 2000, 268 womenhad GDM diagnosed and were treated withinsulin; in 2001 through 2002, 316 womenhad GDM diagnosed of which 236 (75%) re-

ceived glyburide. The two groups were simi-lar with regard to age, nulliparity, and his-torical GDM risk factors; however, womenin the insulin group had a higher mean bodymass index (31.9 vs 30.6 kg/m 2, p = .04),a greater proportion identified themselvesas white (43%, 28%, p < .001) and fewer asAsian (24%, 37%, p = .001), and they had asignificantly higher mean fasting on glucosetolerance test (105.4 vs 102.4 mg/dL, p =.005) compared with the glyburide group.There were no significant differences inbirth weight (3599 ± 650 g vs 3661 ± 629 g,p = .3), macrosomia (24%, 25%, p = .7), orcesarean delivery (35%, 39%, p = .4).Women in the glyburide group had a higherincidence of preeclampsia (12%, 6%, p = .02),and neonates in the glyburide group weremore likely to receive phototherapy (9%,5%, p < .05), and less likely to be admittedto the neonatal intensive care unit (NICU)(15%, 24%, p = .008) though they had alonger NICU length of stay (4.3 ± 9.6 vs 8.0± 10.1, p = .002). Posttreatment glycemiccontrol data were available for 122 womentreated with insulin and 137 women treatedwith glyburide. More women in theglyburide group achieved mean fasting andpostprandial goals (86%, 63%, p < .001).These findings remained significant in logis-tic regression analysis.

CONCLUSION: In a large managed care orga-nization, glyburide was at least as effectiveas insulin in achieving glycemic control andsimilar birth weights in women with GDMwho failed diet therapy. The increased riskof preeclampsia and phototherapy in theglyburide group warrant further study.Reprinted from American Journal of Obstetrics andGynecology, V193(1), Jacobson GF, Ramos GA,Ching JY, Kirby RS, Ferrara A, Field DR, Compari-son of glyburide and insulin for the managementof gestational diabetes in a large managed care or-ganization, 118-24, Copyright 2005, with permissionfrom Elsevier.

CLINICAL IMPLICATION: Our study showed thatglyburide is a reasonable alternative to in-sulin for the treatment of gestational diabet-ics who fail diet therapy. We successfullydemonstrated this in a large clinical setting.

It is important that these women receive allthe other standard prenatal, intrapartum, andpostpartum care that would have been pro-vided if they were on insulin, including fre-quency of visits, counseling, and antepar-tum surveillance. –GJ

From ColoradoRadiation exposure to the handsfrom mini C-arm fluoroscopy.Singer G. J Hand Surg [Am] 2005 Jul;30(4):795-7.

PURPOSE: To quantify the level of radiationexposure to the hands of hand surgeons us-ing intraoperative mini C-arm fluoroscopy andto compare the actual level of exposure withpredicted levels and acceptable limits.

METHODS: Five hand surgeons were givenring dosimeters to measure radiation expo-sure to their hands during surgery of the fin-ger, hand, and wrist. A total of 81 rings wereanalyzed. After the clinical study a phantomwas used to measure scatter at close rangefrom the mini C-arm.

RESULTS: Surgeons’ hands were exposed toan average ±SD of 20 ± 12.3 mrem/case. Forcomparison a chest x-ray results in approxi-mately 20 mrem exposure to the patient. Ra-diation exposure for the group of hand sur-geons ranged from 5 to 80 mrem. Surgeonsused an average of 51 ± 36.9 seconds of fluo-roscopy time per case. Exposure time for thegroup ranged from 6 to 170 seconds. Theradiation scatter rate decreases precipitouslyoutside the beam or beyond the radius of theintensifier. An average exposure to the handsof 20 mrem/case suggests that surgeons’hands must be entering the beam and get-ting direct exposure.

CONCLUSIONS: Hand surgeons work close tothe beam and as a result their hands poten-tially are exposed to a nontrivial amount ofradiation. We recommend that surgeonswho use the mini C-arm use precautions tominimize radiation exposure, particularly totheir hands.Reprinted from Journal of Hand Surgery [AM], 30(4),Singer G, Radiation exposure to the hands from miniC-arm fluoroscopy, 795-7, Copyright 2005, with per-mission from American Society for Surgery of the Hand.



CLINICAL IMPLICATION: The mini C-arm fluo-roscope is being used increasingly in traumaclinics, emergency rooms and operatingrooms. This study provides both clinical dataand experimental scatter data to quantify ex-posure for the health care worker operatingthe machine. Results show that althoughexposure is low relative to allowable levels,they are higher than might be expected.Scatter to the operator’s torso appears to besmall, but radiation from direct exposure tothe operator’s hand is higher than expected.In addition to other measures to minimizeradiation exposure, one should specificallyavoid putting ones’ hand directly in the beamwhen operating the fluoroscope. –GS

From Southern CaliforniaObesity and perioperative morbid-ity in total hip and total kneearthroplasty patients.Namba RS, Paxton L, Fithian DC, Stone ML. J Arthro-plasty 2005 Oct;20(7 Suppl 3):46-50.

The incidence of obesity in 1071 total hiparthroplasty (THA) patients and 1813 totalknee arthroplasty (TKA) patients and its ef-fect on perioperative morbidity were evalu-ated prospectively. Fifty-two percent of TKAand 36% of THA patients were obese (bodymass index ≥30). The obese patients weresignificantly younger, with a higher propor-tion of obese TKA patients being women.Higher rates of diabetes and hypertensionwere found in obese patients. Higher post-

operative infection rates were observed inpatients with body mass index 35 or higher.The odds ratio was 6.7 times higher risk forinfection in obese TKA patients and 4.2 timeshigher for obese THA patients. The increasedrisk of infection in obese patients undergo-ing total joint arthroplasty must be realizedby both the patient and surgeon. ❖Reprinted from Journal of Arthroplasty, V20(7 suppl3), Namba RS, Paxton L, Fithian DC, Stone ML, Obe-sity and perioperative morbidity in total hip and totalknee arthorplasty patients, 46-50, Copyright 2005, withpermission from Elsevier.

What MattersIt’s not what you look at that matters.

It’s what you see.

—Henry David Thoreau, 1817-62, naturalist and poet


abstracts

11th Annual HMO Research Network Conference

Abstracts from the HMO Research Network

With this issue we include abstracts fromthe 2005 11th Annual HMO ResearchNetwork Conference, held in Santa Fe,New Mexico, that focused on “Translat-ing Research into Practice.”

April 4-6, 2005 Santa Fe, NM“Translating Research Into Practice—Scaling New Heights”

From Group Health Center for HealthStudies, Seattle, WA; University ofWashington, Seattle, WAEffect of Mindfulness-Based StressReduction on persons with chronicback pain.Cherkin D, Sherman K, Erro J, Deyo R.

BACKGROUND: Numerous therapies exist fortreating chronic low back pain (CLBP) butfew, if any, have been found to be cost-ef-fective. There remains a need to identify treat-ments whose benefits outweigh their costs.This pilot study evaluated the effect on CLBPof an inexpensive and potentially life-chang-ing training program, Mindfulness-BasedStress Reduction (MBSR).

METHODS: Members of a large health planwith uncomplicated low back pain persistingover three months were invited to participatein a trial comparing MBSR (eight weekly 2.5hour sessions) with a book on self-manage-ment techniques. Forty-six volunteers wererandomized to MBSR (n = 22) or the book (n= 24). Outcomes measured before random-ization and after 12 and 26 weeks includedfunction (Roland) symptom bothersomeness(0 to 10 scale) and general health status (SF-36). MBSR training participants were alsoasked about its effect on their thoughts, feel-ings, reactions, or activities.

RESULTS: Eighty-two percent of participantsrandomized to MBSR attended at least oneclass (median seven classes). Adjusting forbaseline values, the MBSR group fared betterthan the book group by 1.9 points on the

Roland scale at 12 weeks (p > 0.05), but byonly 0.3 points at 26 weeks (p > 0.05). Differ-ences in SF-36 and symptom bothersomenesswere small. However, at 26 weeks, all 16 re-spondents in the MBSR group claimed to bepracticing MBSR for an average of four daysper week and 20 minutes per day and to haveexperienced lasting benefits, most commonlydecreased stress, increased ability to relax,increased mindfulness, and ability to cope.

CONCLUSIONS: Although this pilot study foundonly limited and temporary benefits of MBSRon conventional CLBP outcomes (function,symptoms), informal qualitative feedbacksuggests MBSR may have other importantbenefits (eg, coping, attitude) for persons withCLBP and possibly for other conditions causedor exacerbated by life stress.

From HealthPartners ResearchFoundationThe boomers are coming: A totalcost of care model of the impactof population aging on the cost ofchronic conditions in the US.Garrett N, Martini EM.

BACKGROUND: This study estimates the im-pact of population aging on medical costsover the next five decades in the US. Thefocus is on chronic and/or expensive condi-tions often included in disease managementprograms: coronary artery disease, conges-tive heart failure, diabetes, asthma, obstetrics,psychiatry, and chemical dependency. We gobeyond previous macro-economic studies bymodeling the effects of aging on medical costsat a clinically meaningful level of detail.

METHODS: Our model applies estimated age-,gender-, and condition-specific annualizedcosts to US population projections in eachage and gender group through 2050. Thisprovides an estimate of future health carecosts, assuming the age, gender, and diseasecost profiles remain the same and holdingother factors that could affect costs constant.

The primary data sources are pooled claimsand membership for 2002-2003 forHealthPartners. Secondary sources are USannualized medical costs and US Census Bu-reau demographic projections. Populationsused to create age-specific per capita costsinclude Commercial, Medicaid, and Medicare.We group medical claims, pharmacy claimsand demographic information into clinicallymeaningful Symmetry episode treatmentgroups (ETGs) representing complete epi-sodes of care. We aggregate selected ETGsinto the conditions reported in this study.

RESULTS: We project that from 2000-2050 theaging of the population would result in an18% increase in overall medical costs overthe next five decades, with most of the changetaking place from 2000-2030. However, thereis a great deal of variation of the impact ofpopulation aging on specific chronic diseases.Diseases where the ratio of costs for older vsyounger ages is greater, such as CAD, CHF,and diabetes will be affected most by popu-lation aging.

CONCLUSIONS: These disease-specific projec-tions can inform health policy and planningas providers of health care, health plans, anddisease management vendors anticipate meet-ing future US health care needs.

From KPNWEffectiveness and acceptability ofcomplementary and alternativemedicine for temporomandibularjoint disorder among HMOmembers.Vuckovic NH, Gullion CM.

BACKGROUND: We report on a study testingthe feasibility, acceptability and effects of CAMvs Usual Care as treatment for temporoman-dibular joint disorder (TMD), a chronic, fre-quently intractable pain condition. Althoughprevious studies have indicated the extensiveuse of CAM by the general public and by HMOmembers (including KPNW), as well as the


effectiveness of CAM for treating chronic pain,questions remained regarding the willingnessof HMO members to be randomized to CAMas opposed to usual dental care for TMD,and about the effectiveness of the modalitiesand protocols used in this study.

METHODS: Participants were screened via self-report of pain and by a clinical TMD exam.Eligible volunteers were randomized to ei-ther acupuncture, acupuncture plus herbs,chiropractic, massage, or usual care. Partici-pants in the CAM arms received ten treat-ments following protocols developed by CAMpractitioners. Usual care participants receivedstandard care that included treatment in TMDclinic and possible referral to classes, physi-cal therapy and/or medications. Usual carewas provided in KPNW TMD clinic; CAMtreatments occurred in practitioners’ offices.Study outcomes of change from baseline inusual and worst pain was measured by self-report questionnaire. Acceptability of treat-ment was measured by adherence to treat-ment, self-report, and qualitative interviews.

RESULTS: Of the 216 participants randomized,17 refused initial treatment. Of the remaining199 participants, 165 completed the interven-tion. We used an intent-to-treat analysis usingmixed model analysis of variance with re-stricted maximum likelihood estimation toanalyze the effects of treatment. Analysis indi-cates that CAM treatments reduced usual andworst pain as well as or better than usual care.Most patients indicated they would go backto their study provider or to another CAMprovider for TMD treatment in the future.

CONCLUSIONS: The apparent positive effectsof CAM for chronic pain and its acceptabilityand desirability among members suggest thatmanaged care organizations should considerCAM as a viable service option.

From Henry Ford Health SystemsPatient-physician colorectal cancerdiscussions in primary care.Lafata JE, Moon C, Divine G, Williams LK

BACKGROUND: Routine screening is known toreduce colorectal cancer (CRC) morbidity andmortality. Yet, many people (including thosereceiving routine primary care) fail to receiverecommended screening. How physicians and

patients discuss CRC screening and how thesediscussions impact screening use is not known.

METHODS: We mailed surveys to 4966 HMOenrollees aged 50-80 years with a recent visitto a PCP. The survey collected information onthe content of CRC screening discussions (in-cluding the “5 As”: Assess, Advise, Agree, As-sist, and Arrange) as well as patient preferencesfor shared decision making. Survey responseswere linked with five-year claims data on priorCRC screening use. We estimate the propor-tions of primary care patients receiving recom-mended CRC screening, discussing CRC screen-ing with their physician and, among thosediscussing CRC with their physician, reportingdifferent elements of discussion content.

RESULTS: Among the 2513 survey respondents(50.6% response rate), 58.7% were female,68.1% were married, and 34.4% were AfricanAmerican. Fifty-four percent received recom-mended CRC screening and 79.6% reporteddiscussing CRC screening with their physician.The most frequently discussed screening mo-dality was colonoscopy (70.7%), followed bysigmoidoscopy (41.4%) and fecal occult bloodtesting (40.6%). Approximately two thirds in-dicated discussing their interest in screening(“assess”), 36.1% reported being offered achoice among different screening modalities(“advise”) and 31.1% were asked about theirpreferences for different types of tests (“agree”).Over half (55.5%) reported receiving helpmaking an appointment (“assist”) and 60.9%indicated receiving information on how to gettest results (“arrange”). Three quarters of re-spondents indicated they were involved inthe CRC screening decision-making processas much as they wanted and 13.9% indicatedthere was information they wanted but notdiscussed with their physicians.

CONCLUSIONS: The majority of primary carepatients report discussing CRC screening withtheir physicians. Yet, the content of these dis-cussions varies and almost half have not re-ceived recommended CRC screening. Giventhe limited time PCPs and patients have to dis-cuss CRC screening, it is important that dis-cussions be as productive as possible. Whetherthe use of a shared decision-making processand the “5 As” lead to improved CRC screen-ing adherence remains an important question.

From HealthPartners ResearchFoundationRelationship of psychosocial andhealth factors and continuity ofcare to ED use among seniors.Whitebird RR, Gunnarson TM, Flottemesch TJ,Asche SE, Martinson BC, Degelau JJ.

BACKGROUND: This study examines the rela-tionship between Emergency Department(ED) use and health status, psychological,social factors, and continuity of primary carein a senior population of HMO members.

METHODS: An observational study using sur-vey data and two-year prospective adminis-trative data in a sample of 11,338 seniors en-rolled in an HMO from 1995 through 1997.The study used multinomial logistic regressionanalysis to model relationships betweenbiopsychosocial factors, continuity of care andED utilization. Health status and social supportmeasures were collected by survey. Depressionwas measured with administrative data usingICD9 codes. Continuity of primary care wascalculated based on the number of visits witha single primary care provider for patientswith two or more primary care visits.

RESULTS: The mean age of the study popula-tion was 73 years of age, 42% were male, 27%reported living alone, 13% had a Charlson scoreof two or greater, 29% of the population hadED use during the two-year study period. Re-sults showed that advanced age, male gender,Charlson score, poor perceived health, highermedication use, falls within the prior sixmonths, need for assistance with activities ofdaily living, and use of assistive devices weresignificantly related to one ED visit. Age > 75,multiple medications, depression, low socialcontact, living alone, bereavement in the priorsix months, and low continuity of primary carewere related to multiple ED visits.

CONCLUSION: ED use among seniors is correlatedwith a complex of physical, health status andpsychosocial factors. Psychosocial factors and lowcontinuity of primary care were strongly relatedto multiple ED visits. Interventions directed toED use among seniors should include compo-nents that address these psychosocial issues andimprove continuity in the provision of primarycare, in addition to the management of chronicconditions and declining health status. ❖

abstractsAbstracts from the HMO Research Network


Stereotactic Radiosurgery:Indications and Results — Part 2

By Joseph C T Chen, MD, PhDMichael R Girvigian, MD

clinical contributions

AbstractStereotactic radiosurgery and fractionated stereotactic

radiotherapy represent an increasingly important optionin the treatment of central nervous system disease. In thisarticle, we discuss indications for stereotactic radiosurgeryand review results reported in the medical literature.

IntroductionStereotactic radiosurgery differs from open surgery

insofar as stereotactic radiosurgery has no immediatecytoreductive role. Instead, the goal of radiosurgery isto change the biology of tumor cells so as to inhibittheir proliferative potential. A successful outcome ofradiosurgical treatment is therefore arrest of tumorgrowth, not disappearance of the tumor. Radiosurgeryis therefore inappropriate for patients who are symp-tomatic from mass effect of tumors. Regardless of masseffect, however, another limiting aspect of radiosurgeryis tumor size: Because external beam techniques canachieve only a limited degree of conformity, radiosurgicaltreatment of larger tumors may expose normal tissue toan unacceptably high level of radiation. Large tumorsmay require surgical debulking (ie, to reduce tumorvolume) so that single-fraction radiosurgical treatmentcan be used. Fractionated treatments are another alter-native for patients with large tumors.

Radiosurgery as Treatmentfor Benign Tumors

Radiosurgery has been used extensively for treating be-nign tumors of the central nervous system. The most exten-sively developed data for radiosurgical treatments have per-tained to treatment of acoustic neuroma (vestibularschwannoma) and meningioma of the skull base. The clearmargins and discrete imaging characteristics of these tumorsmake them ideal candidates for radiosurgical treatment.

Radiosurgical treatment eliminates risks of blood loss,infection, anesthesia complications, and otherperioperative risks. In addition, radiosurgery is adminis-

tered on an outpatient basis, thereby eliminating theneed for hospitalization, specialized care in the inten-sive care unit (ICU), and rehabilitation. For these rea-sons, radiosurgery is a compelling treatment alternativefor many patients. For patients who are medically frag-ile or who cannot accept the potential complications ofsurgery (eg, risks inherent in blood transfusion), radio-surgery may be the only feasible treatment alternative.

Radiosurgical Treatmentof Acoustic Neuroma

Acoustic neuroma has been treated with radiosur-gery since the 1960s. However, initial results of thistechnique were poor because the only imaging mo-

Joseph C T Chen, MD, PhD, (left) is the Neurosurgical Director for RadiosurgeryServices in the KP Southern California Region. E-mail: [email protected].

Michael R Girvigian, MD, (right) is a radiation oncologist at the KP Los AngelesMedical Center Department of Radiation Oncology. E-mail: [email protected].

Figure 1. Photograph shows Novalis LINAC device(BrainLAB, Heimstetten, Germany) used at the SouthernCalifornia Kaiser Permanente Regional RadiationOncology Center.

A successfuloutcome of

radiosurgicaltreatment is

therefore arrestof tumor

growth, notdisappearanceof the tumor.


clinical contributionsStereotactic Radiosurgery: Indications and Results — Part 2

dalities available at the time were imprecise, methodsfor planning treatment were relatively primitive, andclinicians selected what we now know to be exces-sively high doses of radiation. Early treatment methodsincluded angiography or contrast cisternography fol-lowed by use of two-dimensional dose-planning tech-niques. Such two-dimensional techniques yielded rela-tively nonconformal treatments that risked not onlyunderdosing of tumor tissue but also overdosing ofnormal tissue. In addition, excessively high doses wereused--as high as 35 Gy in a single fraction. Comparedwith modern methods, this treatment resulted in rela-tively poor tumor control and high incidence of cranialnerve injury. Nonetheless, treatment results were ac-ceptable for some high-risk patients.

The advent of MRI imaging, three-dimensional com-puter-assisted dose planning, and modern dosingschedules have dramatically improved rates of morbid-ity from radiosurgery as well as overall tumor control(Figure 1). Numerous studies from various centers aroundthe world have repeatedly shown the safety and effi-cacy of classical radiosurgery for treating acoustic neu-roma. Five-year follow-up has shown that current tech-niques provide overall clinical tumor control in 97% to98% of lesions treated.1-4 The facial nerve is preserved inapproximately 99% of patients receiving this treatment,and hearing is preserved in more than 70% of treatedpatients. Mortality and morbidity from the procedure isextraordinarily low in comparison with contemporaryseries describing surgical extirpation of these tumors.

From the standpoint of hearing preservation, intro-duction of fractionated stereotactic radiotherapy mayimprove upon the already superior results of radiosur-gery and may allow use of radiosurgery for larger tu-mors not previously treatable with classical radiosurgery.5

Radiosurgery using present techniques results in out-standing cranial nerve preservation and tumor-controlrates similar to those reported in the surgical literaturewhile eliminating the risk of immediate periproceduralcomplications. We and others believe that radiosurgeryshould be firstline treatment for all acoustic tumors mea-suring <2.5 cm in diameter.6 Patients with larger tumorsshould be given the choice of receiving either fraction-ated stereotactic radiotherapy or surgical extirpation. Theresults of radiosurgical intervention for acoustic neuromacan also be applied to other types of cranial nerveschwannoma, such as trigeminal schwannoma.

MeningiomaMeningioma is a tumor that arises from arachnoidal

cap cells commonly associated with arachnoid granu-

lations at the dural venous sinuses, cranial nerve fo-ramina, cribriform plate, and medial middle fossa. Thetumor is most commonly benign but may exhibit atypi-cal or even malignant features and behavior. The le-sion may arise anywhere along the dura, including theconvexity and base of the skull. Modern imaging tech-niques have enabled highly reliable diagnosis of thistype of tumor.

Convexity and falcine meningiomas are easily treatedusing conventional open surgical techniques. Modernanesthesia combined with meticulous surgical tech-niques may result in high rates of gross total surgicalresection with minimal morbidity and mortality (Fig-ure 2). For these lesions, open surgical treatment re-mains the preferred treatment for patients with lowmedical risk.

Various lesions of the skull base present substantiallyhigher overall operative risk. Most tumors located inthis region are intimately associated with critical ner-vous and vascular structures; therefore, attempts at to-tal resection carry substantial risk of morbidity to thesenerves. Published surgical series7,8 have shown rela-tively high rates of cranial nerve palsy as well as leak-age of cerebrospinal fluid and high risk of tumor re-currence.

Because of these risks, radiosurgery has become anincreasingly attractive alternative to microsurgical re-section for lesions located at the skull base. Publishedseries9 have described radiosurgical management ofthese lesions and have shown excellent overall tumor

Figure 2. MRI scan shows response of craniopharyn-gioma to fractionated stereotactic radiotherapy in a boyaged eight years at time of treatment. Left, postoperativeview. Right, MRI obtained nine months after the patientreceived fractionated stereotactic radiotherapy at theSouthern California Kaiser Permanente RegionalRadiation Oncology Center. Note that resolution of cysticcomponent of tumor is accompanied by reducedbrainstem compression and relief of temporal horndilatation.

Numerousstudies from

various centersaround the worldhave repeatedly

shown the safetyand efficacy of

classicalradiosurgery fortreating acoustic

neuroma.



control and extremely low rates of morbidity. In fact,in patients with meningioma, tumor control with ra-diosurgery has been shown equivalent to that of grosstotal resection and produced only minimal morbidity.10

For certain types of meningioma of the skull base,such as meningioma affecting the cavernous sinus,11-15

orbital apex, clivus, and petrous bones,16-18 radiosur-gery has been clearly shown to be the most preferabletreatment. In addition to the data developed by nu-merous groups showing superior tumor control andextraordinarily low risk of cranial nerve deficits, radio-surgery and fractionated stereotactic radiotherapy clearlyhave improved cranial nerve function in a high per-centage of patients who had functional impairmentcaused by tumor progression.

Pituitary AdenomaPituitary adenoma is a benign tumor of the anterior

pituitary gland. Most of these tumors are nonfunctionalfrom the standpoint of their endocrine activity, althoughothers can be the proximal cause of Cushing’s disease,hyperprolactinemia, acromegaly, and hyperthyroidism.Generally, the preferred means of managing these le-sions is transsphenoidal excision, an approach whichhas been proved safe and effective. Benefits of thisapproach are relatively low morbidity and rapid cor-rection of endocrinopathy. Nonetheless, subtotal re-section and failure of inducing endocrine remissionremain problems. The endocrine remission rate for func-tional adenoma remains approximately 70% among allpatients who receive treatment for this tumor.19

Salvage treatments given after failed transsphenoidalexploration include reoperation and conventional frac-tionated external-beam radiotherapy. Conventional ra-diotherapy has been a time-tested option but has thedisadvantage of long latency of effect before endo-crine remission is established.20,21

In instances of endocrine failure or presence of grossresidual disease, stereotactic radiosurgery has becomean important means of salvage treatment. Of patientswho had no disease remission after having surgery forCushing’s disease, 60% to 85% may have disease re-mission after receiving salvage stereotactic radiosur-gery.22-24 Similar outcomes have resulted from using ste-reotactic radiosurgery to treat prolactinoma and growthhormone-secreting adenoma.25,26

ChordomaChordoma is a highly aggressive tumor which can

arise from the skull base or from the spine. The tumoris malignant and has a high rate of recurrence after

resection. Modern management of these tumors uses amultimodality approach which includes aggressive sur-gical resection followed by stereotactic radiosurgery, ste-reotactic radiotherapy, or particle-beam irradiation.27-29

Multimodality treatment results in an overall five-yearsurvival rate of approximately 80%. Conventional ex-ternal-beam techniques are difficult to use because theyrequire use of very high radiation doses to achievetumor control.

CraniopharyngiomaCraniopharyngioma arises from remnants of the cran-

iopharyngeal pouch. This type of tumor is histologi-cally benign but tends to recur locally after surgicalremoval. Nonetheless, aggressive surgical removal of thistumor can be hazardous because it can be locally inva-sive of brain tissue. Common complications associatedwith these tumors include pituitary insufficiency (includ-ing diabetes insipidus), hypothalamic injury, and loss ofvision. Surgical excision of these tumors can produce highrates of local control, but this treatment carries a substan-tial risk of recurrence. In cases where subtotal resection isachieved, stereotactic radiosurgery and fractionated ster-eotactic radiation treatment can be of great utility (Fig-ures 3, 4), yielding high overall rates of tumor control andsurvival as well as low rates of morbidity.30-32

GliomaPatients with high-grade malignant glioma continue

to have a dismal prognosis despite decades of inten-sive clinical and laboratory investigation. Currentpractice for management of these lesions commonlyincludes surgery, conventional external-beam radio-therapy, and chemotherapy.

Radiosurgery as an additional treatment modality forthese tumors has been suggested to be useful in some

Figure 3. MRI scan shows early result nine months aftersingle-fraction stereotactic radiosurgery performed atSouthern California Kaiser Permanente RegionalRadiation Oncology Center for left-sided acousticneuroma. Note response to radiation as shown by loss ofcentral contrast enhancement within tumor. Tumor sizewas not substantially changed in this case.

Patients withhigh-grademalignant

glioma continueto have a

dismalprognosis

despite decadesof intensiveclinical andlaboratory

investigation.



limited circumstances.33,34 However, a recent RadiationTherapy Oncology Group phase III trial, RTOG 93-05,was unable to show any advantage of using radiosur-gery for high-grade glioma.35 Thus, effective long-termcontrol of malignant gliomas cannot be achieved bylocal treatment, such as radiosurgery. Effective man-agement of this devastating disease awaits a method oftreating the central nervous system as a whole.

Similarly, data regarding use of radiosurgery to treatlow-grade and anaplastic-grade infiltrative glioma areweak. Use of radiosurgery to treat such lesions, there-fore, cannot be considered as routine adjuvant therapy.

Pilocytic astrocytoma is a type of low-grade gliomathat is typically well circumscribed and often amenableto surgical resection that results in long-term survival.Nonetheless, these tumors may develop in locationsunfavorable for surgical management. As standalonetreatment or in conjunction with conservative debulkingsurgery, radiosurgery for these lesions may offer im-portant advantages over open surgery alone,36,37 al-though data conclusively proving this point are stillunavailable.

Metastatic DiseaseIn contrast to glioma, where progression of disease

is marked by infiltrative changes, metastases to the braintypically have discrete margins. Before radiosurgery wasfirst introduced, metastases to the brain were best treatedby surgical excision (whenever feasible) in conjunc-tion with whole-brain radiotherapy.38

The advent of radiosurgery has heralded a revolu-tion in management of metastatic lesions. Althoughexternal-beam radiotherapy remains an important treat-ment component, radiosurgery can in many instancesreplace surgical resection.39-41 This treatment approachresults in high rates of lesion control and overall post-operative survival rates comparable to those producedby surgery with whole-brain radiotherapy. In this field,current controversy surrounds the role of radiosurgeryin relation to whole-brain radiotherapy.

General selection criteria for treating metastases in-clude Karnofsky score >70, four or fewer lesions, andlesion volume <9 mL.

Trigeminal NeuralgiaTrigeminal neuralgia is characterized by paroxysms

of severe, lancinating facial pain which is sometimescaused by an arterial vessel loop compressing thetrigeminal nerve in the root-entry zone. Trigeminalneuralgia typically responds well to anticonvulsantmedication such as carbamazepine; in many patients,however, the condition becomes refractory to medicalmanagement. Surgical intervention may be indicatedin such instances. Surgical intervention falls into twogeneral categories: destructive techniques and microvas-cular decompression.

Figure 4. Images of cranium of a 78-year-old womanwho had loss of vision and sellar tumor with dural tail(tuberculum sella meningioma) treated with fractionatedstereotactic radiotherapy at the Southern California KaiserPermanente Regional Radiation Oncology Center. A,Pretreatment MRI scan shows sellar tumor; B, MRI scanshows clinically significant reduction of tumor volume ninemonths after treatment. Comparison of automatedperiphimetry scans obtained before treatment (C) andafter treatment (D) shows improvement in visual fields.

Figure 5. Typical dose plan for stereotactic radiosurgerytreatment of trigeminal neuralgia.

The advent ofradiosurgery

has heralded arevolution in

management ofmetastatic

lesions.



Destructive techniques include percutaneousradiofrequency rhizolysis, balloon microcompression,and glycerol injection. These procedures have the ad-vantage of low procedural risk and have the disadvan-tage of precipitating facial numbness. These procedurescan also be very uncomfortable for the patient.

Microvascular decompression involves craniotomyand microdissection with the goal of separating a com-pressing vascular loop away from the trigeminal rootentry zone. Microvascular decompression offers thehighest rates of long-term remission from facial pain aswell as low risk of causing facial numbness. Microvas-cular decompression is highly invasive, however, andcarries with it the risk associated with craniotomy.

Trigeminal radiosurgery is a destructive technique thetarget of which is the segment of the trigeminal nervewithin the prepontine cistern (Figure 5). This proce-dure could therefore be described as a retrogasserianradiosurgical rhizolysis. Overall, it results in initially goodand excellent outcomes for approximately 80% of pa-tients who receive the procedure.42-44 Complicationssuch as facial numbness are uncommon, and the risksof an invasive procedure are entirely eliminated. How-ever, the risk of recurrent pain is substantial, andretreatment may become necessary.45

Arteriovenous MalformationSurgical treatment of arteriovenous malformation has

long represented the pinnacle of vascular neurosur-gery practice. The complex anatomy of these lesionsand the challenges of their surgical management havegiven many generations of neurosurgeons great respectfor these lesions. Surgery has been a time-tested treat-ment that can result in complete resection of these le-sions; however, rates of morbidity and mortality asso-ciated with this surgical treatment can be substantial,and great effort has been made to develop alternativemethods for treating these difficult lesions. Over thepast 15 years, therefore, a balanced multimodality ap-proach has emerged that includes endovascular embo-lization, surgery, and stereotactic radiosurgery.

Radiosurgical treatment of these lesions has been usedsince the 1970s. This approach is controversial in somecircles; for properly selected patients, however, webelieve that radiosurgery can yield outstanding resultswhen used alone or in a multimodality managementstrategy (eg, with endovascular treatment).

When used as treatment for arteriovenous malforma-tions, radiosurgery acts by causing hyalinization withinthe blood vessels of an arteriovenous malformation,thereby resulting in gradual occlusion of flow through

these lesions.46 Complete obliteration of the arterio-venous malformation is generally achieved two to threeyears after treatment. The likelihood of angiographicobliteration of the arteriovenous malformation is a func-tion of its size, the marginal dose delivered, and thelength of time since completion of the radiosurgicalprocedure. Radiosurgery has been shown to effectivelyobliterate approximately 80% of lesions with mean di-ameter <3 cm.47-50

Radiosurgery and FractionatedStereotactic Radiotherapy

On a typical treatment day, patients undergoing ra-diosurgery are admitted to the radiation clinic, whereneurosurgical members of the radiosurgery team applythe stereotactic frame with the patient placed underlocal anesthesia (Figures 6, 7). In some cases, an

Figure 6. Photograph shows patient positioned ontreatment table after placement of stereotactile frame.

Figure 7. Photograph shows patient on treatment tableafter placement of mask used for fractionated stereotacticradiotherapy.

The likelihood ofangiographic

obliteration ofthe arteriovenousmalformation is a

function of itssize, the marginal

dose delivered,and the length of

time sincecompletion of the

radiosurgicalprocedure.



anxiolytic agent is orally administered. A high-resolutionCT scan is then obtained. Images from a fiducialized CTand from a previously obtained fine-cut MRI scan arethen combined in a process called image fusion. Thisprocess is critical for eliminating the spatial distortion seenwhen MRI images are used alone in planning treatment.A protocol of dose planning and quality control is thenundertaken before treatment is begun. The treatment isthen delivered, typically for approximately 20 minutes to40 minutes. When treatment is completed, the stereotac-tic frame is immediately removed. Most treated patientsare then discharged home; in unusual instances (such asif general anesthesia is required), patients may be admit-ted to the hospital for overnight observation.

Patients undergoing fractionated stereotactic radio-therapy procedures do not undergo placement of astereotactic frame but instead are fitted with a rigidthermoplastic mask that enables precise repositioning(Figure 8). Depending on the type of pathology beingtreated, fractionation regimens can range from two frac-tions to more than 30 fractions.

Follow-up protocols for benign tumors and vascular con-ditions include serial MRI imaging done once every sixmonths for the first two years after treatment, then annualscanning thereafter for three years. Malignant conditionswarrant more frequent imaging and clinical follow-up.

ConclusionsStereotactic radiosurgery and fractionated stereotac-

tic radiotherapy have emerged as important additionsto the neurosurgical treatment armamentarium and assuch have wide application. For many indications, ra-diosurgery has proved safe and highly effective. Forsome indications, radiosurgery is emerging as the pre-ferred treatment. ❖

References1. Petit JH, Hudes RS, Chen TT, Eisenberg HM, Simard JM,

Chin LS. Reduced-dose radiosurgery for vestibularschwannomas. Neurosurgery 2001 Dec;49(6):1299-306;discussion 1306-7.

2. Kondziolka D, Lunsford LD, Flickinger JC. Gamma kniferadiosurgery for vestibular schwannomas. Neurosurg ClinN Am 2000 Oct;11(4):651-8.

3. Prasad D, Steiner M, Steiner L. Gamma surgery for vestibularschwannoma. J Neurosurg 2000 May;92(5):745-59.

4. Noren G. Long-term complications following gamma kniferadiosurgery of vestibular schwannomas. Stereotact FunctNeurosurg 1998 Oct;70 Suppl 1:65-73.

5. Andrews DW, Suarez O, Goldman HW, et al. Stereotacticradiosurgery and fractionated stereotactic radiotherapy forthe treatment of acoustic schwannomas: comparativeobservations of 125 patients treated at one institution. Int JRadiat Oncol Biol Phys 2001 Aug 1;50(5):1265-78.

6. Pellet W, Regis J, Roche PH, Delsanti C. Relativeindications for radiosurgery and microsurgery for acousticschwannoma. Adv Tech Stand Neurosurg 2003;28:227-82;discussion 282-4.

7. Sekhar LN, Sen CN, Jho HD, Janecka IP. Surgical treatmentof intracavernous neoplasms: a four-year experience.Neurosurgery 1989 Jan;24(1):18-30.

8. De Jesus O, Sekhar LN, Parikh HK, Wright DC, Wagner DP.Long-term follow-up of patients with meningiomasinvolving the cavernous sinus: recurrence, progression, andquality of life. Neurosurgery 1996 Nov;39(5):915-9;discussion 919-20.

9. Pollock BE, Stafford SL, Link MJ. Gamma knife radiosurgeryfor skull base meningiomas. Neurosurg Clin N Am 2000Oct;11(4):659-66.

10. Pollock BE, Stafford SL, Utter A, Giannini C, Schreiner SA.Stereotactic radiosurgery provides equivalent tumor controlto Simpson Grade 1 resection for patients with small- tomedium-size meningiomas. Int J Radiat Oncol Biol Phys2003 Mar 15;55(4):1000-5.

11. Chen JC, Giannotta SL, Yu C, Petrovich Z, Levy ML, ApuzzoML. Radiosurgical management of benign cavernous sinustumors: dose profiles and acute complications. Neurosur-gery 2001 May;48(5):1022-30; discussion 1030-2.

12. Duma CM, Lunsford LD, Kondziolka D, Harsh GR 4th,Flickinger JC. Stereotactic radiosurgery of cavernous sinusmeningiomas as an addition or alternative to microsurgery.Neurosurgery 1993 May;32(5):699-704; discussion 704-5.

13. Lee JY, Niranjan A, McInerney J, Kondziolka D, FlickingerJC, Lunsford LD. Stereotactic radiosurgery providing long-term tumor control of cavernous sinus meningiomas. JNeurosurg 2002 Jul;97(1):65-72.

14. Nicolato A, Foroni R, Alessandrini F, Maluta S, Bricolo A,Gerosa M. The role of Gamma Knife radiosurgery in themanagement of cavernous sinus meningiomas. Int J RadiatOncol Biol Phys 2002 Jul;53(4):992-1000.

15. Liscak R, Simonova G, Vymazal J, Janouskova L, Vladyka V.Gamma knife radiosurgery of meningiomas in the cavernoussinus region. Acta Neurochir (Wien) 1999;141(5):473-80.

16. Roche PH, Pellet W, Fuentes S, Thomassin JM, Regis J.Gamma knife radiosurgical management of petroclival

Figure 8. Photograph shows patient positioned to receivestereotactic radiosurgery.

For manyindications,

radiosurgery hasproved safe andhighly effective.



meningiomas: results and indications. Acta Neurochir(Wien) 2003 Oct;145(10):883-8.

17. Nicolato A, Foroni R, Pellegrino M, et al. Gamma kniferadiosurgery in meningiomas of the posterior fossa.Experience with 62 treated lesions. Minim InvasiveNeurosurg 2001 Dec;44(4):211-7.

18. Subach BR, Lunsford LD, Kondziolka D, Maitz AH,Flickinger JC. Management of petroclival meningiomas bystereotactic radiosurgery. Neurosurgery 1998Mar;42(3):437-43; discussion 443-5.

19. Thapar K, Laws ER Jr. Pituitary tumors. In: Kaye AH, LawsER Jr, editors. Brain tumors: an encyclopedic approach. 2nded. London: Churchill Livingstone; 2001. p 803-56.

20. Tsang RW, Brierley JD, Panzarella T, Gospodarowicz MK,Sutcliffe SB, Simpson WJ. Role of radiation therapy inclinical hormonally-active pituitary adenomas. RadiotherOncol 1996 Oct;41(1):45-53.

21. Estrada J, Boronat M, Mielgo M, et al. The long-termoutcome of pituitary irradiation after unsuccessfultranssphenoidal surgery in Cushing's disease. N Engl J Med1997 Jan 16;336(3):172-7.

22. Sheehan JM, Vance ML, Sheehan JP, Ellegala DB, Laws ER Jr.Radiosurgery for Cushing's disease after failed transsphenoidalsurgery. J Neurosurg 2000 Nov;93(5):738-42.

23. Kobayashi T, Kida Y, Mori Y. Gamma knife radiosurgery inthe treatment of Cushing disease: long-term results. JNeurosurg 2002 Dec;97(5 Suppl):422-8.

24. Hoybye C, Grenback E, Rahn T, Degerblad M, Thoren M,Hulting AL. Adrenocorticotropic hormone-producingpituitary tumors: 12- to 22-year follow-up after treatmentwith stereotactic radiosurgery. Neurosurgery 2001Aug;49(2):284-91; discussion 291-2.

25. Landolt AM, Lomax N. Gamma knife radiosurgery forprolactinomas. J Neurosurg 2000 Dec;93 Suppl 3:14-8.

26. Landolt AM, Haller D, Lomax N, et al. Stereotacticradiosurgery for recurrent surgically treated acromegaly:comparison with fractionated radiotherapy. J Neurosurg1998 Jun;88(6):1002-8.

27. Debus J, Schulz-Ertner D, Schad L, et al. Stereotacticfractionated radiotherapy for chordomas and chondrosarco-mas of the skull base. Int J Radiat Oncol Biol Phys 2000 Jun1;47(3):591-6.

28. Muthukumar N, Kondziolka D, Lunsford LD, Flickinger JC.Stereotactic radiosurgery for chordoma and chondrosar-coma: further experiences. Int J Radiat Oncol Biol Phys1998 May 1;41(2):387-92.

29. Hug EB, Slater JD. Proton radiation therapy for chordomasand chondrosarcomas of the skull base. Neurosurg Clin NAm 2000 Oct;11(4):627-38.

30. Schulz-Ertner D, Frank C, Herfarth KK, Rhein B,Wannenmacher M, Debus J. Fractionated stereotacticradiotherapy for craniopharyngiomas. Int J Radiat OncolBiol Phys 2002 Nov 15;54(4):1114-20.

31. Selch MT, DeSalles AA, Wade M, et al. Initial clinical resultsof stereotactic radiotherapy for the treatment of craniophar-yngiomas. Technol Cancer Res Treat 2002 Feb;1(1):51-9.

32. Ulfarsson E, Lindquist C, Roberts M, et al. Gamma kniferadiosurgery for craniopharyngiomas: long-term results inthe first Swedish patients. J Neurosurg 2002 Dec;97(5Suppl):613-22.

33. Nwokedi EC, DiBiase SJ, Jabbour S, Herman J, Amin P,Chin LS. Gamma knife stereotactic radiosurgery for patientswith glioblastoma multiforme. Neurosurgery 2002Jan;50(1):41-6; discussion 46-7.

34. Regine WF, Patchell RA, Strottmann JM, Meigooni A,Sanders M, Young B. Combined stereotactic split-coursefractionated gamma knife radiosurgery and conventionalradiation therapy for unfavorable gliomas: a phase I study. JNeurosurg 2000 Dec;93 Suppl 3:37-41.

35. Roberge D, Souhami L. Stereotactic radiosurgery in themanagement of intracranial gliomas. Technol Cancer ResTreat 2003 Apr;2(2):117-25.

36. Boethius J, Ulfarsson E, Rahn T, Lippittz B. Gamma kniferadiosurgery for pilocytic astrocytomas. J Neurosurg 2002Dec;97(5 Suppl):677-80.

37. Hadjipanayis CG, Kondziolka D, Gardner P, et al. Stereotacticradiosurgery for pilocytic astrocytomas when multimodaltherapy is necessary. J Neurosurg 2002 Jul;97(1):56-64.

38. Patchell RA, Tibbs PA, Regine WF, et al. Postoperativeradiotherapy in the treatment of single metastases to the brain:a randomized trial. JAMA 1998 Nov 4;280(17):1485-9.

39. Chen JC, Petrovich Z, O'Day S, et al. Stereotactic radiosur-gery in the treatment of metastatic disease to the brain.Neurosurgery 2000 Aug;47(2):268-79; discussion 279-81.

40. Flickinger JC, Lunsford LD, Somaza S, Kondziolka D.Radiosurgery: its role in brain metastasis management.Neurosurg Clin N Am 1996 Jul;7(3):497-504.

41. Flickinger JC, Kondziolka D, Lunsford LD, et al. A multi-institutional experience with stereotactic radiosurgery forsolitary brain metastasis. Int J Radiat Oncol Biol Phys 1994Mar 1;28(4):797-802.

42. Pollock BE, Phuong LK, Gorman DA, Foote RL, Stafford SL.Stereotactic radiosurgery for idiopathic trigeminalneuralgia. J Neurosurg 2002 Aug;97(2):347-53.

43. Huang CF, Kondziolka D, Flickinger JC, Lunsford LD.Stereotactic radiosurgery for trigeminal schwannomas.Neurosurgery 1999 Jul;45(1):11-6; discussion 16.

44. Regis J, Manera L, Dufour H, Porcheron D, Sedan R, PeragutJC. Effect of the Gamma Knife on trigeminal neuralgia.Stereotact Funct Neurosurg 1995;64 Suppl 1:182-92.

45. Pollock BE, Foote RL, Stafford SL, Link MJ, Gorman DA,Schomberg PJ. Results of repeated gamma knife radiosur-gery for medically unresponsive trigeminal neuralgia. JNeurosurg 2000 Dec;93 Suppl 3:162-4.

46. Schneider BF, Eberhard DA, Steiner LE. Histopathology ofarteriovenous malformations after gamma knife radiosur-gery. J Neurosurg 1997 Sep;87(3):352-7.

47. Colombo F, Pozza F, Chierego G, Casentini L, De Luca G,Francescon P. Linear accelerator radiosurgery of cerebralarteriovenous malformations: an update. Neurosurgery1994 Jan;34(1):14-20; discussion 20-1.

48. Friedman WA. Radiosurgery for arteriovenous malforma-tions. Clin Neurosurg 1995;42:328-47.

49. Pollock BE. Stereotactic radiosurgery for arteriovenousmalformations. Neurosurg Clin N Am 1999 Apr;10(2):281-90.

50. Lunsford LD, Kondziolka D, Flickinger JC, et al. Stereotacticradiosurgery for arteriovenous malformations of the brain. JNeurosurg 1991 Oct;75(4):512-24.


Predictive Value of the Rapid Whole BloodAgglutination D-Dimer Assay (AGEN SimpliRED)in Community Outpatients with SuspectedDeep Venous ThrombosisBy Julieta E Hayag, MDPrem P Manchanda, MD

AbstractContext: D-dimer assay has been used to screen patients with

deep venous thrombosis (DVT). Because both the predictive valueand sensitivity/specificity of the test vary according to the type ofassay, prevalence, and pretest probability of DVT, clinicians mustknow the local performance of the d-dimer assay.Objective: To evaluate the predictive value of the rapid whole

blood agglutination d-dimer Assay (AGEN SimpliRED) in commu-nity outpatients with suspected DVT in the Kaiser Permanente (KP)Mid-Atlantic Region.

Design: Retrospective, randomized, cross-sectional review ofelectronic medical records of patients with suspected DVT whounderwent d-dimer testing for venous thromboembolism.Methodology: A total of 5104 patients with suspected venous

thromboembolism underwent d-dimer testing using AGENSimpliRED from April 2001 to December 2002. A total of 551electronic medical records were reviewed, and results of d-dimerassay and compression ultrasonography were tabulated. Recordswere analyzed to determine later diagnosis of DVT or unexplaineddeath occurring as late as six months after initial testing.Results: Electronic records showed a 5.3% disease prevalence.

Ten patients were excluded from data analysis. A total of 129 (23.8%)patients had positive d-dimer; the positive predictive value was 20.2%(CI, 13.2% to 27%). A total of 412 (76.1%) patients had negative testresults; three of these patients had DVT shown by compression ultra-sonography; negative predictive value was 99.3% (CI, 98.4% to100%). Calculated sensitivity was 89.7%; specificity was 79.9%.Conclusion: In the outpatient setting, the rapid whole blood ag-

glutination d-dimer assay (AGEN SimpliRED) used in combina-tion with both clinical judgment and compression ultrasonogra-phy exhibited a high negative predictive value comparable withpreviously reported values.

*Approved by KP Mid-Atlantic Institutional Review Board on April 2004.

IntroductionIn the evaluation and management of sus-

pected deep venous thrombosis (DVT), clini-cal evaluation alone is not sufficient to con-firm or exclude presence of the disease.1,2 Thereference standard for diagnosing DVT is byvenography, which is invasive. Because of itsnoninvasive nature, compression ultrasonog-raphy (CUS) has replaced venography; how-ever, although CUS is highly sensitive and spe-cific for symptomatic proximal DVT, thistechnique is not as sensitive as venographyfor detecting thrombus in the distal vein ofthe calf.3,4 Because approximately 13% to 30%of affected patients have distal DVT that maypropagate proximally,5,6 a second examinationis recommended five to seven days later todetect unvisualized calf thrombi that may havepropagated proximally.7-12 This additional ex-amination can be costly, inconvenient, andcould still miss acute DVT. In past years, d-dimer assays have been studied as a tool toaid diagnosis of thromboembolic disease. D-dimers are products of fibrin degradation whenfibrin in the thrombus is lysed by plasmin. D-dimer assays cannot differentiate between clotsassociated with spontaneous venous throm-boembolism and other causes of thrombus (eg,sepsis, trauma, surgery, malignancy, postop-erative states, posttraumatic states, infection,autoimmune disease, inflammatory disease).13

The combination of clinical decision rules orguidelines, d-dimer assay, and CUS also has


Julieta E Hayag, MD, (left) graduated from the University of Santo Tomas Faculty of Medicine and Surgery, Manila,Philippines and completed Internal Medicine Residency at University of Pittsburgh-Shadyside Hospital, Pittsburgh,Pennsylvania. She was a member of Mid-Atlantic Permanente Medical Group since 1997 until her recent death.Prem P Manchanda, MD, (right) graduated from Maulana Azad Medical College, University of Delhi, India andcompleted Internal Medicine Residency at University of Pittsburgh-Shadyside Hospital, Pittsburgh, Pennsylvania.He has been with the Mid-Atlantic Permanente Medical Group since 1999. E-mail: [email protected].

CME

The referencestandard fordiagnosingDVT is by

venography,which isinvasive.



been studied for diagnosis of DVT. These reports showthat when used and interpreted in the proper clinicalsetting, the d-dimer assay provides a safe, cost-effec-tive, clinician/patient-friendly means of ruling outDVT.2,7,14-16

Several assays are used to measure d-dimer: ELISA,which is the most accurate but which is lengthy andcostly;8,17,18 the latex agglutination test, which has highfalse-negative rates;19 and the red blood cell agglutina-tion test, which has wide ranges of specificity and sen-sitivity.20 These tests have different characteristics; andbecause each test uses different reagents, the reportedsensitivity and specificity for each assay cannot be ap-plied interchangeably.7,21 Because both predictive valueand sensitivity/specificity of the d-dimer test vary ac-cording to the type of assay and pretest probability ofDVT,2,13 clinicians must understand the indications forand limitations of d-dimer measurement in the diagno-sis of DVT and must inquire whether the assay’s per-formance has been investigated locally.

The AGEN SimpliRED d-dimer test kit currently usedin our laboratory is an autologous red cell agglutinationassay which uses a chemical conjugate of a monoclonalantibody specific to d-dimer. D-dimer levels in excess of0.12 mg/L result in visible agglutination of whole blood.

Predictive Value of the Rapid Whole Blood Agglutination D-Dimer Assay (AGEN SimpliRED) in Community Outpatients with Suspected Deep Venous Thrombosis

Patients tested with d-dimer n = 551

excluded n = 10

(-) d-dimer n = 412

(+) d-dimer n = 129

(+) DVT n = 26

(-) DVT n = 103

CUS n = 54

No further work-up

n = 26

(+) DVT n = 3

(+) DVT n = 51

CUS

Figure 1. Summary of results of SimpliRED and CompressionUltrasonography (CUS) in patients with suspected deep venousthrombosis (DVT).

Table 1. Referral guideline for suspected deep venous thrombosis (DVT)a Clinicalindicationsfor referral

Patients with suspected DVT who are also at high risk for DVT should be referred to theRadiology Department for evaluation by CUS.

Patients who are not at high risk of DVT may be referred to the laboratory for a d-dimer study.

High risk for DVT may be defined as: • three or more MAJOR criteria and no alternate diagnosisOR• two or more MAJOR criteria and two or more MINOR criteria and an alternate diagnosis

Major criteria for DVT: • Active cancer • Paralysis, paresis, immobilization • Surgery <4 weeks ago, bedridden >3 days • Positive family history of DVT (>2 relatives) • Thigh and calf swollen (measure and compare the circumference of each leg at midcalf

and above the knee) • Calf >3 cm of normal calf

Minor criteria for DVT: • Trauma <60 days • Pitting edema of the leg • Erythema • Dilated veins • Hospitalization <6 months

Adapted and reproduced with permission of the publisher from: Kaiser Permanente. Mid Atlantic States. MAPMG referral guidelines. Deep vein thrombosis / D-dimer assay [monograph on the Intranet]; 2001 Sep 24. [updated 2005 Mar 30; cited 2005 Aug 22].Available from: http://cl.kp.org/portal/site/mid-atlantic/index.jsp?epi-content=GENERIC&browse_folder=Specialty%20Referral%20%7C%20Utilization%2F&mountpoint_id=376c92d3f62c90a16bbb706503e951ca&beanID=1414549487&viewID=user_browse&epi_menuItemID=7e85504896e476f8401fdf702a71eea0&epi_menuID=3c518a725d0366f8401fdf702a71eea0&mountPointID=376c92d3f62c90a16bbb706503e951ca.

.

24

a Since 2003, guideline recommends CUS for pregnant patients.



Reported sensitivity ranges from 77% to 100%, and re-ported specificity ranges from 64% to 75%.22,23

Use of the AGEN SimpliRED d-dimer assay began inthe KP Mid-Atlantic States Region in April 2001. Weanalyzed the predictive value of the rapid whole bloodagglutination d-dimer assay in community outpatientsseen for suspected DVT.

MethodsOver the 20-month period extending from April 2001

to December 2002, 5104 d-dimer tests using AGENSimpliRED were conducted on outpatients in whom aclinician suspected venous thromboembolism. The testswere performed at ten different laboratory sites.

We conducted a retrospective, randomized review ofthe electronic medical records of 551 patients who hadd-dimer testing for suspected DVT (Figure 1). Resultsof d-dimer testing were categorized according to testresult. Current guidelines recommend CUS for all pa-tients with positive d-dimer test results. Results of CUSwere tabulated. Each medical record of patients withnegative d-dimer results was reviewed to identify pa-tients who subsequently had recorded results of CUS.The decision to refer patients with negative d-dimerfor CUS was made independently by each clinician onthe basis of physical findings as well as clinical judg-ment. Although we currently have a Referral Guidelinefor Evaluation of Suspected DVT24 (Table 1) that cat-egorizes patients into risk levels by using several ma-jor/minor criteria, this guideline is meant to be infor-mational and does not replace reasonable, independentclinical judgment.

All records showing a negative d-dimer and no CUSas well as records that showed positive d-dimer butnegative CUS results were further reviewed to deter-mine later diagnosis of DVT or unexplained death oc-curring as long as six months after initial testing.

Data analysis was performed using the standard Baye-sian statistical formula and calculations.

ResultsOf the 551 patients whose electronic medical records

were reviewed, ten patients were excluded for the fol-

lowing reasons: no electronic records documenting ex-amination (seven patients); negative d-dimer with pre-vious diagnosis of DVT several weeks before the testand preexisting receipt of anticoagulation therapy (onepatient); negative d-dimer but patient unavailable forfollow-up (one patient); positive d-dimer but additionaltesting refused (one patient).

Of the 541 records (Table 2), 29 showed DVT diag-nosed by CUS, indicating a 5.3% prevalence (95% CI,3.5% to 7.3%). For 129 (23.8%) patients, records showedpositive d-dimer; and 412 (76.1%) patients tested nega-tive. Of the 129 patients who tested positive, 103 pa-tients had negative results of CUS, and CUS was usedto diagnose 26 patients with DVT; these results indi-cated 89.7% sensitivity (95% CI, 78.6% to 100%) and20.2% positive predictive value (95% CI, 13.2% to 27%).Of the 412 patients who tested negative, 54 patients(13.1%) were referred for CUS on the basis of aclinician’s evaluation and judgment. CUS was used todiagnose DVT in 3 of the 54 patients, indicating 79.9%specificity (95% CI, 76.4% to 83.4%); the negative pre-dictive value was 99.3% (95% CI, 98.4% to 100%), andthe false-negative rate was 0.7%.

Of the 541 patients, 183 (34%) had CUS. This grouprepresented all patients with positive d-dimer and thosewith negative d-dimer referred for CUS by the clinician.None of the patients with positive d-dimer who hadnegative CUS or negative d-dimer results who did nothave CUS had later diagnosis of DVT or unexplaineddeath within six months after initial d-dimer testing.

We also reviewed the electronic medical records ofthe three patients who had false negative results of d-dimer testing. One of these patients was a 44-year-oldman with a history of alcoholism who was seen forright lower leg pain and swelling, had negative resultsof d-dimer testing, and right peroneal clot shown sub-sequently by CUS. The second patient with false nega-tive test results was a 25-year-old man with a history ofDVT (in 1992) following fibular stress fracture and bothgrandparents with history of blood clots. He was ini-tially seen for left lower leg pain and erythema andwas treated with cephalexin; two days later, he returnedwith swelling of the left leg and received d-dimer test-ing that yielded negative results. Because of the patient’smedical history, CUS was done; this technique showedextensive superficial venous thrombotic disease as wellas a partial narrowing in the popliteal vein. The thirdpatient with false-negative test results was a 35-year-old woman with a history of advanced cervical cancertreated with radiation who was initially seen for a two-week history of bilateral swelling of the lower extremi-


Table 2. D-dimer assay diagnostic performance in 541 patientswith clinical signs of deep venous thrombosis (DVT)

Results ofd-dimer assay

DVTpresent

DVTabsent Total

Positive (n = 129) 26 103 129Negative (n = 412) 3 409 412

Total 29 512 541



ties. D-dimer test results for this patient were negative.CUS showed left-sided DVT.

DiscussionOur study showed sensitivity of 89.7%, specificity of

79.9%, negative predictive value of 99.3%, and a posi-tive predictive value of 20.2%. These results are com-parable with several published studies, which showedhigh negative predictive value in patients who are atlow to moderate risk for DVT.7,15 Several reports showthat sensitivity decreased with higher disease preva-lence.14 Our three patients with false negative d-dimertest results were at high risk for DVT. The questionarises as to whether d-dimer testing should have beenomitted in these patients and the patients instead re-ferred directly for CUS. Review of electronic medicalrecords for each of the 54 patients with negative d-dimer results who had CUS showed that the risk forDVT among these patients ranged from low to moder-ate to high on the basis of our current guideline (cat-egorizing patients into risk levels by using major andminor criteria).

The decision to refer patients with negative d-dimertest results for CUS was made by each clinician inde-pendently on the basis of physical signs and clinicaljudgment. Several factors may influence a clinician’schoice to refer a patient for CUS. Some clinical instances(for example, pregnancy) might not have been cap-tured in the guideline: Our guideline, which was re-vised in April 2003, recommends CUS for pregnantpatients because this population has a high rate of false-positive d-dimer test results.25 The guideline for man-aging suspected DVT is mainly informational and isnot meant to substitute or replace clinical judgment.Several reports show that clinical assessment of pretestprobability—whether performed empirically or by pre-diction rule—did not alter the overall prevalence ofDVT among patients who had been assigned a lowpretest probability of having the condition.2,26

We also noted other benefits of using d-dimer assay.The approximate turnaround time for the test is 30minutes, a timespan that indicates timesaving. In addi-tion, before we started using the d-dimer assay, all 551patients would have been referred for CUS. With intro-duction of the d-dimer assay, CUS was administered to34% of the patients—those with positive as well asthose with negative d-dimer test results—who wereadjudged to be at risk for DVT. The other 66% of pa-tients (ie, those who did not have CUS) did not havelater diagnosis of DVT or unexplained death within sixmonths after initial testing. This finding supports other

studies that show incorporating the d-dimer assay withclinical assessment has reduced the need for CUS with-out apparent compromise of safety.2,14,15,27,28

We conclude that, used in combination with clinicaljudgment and CUS, the rapid whole blood agglutina-tion d-dimer assay (AGEN SimpliRED) had a 99.3%negative predictive value and a 20.2% positive predic-tive value in the outpatient setting—results comparablewith previous reports.

Study LimitationsAmong the study population, clinical probability for

DVT ranged from low to moderate to high—a findingthat may lower the sensitivity/specificity of the test be-cause this probability may vary according to the preva-lence and pretest probability of DVT. That is, the lowerthe prevalence of the disease, the higher the negativepredictive value.2,13 Although venography is the refer-ence standard used to rule out DVT, in our true-nega-tive and false-positive population we based true nega-tivity on endpoints such as a patient having neither alater diagnosis of DVT nor unexplained death withinsix months after initial testing. ❖

AcknowledgmentsThe authors would like to acknowledge the following

members of the KP Mid-Atlantic States Region and the Mid-Atlantic States Permanente Medical Group (MAPMG) forassistance in collection and interpretation of the data: Earle DHales, MD, Radiology, Springfield, Virginia, MAPMG; Jade VuHenry, MPH, formerly Health Services Research Fellow,Washington, DC, MAPMG; Jane W Price, MT, AMT, MBA,Laboratory Operations Manager, Springfield, Virginia; Sherry JWeinstein-Mayer, MD, Internal Medicine, Lutherville, Maryland,MAPMG; and Margaret A Brown, MD, Pathology, Falls Church,Virginia, MAPMG.

References1. Tapson VF, Carroll BA, Davidson BL, et al. The diagnostic

approach to acute venous thromboembolism. Clinicalpractice guideline. American Thoracic Society. Am J RespirCrit Care Med 1999 Sep;160(3):1043-66.

2. Kearon C, Ginsberg JS, Douketis J, et al. Management ofsuspected deep venous thrombosis in outpatients by usingclinical assessment and d-dimer testing. Ann Intern Med2001 Jul 17;135(2):108-11.

3. Appelman PT, De Jong TE, Lampmann LE. Deep venousthrombosis of the leg: US findings. Radiology 1987Jun;163(3):743-6.

4. Cronan JJ, Dorfman GS, Scola FH, Schepps B, Alexander J.Deep venous thrombosis: US assessment using veincompression. Radiology 1987 Jan;162(1 Pt 1):191-4.

5. Lagerstedt CI, Olsson CG, Fagher BO, Oqvist BW,Albrechtsson U. Need for long-term anticoagulanttreatment in symptomatic calf-vein thrombosis. Lancet


We alsonoted otherbenefits of

using d-dimerassay. The

approximateturnaroundtime for the

test is 30minutes, a

timespan thatindicates

timesaving.



1985 Sep 7;2(8454):515-8.6. Hull RD, Hirsh J, Carter CJ, et al. Diagnostic efficacy of

impedance plethysmography for clinically suspected deepvein thrombosis. A randomized trial. Ann Intern Med 1985Jan;102(1):21-8.

7. Wells PS, Brill-Edwards P, Stevens P, et al. A novel andrapid whole blood assay for d-dimer in patients withclinically suspected deep vein thrombosis. Circulation1995 Apr 15;91(8):2184-7.

8. Stevens SM, Elliott CG, Chan KJ, Egger MJ, Ahmed KM.Withholding anticoagulation after a negative result onduplex ultrasonography for suspected symptomatic deepvenous thrombosis. Ann Intern Med 2004 Jun15;140(12):985-91.

9. Birdwell BG, Raskob GE, Whitsett TL, et al. The clinicalvalidity of normal compression ultrasonography inoutpatients suspected of having deep venous thrombosis.Ann Intern Med 1998 Jan 1;128(1):1-7.

10. Cogo A, Lensing AW, Koopman MM, et al. Compressionultrasonography for diagnostic management of patientswith clinically suspected deep vein thrombosis: prospectivecohort study. BMJ 1998 Jan 3;316(7124):17-20.

11. Kearon C, Julian JA, Newman TE, Ginsberg JS. Noninvasivediagnosis of deep venous thrombosis. McMaster DiagnosticImaging Practice Guidelines Initiative. Ann Intern Med1998 Apr 15;128(8):663-77. Erratum in: Ann Intern Med1998 Sep 1;129(5):425.

12. Philbrick JT, Becker DM. Calf deep venous thrombosis. Awolf in sheep’s clothing? Arch Intern Med 1988Oct;148(10):2131-8.

13. DeBoisblanc B. Venous thromboembolic disease. In:Internal medicine updates—2003. [Philadelphia (PA)]:American College of Physicians; [2003]. p 309-14.

14. Kraaijenhagen RA, Piovella F, Bernardi E, et al. Simplifica-tion of the diagnostic management of suspected deep veinthrombosis. Arch Intern Med 2002 Apr 22;162(8):907-11.

15. Perone N, Bounameaux H, Perrier A. Comparison of fourstrategies for diagnosing deep vein thrombosis: a cost-effectiveness analysis. Am J Med 2001 Jan;110(1):33-40.

16. Handler J, Hedderman M, Davodi D, Chantry D, AndersonC, Moore J. Implementing a diagnostic algorithm for deepvenous thrombosis. Perm J 2003 Spring;7(2):54-60.

17. Ginsberg JS, Brill-Edwards PA, Demers C, Donovan D,Panju A. D-dimer in patients with clinically suspectedpulmonary embolism. Chest 1993 Dec;104(6):1679-84.

18. Bounameaux H, de Moerloose P, Perrier A, Reber G.Plasma measurement of d-dimer as diagnostic aid in

suspected venous thromboembolism: an overview. ThrombHaemost 1994 Jan;71(1):1-6.

19. Farrell S, Hayes T, Shaw M. A negative SimpliRED D-dimerassay result does not exclude the diagnosis of deep veinthrombosis or pulmonary embolus in emergency departmentpatients. Ann Emerg Med 2000 Feb;35(5):121-5.

20. Frost SD, Brotman DJ, Michota FA. Rational use of d-dimermeasurement to exclude acute venous thromboembolicdisease. Mayo Clin Proc 2003 Nov;78(11):1385-91.

21. Kelly J, Rudd A, Lewis RR, Hunt BJ. Plasma d-dimers in thediagnosis of venous thromboembolism. Arch Intern Med2002 Apr 8;162(7):747-56.

22. Bounameaux H, de Moerloose P, Perrier A, Miron MJ.D-dimer testing in suspected venous thromboembolism:an update. QJM 1997 Jul;90(7):437-42.

23. Bates SM, Kearon C, Crowther M, et al. A diagnosticstrategy involving a quantitative latex D-dimer assayreliably excludes deep venous thrombosis. Ann Intern Med2003 May 20;138(10):787-94.

24. Kaiser Permanente. Mid Atlantic States. MAPMG referralguidelines. Deep vein thrombosis / d-dimer essay[monograph on the Intranet]; 2001 Sep 24. [updated 2005Mar 30; cited 2005 Aug 22]. Available from: http://cl.kp.org/portal/site/mid-atlantic/index.jsp?epi-content=GENERIC&browse_folder=Specialty%20Referral%20%7C%20Utilization%2F&mountpoint_id=376c92d3f62c90a16bbb706503e951ca&beanID=1414549487&viewID=user_browse&epi_menuItemID=7e85504896e476f8401fdf702a71eea0&epi_menuID=3c518a 725d0366f8401fdf702a71eea0&mountPointID=376c92d3f62c90a16bbb706503e951ca.

25. Bombeli T, Raddatz-Mueller P, Fehr J. Coagulationactivation markers do not correlate with the clinical risk ofthrombosis in pregnant women. Am J Obstet Gynecol 2001Feb;184(3):382-9.

26. Miron MJ, Perrier A, Bounameaux H. Clinical assessment ofsuspected deep vein thrombosis: comparison between ascore and empirical assessment. J Intern Med 2000Feb;247(2):249-54.

27. Wells PS, Anderson DR, Rodger M, et al. Evaluation ofd-dimer in the diagnosis of suspected deep-vein thrombo-sis. N Engl J Med 2003 Sep 25;349(13):1227-35.

28. Wells PS, Anderson DR, Bormanis J, et al. Value ofassessment of pretest probability of deep-vein thrombosis inclinical management. Lancet 1997 Dec 20-27;350(9094):1795-8.


PredictionPrediction is extremely difficult. Especially about the future.

—Niels Bohr, 1885-1962, Danish physicist


Snoring Versus Obstructive Sleep Apnea:A Case Report

Report of a CaseA 67-year-old man with a long-standing history of

snoring noted that, in recent years, the snoring hadworsened so much that his wife banned him from theirbedroom. Since his retirement, he gained 20 pounds,and knee problems reduced his physical activity. Hisnasal allergies also had worsened. He noted increasedfatigue, daytime sleepiness, and some trouble concen-trating. He reported following a medication regimenas treatment for hypertension, but he otherwise de-nied having any medical problems. He had a tonsillec-tomy and adenoidectomy as a child and had no his-tory of thyroid disease.

Physical examination showed nasal congestion withmoderately swollen, pale turbinates and no purulentdischarge. The septum was midline. Oropharyngealexamination showed no tonsils and a low soft palatewith elongated uvula that tended to collapse againstthe posterior aspect of the pharynx and abutted thebase of tongue. Fiberoptic laryngeal examinationshowed a normal larynx with moderate collapse of thelateral pharyngeal walls in “blocked” inspiration (a re-verse Müller’s maneuver whereby the patient holds hisnose, closes his mouth, and attempts to breathe in-ward). He had a short, thick neck and was overweight.

The working diagnosis was obstructive sleep apnea.

Diagnosis of ObstructiveSleep Apnea

The reference standard for diagnosis of sleep disor-ders is to perform polysomnography (a sleep study),during which the sleeping patient is observed for oxy-gen saturation level, amount of oral and nasal airflow,degree of respiratory effort, electrocardiographic mea-surements, body position, and overall body movement.This examination can be done both “inhouse” in a sleeplaboratory and with home sleep studies for which the


Paul Bernstein, MD, FACS, (left) is the Regional Chief of Head and Neck Surgery for SCPMG. He is the MedicalDirector of Quality Assurance for HEARx West, and Chair of the Head and Neck Division of the American Cancer

Society. He was also the 2005 San Diego Area Partner of the Year. E-mail: [email protected] Higa Ebba, MD, (right) is the Chief of Head and Neck Surgery at the South Bay Medical Center in Harbor

City, CA. She is also a staff physician at the KP Bellflower Tricentral Sleep Center. E-mail: [email protected].

patient is connected to monitors and observed in thepatient’s natural sleep environment.

On the basis of the apnea-hypopnea index, the se-verity of sleep apnea is categorized as mild, moderate,or severe. Mild sleep apnea is defined by an apnea-hypopnea index score anywhere from 5 to 14, oxygensaturation level of at least 86%, and minimal daytimedisability. Moderate sleep apnea is defined by an in-dex score anywhere from 15 to 30 or an oxygen satu-ration level of 80% to 85% and clinically significantdysfunction at work or socially because of daytimesomnolence and loss of concentration. Severe sleepapnea is defined by an index score >30 or an oxygensaturation level of <79% and incapacitation caused bythe sleep disorder.

Common causes of obstructive sleep apnea includeobesity or excessive weight gain (fatty tissue in thethroat tissue narrows and blocks the airway when themuscles relax), age (loss of muscle mass and tone inthe upper airway), gender (men tend to have narrowerairways than women), irregular sleep hours, anatomicabnormality (nasal obstruction, enlarged tongue, elon-gated soft palate, large tonsils and adenoids), use ofalcohol and sedatives (relaxes the musculature), smok-ing (causes inflammation and swelling of the upperairway), and severe reflux (gastroesophageal refluxdisease). Snoring is a common symptom of sleep apneaand results from obstruction, usually by the soft palateand uvula (Figure 1).1 However, snoring itself does notinvolve cessation of breathing, and many “snorers” havenormal results of sleep studies.

Treatment of Obstructive Sleep ApneaWhere “sleep classes” are available, most patients are

referred to these classes, group appointments at whichpatients receive educational material on snoring andsleep apnea. This material advises patients to eliminate

Corridor C

onsult

By Paul Bernstein, MD, FACSJoAnne Higa Ebba, MD



their use of alcohol, tobacco, and sedatives, to sleepon their side instead of their back, and to regularizetheir sleep hours. Overweight patients receive a planfor weight reduction and appropriate exercise to main-tain mobility. Physicians prescribe intranasal steroidmedication and nonsedating antihistamine drugs fornasal allergies.

Patients with moderate to severe sleep apnea aretreated with continuous positive airway pressure (CPAP).This therapy requires the patient to wear a mask overtheir nose during sleep, when the pressure is adjustedto keep the airway open at night. Although CPAPtherapy is the most effective treatment for obstructivesleep apnea, this therapy is often unsuccessful be-cause of patient noncompliance: Some studies havereported compliance rates lower than 70%.2 The pa-tient described in the present case report was treatedwith CPAP and noted substantial reduction in both fa-tigue and daytime somnolence.

Obstructive sleep apnea has been treated with manysurgical procedures: uvulopalatopharyngoplasty(UPPP), a procedure which removes soft tissue at theback of the throat—uvula, tonsils (if present), andpart of the redundant soft palate—but does not ad-dress problems originating at the base of tongue orhypopharynx; tonsillectomy and adenoidectomy (ef-fective in some children); mandibular and hyoid ad-vancement procedures (operations which are difficult,risky, and inconsistently successful); and radiofrequencyablation procedures (effective treatment for snoring but

Snoring Versus Obstructive Sleep Apnea: A Case Report

Figure 1. Diagram shows anatomic structures involved insnoring. Adapted and reproduced by permission from:Abeloff D. Medical art: graphics for use. Baltimore:Williams & Wilkins; 1982.1

inconsistently successful for treating sleep apnea). Allof these treatments have substantial risks and are onlymoderately successful. Tracheostomy is the most ef-fective treatment because it bypasses the upper air-way completely; however, this procedure is also theleast popular and is technically challenging in themorbidly obese patient. For most patients, the postop-erative care necessitated by tracheostomy makes thisoption untenable as an elective procedure.

ConclusionSnoring is part of the spectrum of sleep-disordered

breathing that may be a symptom of obstructive sleepapnea, but not all patients who snore have clinicallysignificant sleep apnea. Snoring may be present in30% to 50% of the general adult population, whereas2% of women and 4% of men have clinically signifi-cant (moderate to severe) obstructive sleep apnea.3

Complications of untreated obstructive sleep apneacan include cardiovascular changes such as hyper-tension, ventricular dysfunction, or pulmonary hyper-tension. To determine the proper intervention requiredto reduce these complications, patients should receivea polysomnogram, either on an outpatient (“home”study) basis or in a sleep laboratory with a technicianin attendance. Severity of sleep apnea does not al-ways correlate with anatomic findings or with medi-cal history; therefore, patients who snore should re-ceive at least a nocturnal screening test measuring oxygensaturation and airflow, and patients with daytime som-nolence or symptoms suggestive of sleep apnea shouldreceive a full sleep study.

Patients with sleep apnea have an increased risk ofairway problems after general anesthesia and shouldbe observed carefully during the perioperative period.In addition, use of opioid and sedative drugs shouldbe minimized for these patients to prevent airwaycompromise and desaturation.

To splint and keep the upper airway patent dur-ing sleep, the most effective treatment for sleep ap-nea is CPAP given at a level determined by resultsof a titration study; variations of this treatment in-clude bi-level positive air pressure (BIPAP, a proce-dure in which expiratory pressure is lower than pre-scribed inspiratory pressure if high pressure isrequired) or auto titration (self-adjusting pressure).

Treatment for snoring may include weight loss,avoidance of supine sleeping position, sleeping withhead elevated, avoidance of alcohol or sedatives atnight, and treatment of nasal symptoms. Patients

Treatment forsnoring may

include weightloss, avoidance

of supinesleepingposition,

sleeping withhead elevated,avoidance of

alcohol orsedatives atnight, and

treatment ofnasal

symptoms.



who snore may opt to use a dental appliance atnight or may consider various procedures for treat-ing snoring—eg, radiofrequency ablation of the pal-ate (somnoplasty), a procedure designed to stiffenthe soft palate or to increase airway patency. Theseprocedures are considered cosmetic and thus are notcovered either by the Kaiser Foundation Health Planor by other insurance providers, but many Head andNeck Surgery Departments will soon offer snoringtreatment procedures on a fee-for-service basis. ❖

References1. Abeloff D. Medical art: graphics for use. Baltimore:

Williams & Wilkins; 1982.2. Flemons WW. Clinical practice. Ostructive sleep apnea.

N Engl J Med 2002 Aug 15;347(7):498-504.3. Young T, Palta M, Dempsey J, et al. The occurrence of

sleep-disordered breathing among middle-aged adults.N Engl J Med 1993 Apr 29;328(17):1230-5.

Recommended Reading• Dart RA, Gregoire JR, Gutterman DD, Woolf SH. The

association of hypertension and secondary cardiovasculardisease with sleep-disordered breathing. Chest 2003Jan;123(1):244-60.

• Dreher A, de la Chaux R, Klemens C, et al. Correlationbetween otorhinolaryngologic evaluation and severity ofobstructive sleep apnea syndrome in snorers. ArchOtolaryngol Head Neck Surg 2005 Feb;131(2):95-8.

• Iseri M, Balcioglu O. Radiofrequency versus injectionsnoreplasty in simple snoring. Otolaryngol Head Neck Surg2005 Aug;133(2):224-8.

• Riley RW, Powell NB, Li KK, Troell RJ, Guilleminault C.Surgery and obstructive sleep apnea: long-term clinicaloutcomes. Otolaryngol Head Neck Surg 2000Mar;122(3):415-21.

• Sher AE, Schechtman KB, Piccirillo JF. The efficacy ofsurgical modifications of the upper airway in adults withobstructive sleep apnea syndrome. Sleep 1996Feb;19(2):156-77.

Snoring Versus Obstructive Sleep Apnea: A Case Report

Rising from BedThe sound of the belch’d words of my voice loos’d to the eddies of the wind,

A few light kisses, a few embraces, a reaching around of arms,The play of shine and shade on the trees as the supple boughs wag,

The delight alone or in the rush of the streets, or along the fields and hill-sides,The feeling of health, the full-noon trill,

The song of me rising from bed and meeting the sun.

—Walt Whitman, 1819-1892, American poet, from Song of Myself


soul of the healer

“Green Sea Turtle”

photograph

By Joseph MacKenzie, PA

Mr MacKenzie is in the Department of Gastroenterologyon the Interstate campus in Portland, OR.More of his art can be seen on the cover.

New Technology


health systems

Fantastic Voyage:Questions from the 21st Century

s a child, did you like readingscience fiction or watching

Star Trek? If so, this issue is really atreat for you!

Robots the size of small VW bugsin the operating room assistingurologists in removing a prostate.Wireless endoscopy capsules, thesize of large vitamin pills, touringthrough the small intestine, filminga scene straight out of FantasticVoyage. Preimplantation genetictesting on one cell from an embryo.Molecular-targeted therapies forcancer.

This issue of The PermanenteJournal will explore these and otherexciting new technologies, devices,tests, and drugs, but it will onlyscratch the surface of the plethora

A of new technologies being devel-oped in the 21st century. Many chal-lenges for Kaiser Permanente (KP)arise from this exploding pace ofdevelopment. Which new technolo-gies should we deploy? Where andin how many medical centers? Howdo we retrain our physicians in thesenew procedures? Who are the ap-propriate patients to receive thesenew procedures? How do we moni-tor results?

The answers to these questionsand the technology managementprocess in KP will also be reviewedin this issue. This issue focuses onNEW technology, but we cannotlose sight of the fact that a recentstudy revealed that Americans ingeneral receive medical procedures

supported by evidence-based medi-cine only about half the time.1 Theevidence-based technology man-agement process has also been uti-lized in KP to address inadequateutilization of older technologies.

Finally, we also hope to help an-swer a burning question for clini-cians—how do I keep up with suchrapidly changing medical advance-ments? Resources to answer thisquestion are in this issue. ❖

Reference1. McGlynn EA, Asch SM, Adams J, et

al. The quality of health caredelivered to adults in the UnitedStates. N Eng J Med 2003 Jun26;348(26):2635-45.

Joanne Schottinger, MDOncologist and Assistant

Medical Director at theKP Southern California

Regional Offices

DiscoveriesThe most important discoveries will provide answers to questions that we do not yet

know how to ask and will concern objects we have not yet imagined.

—John N Bahcall, 1934-2005, American astrophysicist

Special Feature


health systems

Advances in Imaging—The ChangingEnvironment for the Imaging SpecialistBy John Rego, MDKM Tan, MD

Over the last two to three decades, the demand forimaging services has blossomed at an unprecedentedrate. New modalities have either been introduced as inmagnetic resonance imaging (MRI) and positron emis-sion tomography (PET) or significantly improved as incomputed tomography (CT) and ultrasound (US).

The increasing sophistication of cross-sectional im-aging with very rapid development and integration ofinterventional radiology into the clinical arena has hada dramatic impact on patient care. The imaging spe-cialist now faces a remarkable transition in his/her workenvironment.

Bryan refers to two separate but related phenom-ena.1 The marked increase in information available frommodality advances, and now available in three dimen-sions, accompanied by technology allowing extensivedigital manipulation of such data presages a new erain medical imaging.

Digital data and technology have revolutionized theimaging field. The electronic acquisition, interpretation,transmission and storage of image data has not onlyincreased access for patients but also benefits their re-ferring physicians. Imaging interpretations are avail-able earlier and more readily, and there is almost in-stantaneous access to these examinations on their officecomputers. This, of course, mandates an integratedinformation enterprise that all Kaiser Permanente (KP)Regions have now or will have soon. Picture archivingand communications systems (PACS), radiology infor-mation systems (RIS), and hospital information systems(HIS) all contribute to seamless acquisition of imagedata through PACS, which, together with informationfrom the RIS and the HIS, result in rapid interpretationavailable to clinicians together with the original im-ages pulled from archival storage. Thus, images andreports are at the right place at the right time.

This technology has inevitably resulted in increasingefficiencies, particularly during off hours, allowing one

radiologist to offer interpretation coverage for 17 hospi-tals in Northern California. A similar situation prevails inSouthern California (see page 47). It allows immediateaccess during the working day to subspecialty imagingexpertise of multiple experts located throughout the Re-gion and also allows the ability to provide interpretationservices to some of the personnel-strapped Regions bothwithin and outside of California.

Perhaps nowhere else in medicine has there beensuch rapid advance in technology than in CT scanning.With the advent of multidetector CT (MDCT) five yearsago and, more recently volume CT (VCT), a relativelyquiet revolution has taken place. CT scanners are nowcapable of obtaining 128 slices in less than one sec-ond. The entire chest, abdomen and pelvis can nowbe examined with submillimeter imaging in less than15 seconds. This has led for the first time to true CTvolume imaging where image reconstruction can takeplace in any plane with equal resolution.

We are just beginning to feel the impact of this veryvaluable tool in such areas as vascular imaging andvirtual colonoscopy. The VCT has replaced peripheral

John Rego, MD, (left) is Chair of the Northern California Chief Group. He is a member of the NorthernCalifornia Medical Imaging Tech Committee and the National Imaging Core Croup. E-mail: [email protected] Tan, MD, (right) is Chief of Radiology at Kaiser Permanente in San Rafael California and is Chair of theNational Imaging Core Group. He is a member of the Editorial Team for TPJ and has served in multiple stateand national positions in CME, including the KP National CME Committee. E-mail: [email protected].

Radiologist Kurt Dibbern with a digital PACS setup forreading apropos.

CT scannersare now

capable ofobtaining 128slices in less

than onesecond.

New Technology


health systemsAdvances in Imaging—The Changing Environment for the Imaging Specialist

diagnostic angiography in many centers and is poised todo the same for diagnostic coronary angiography. In thestudy of the colon, VCT has been shown to be superiorto barium enema, approaching the sensitivity ofcolonoscopy in the detection of polyps larger than 9 mm.2

Advances in software have allowed almost instanta-neous display of the images in shaded 3-D representa-tions. This is proving invaluable in preoperative plan-ning. The addition of CT fluoroscopy has allowed rapid,accurate real-time placement of biopsy needles, drain-age catheters, and therapy devices.

As the technology advances, several vendors plan tointroduce scanners that will acquire up to 512 imagesper half second with coverage of 12 cm. This will al-low for perfusion imaging where viability of tissue canbe evaluated. Coronary arterial and myocardial viabil-ity will be able to be evaluated simultaneously. Be-yond 512 imaging, scanners are being tested that willuse large-area detectors that will allow examination ofthe entire abdomen in just one pass of the x-ray tube.

Advances in MRI are equally as remarkable. As the1.5T technology matures, there is new technology inthe form of 3T-fieldstrength magnets that allow for faster,more detailed, and thinner imaging sections than its 1.5Tcounterpart. MRI is showing that it can compete withCT in noninvasive imaging of the heart. Multiplanar real-time images of the beating heart can now be obtainedthat allow for full, functional assessment of the heart.With contrast, perfusion studies can also be obtained.

MRI remains the imaging examination of choice formusculoskeletal and neurologic applications and willcontinue to compete with CT in evaluation of the vas-cular tree. And many new applications of MRI will spurfurther growth. For example, in the breast, with theuse of gadnolinium contrast agents, MRI is proving tobe very sensitive for detection of small breast cancers.Its role in this regard is still being evaluated. Whencoupled with focused high-energy ultrasound, MRI canbe used to guide noninvasive tumor therapies. It hasshown its usefulness in treating such tumors and uter-ine fibroids and in limited applications of other vis-ceral tumors.

Spurred on by miniaturization and by advances incomputing power, the applications of ultrasound con-tinue to grow. It is now possible to do high-quality ultra-sound on devices the size of a laptop computer. Somedevices in development are no larger than a PDA; thesemay indeed be the stethoscopes of the future. Three- and4-D ultrasound have been further refined and are nowbeing used in fetal imaging and ultrasound contrastimaging. Voice recognition and real-time image opti-

mization (tuning of the image to the patient’s ownacoustic properties) have improved patient workflow.With the pending approval of ultrasound contrastagents, ultrasound will compete with CT and MRI inthe evaluation of the liver.

Interventional radiology continues to grow as pro-cedures migrate from the OR to the IR suite. Stentsand stent grafts have dramatically changed the prac-tice of vascular surgery. Vascular surgeons andinterventional radiologists have joined forces in manylabs with a merging of their two specialties. Percuta-neous tumor ablation, stabilization of vertebral bodyfractures, tumor embolization, venous ablation andrecanalization are all procedures now common to theinterventional labs.

New flat panel detectors have improved image qual-ity and decreased radiation dose. New rotationangiographic techniques have allowed 3-D vascularimage displays. With tube rotation it is now possiblethrough post processing to obtain multislice CT im-ages from the IR equipment.

Digital image acquisition has replaced film through-out the Radiology Department. Digital detectors arenow used instead of film to allow immediate imagereview. This advance has lead to an increase in imagequality and a 50% decrease in imaging time. Dual-energy subtraction has allowed improved evaluationof the lungs by subtraction of the bony structures.Additional application of computer-aided diagnosis(CAD) has led to a 10% increase in tumor detection in

64 slice CT scanner now used for cardiac work.

Digitaldetectors are

now usedinstead of

film to allowimmediate

image review.This advancehas lead to an

increase inimage quality

and a 50%decrease in

imaging time.

Special Feature


health systems

the chest and breast. This same application is beingtrialed in CT colonoscopy as well.

Thus several trends are becoming clearer. The earlierand more frequent use of imaging will continue with ashortening of the initial clinical evaluation. As indicatedabove, the 64-slice CT scanner will allow immediateevaluation of a patient’s chest pain, allowing differentia-tion between a benign situation and the possibility of aheart attack, an aneurysm, or a pulmonary embolism.

Technology will continue to drive care from the hos-pital. Decreasing cost and size of equipment will allowCT and MRI to devolve outside the hospital RadiologyDepartment into freestanding situations.

The readily available image distribution process ironi-cally will decrease reliance on the radiologist and therewill be an enhanced shift to proactive, prophylacticscreening in imaging. Computer-assisted detection anddiagnosis in the areas of breast, lung, and colon dis-ease are but a harbinger of such use in all clinical ar-eas. Last but not least, functional and metabolic imag-ing is becoming a reality, and the promise of geneticand molecular marker imaging is not far behind.

One issue merits ongoing discussion and research.Advances in technology serve as one of the most im-portant drivers of health care spending growth. Cur-rently in the United States, medical care consumes morethan 14% of the gross domestic product and is likely toreach 17.7% by 2012.3

Increases in the supply of specific technologies suchas CT and MRI are associated with higher numbers ofprocedures per population and with consequent higherhealth care spending. Experience has shown that co-ex-istence of CT and MRI is not complementary but supple-mentary. Thus, MRI availability does not offset CT use.4

While there may be a legitimate argument for by-passing the current progression of imaging tests fromthe least expensive to more costly examinations in fa-vor of expensive high-tech imaging as a first-time testthat provides more information, the effect is a distinctoverall increase in health care spending. With the num-ber of uninsured Americans approaching 50 millionand with more of us unable to afford soaring healthcare costs, it is appropriate to question to what extentwe can and should continue to spend dollars in pur-suit of increasing diagnostic capabilities that in turnincrease the probability of detecting multiple benignabnormalities and the consequent need to resolve them.Can we afford an “arms race” among manufacturers asthey continue to outdo one another in the increasingdetail and sophistication of their imaging devices? Is itappropriate to tolerate surging health care costs, espe-cially in view of the lack of well-planned cost effec-tiveness and outcomes studies to support the increas-ing use of such modalities? ❖

References1. Bryan RN. The digital rEvolution: the millennial change in

medical imaging. Radiology 2003 Nov;229(2):299-304.2. Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomo-

graphic virtual colonoscopy to screen for colorectalneoplasia in asymptomatic adults. N Engl J Med 2003 Dec4;349(23):2191-200. Epub2003 Dec1.

3. Gazelle GS, McMahon PM, Siebert U, Beinfeld MT. Cost-effectiveness analysis in the assessment of diagnosticimaging technologies. Radiology 2005 May;235(2):361-70.

4. Baker L, Birnbaum H, Geppert J, Mishol D, Moyneur E. Therelationship between technology availability and healthcare spending. Health Aff (Millwood) 2003 Jul-Dec; SupplWeb Exclusives:W3-537-51.

Advances in Imaging—The Changing Environment for the Imaging Specialist

InventionsOur inventions mirror our secret wishes.

—Mountolive, Lawrence Durrell, 1912-1990, Anglo-Irish novelist and playwright

New Technology


health systems

Genetic Services in the KP SouthernCalifornia Region: Delivering the Promisesof Tomorrow Today

By Mónica Alvarado, MSNancy Shinno, MD

C Douglas Monroe, MS, RPhMehdi Jamehdor, MD, FACMG

Kermit Anderson, MA

AbstractThe impact of advances in molecular biology over the past 25 years—espe-

cially the completion of the Human Genome Project—touches every branchof medicine and will continue to have profound influence on medical prac-tice. Advances in genetic technology are changing the traditional patient/doctor paradigm. For some medical conditions, current genetic technologyand predictive testing enable us to offer medical management before a pa-tient is diagnosed with a disorder. However, advances in genetic technol-ogy impose on all clinicians the added requirement of identifying patientswho may benefit from having access to this technology. Kaiser Permanente(KP) provides a unique, integrated approach to this challenge by serving asa model for delivery of genetic services. This article outlines the history andcurrent status of genetic services provided in the KP Southern California Re-gion and summarizes current and future developments in medical geneticstechnology.

ern California Region (KPSC) andsummarizes current and future de-velopments in medical geneticstechnology.

From HumbleBeginnings to State-of-the-Art Practice

Clinical geneticist Nancy Shinno,MD—who is now KPSC Chief ofRegional Genetic Services—startedher KP career in 1978 as one of onlyfour KPSC clinical geneticists. Inthose early years, KP geneticists di-vided their time between medicalgenetics practice and pediatrics.Moreover, the practice of geneticsprimarily consisted of evaluatingchildren with dysmorphic featuresand developmental delay and coun-seling women about the risks ofadvanced maternal age. Other thancytogenetic analysis performed todetermine chromosome abnormal-ity, few options existed for prenataldiagnosis of genetic disorders.

Now Dr Shinno leads the KPSCRegional Genetics Department,which includes 8 full-time medicalgeneticists, 22 genetic counselors,a regional genetic screening pro-gram, and a regional metabolic ge-netics program. The KPSC GeneticsDepartment provides genetic ser-

Dawn of a New EraThe integral role of genetics in

everyday medical practice is theresult of more than five decades ofrevolutionary clinical and molecu-lar research. The impact of advancesin molecular biology over the past25 years—especially the completionof the Human Genome Project1—touches every branch of medicineand will continue to profoundly in-fluence medical practice. Applica-tion of genomics to the study ofresponses to pharmaceuticals isopening new opportunities in drugdevelopment and in pharmacoge-netic tools for lowering risks of drug

therapy and for increasing its ben-efits. While genetic technology con-tinues to evolve, however, cliniciansface the daunting task of integrat-ing emerging technologies into dailymedical practice to improve thehealth and welfare of patients. Asmedical genetics gained unparal-leled prominence in the 1990s, Kai-ser Permanente (KP) has enhancedits unique system of integratedhealth care services by becoming anational leader in delivering cutting-edge genetic services to KP mem-bers. This article outlines the his-tory and current status of geneticservices available in the KP South-

Mónica Alvarado, MS, is the Regional Administrator for Genetic Services for Southern California. E-mail: [email protected] Shinno, MD, is the Southern California Chief of Regional Genetic Services and the Southern California Director of

Craniofacial Service. E-mail: [email protected] Douglas Monroe, MS, RPh, is a formulary pharmacist specializing in biotechnology for Drug Information Services in the Southern

California Region. E-mail: [email protected] Jamehdor, MD, FACMG, is the Director/PIC of the Southern California Regional Genetic Testing Laboratories and an

Associate Clinical Professor in Pediatrics/Genetics at UCLA. E-mail: [email protected] Anderson, MA, manages the KP Southern California Genetic Screening Department. E-mail: [email protected].

CME

Special Feature


health systems

vices to KP members at every KPSCmedical center. The “menu” of avail-able genetic tests has expanded ex-ponentially, and the practice of ge-netics has grown beyond the realmof prenatal and pediatric genetics toinclude cancer genetics andneurogenetics, among other areas(see Tables 1 and 2). KPSC geneti-cists and genetic counselors also par-ticipate in programs where geneticdisorders are managed by other spe-cialists, such as those practicing inthe craniofacial service, the sickle-cell disease center, and clinics thatevaluate patients for neuromuscu-lar or neurodegenerative disorders.

The impact of genetic technologyon diagnosis and management ofgenetic disorders over time is clearlyillustrated by treatment of Fabry dis-ease, an X-linked recessive storagedisorder first described in 1898. Thedisorder causes painful, disablingcrises in boys as young as ten yearsof age; progressive damage to thekidneys, heart, and central nervoussystem, among other organs; andgenerally results in renal failure thatcan lead to early death in men intheir thirties and forties.2 Fabry dis-ease is caused by mutation in thealpha galactosidase A (GAL) gene.2

lection of patients has helped tomaximize the benefits provided byagalsidase beta (Fabrazyme,Genzyme Therapeutics, Cambridge,MA) a new recombinant enzymetreatment for Fabry disease. Treat-ment of at least one patient via com-passionate protocol began nearlytwo years before marketing ofFabrazyme. Fabrazyme infusiontherapy became available in KPSCin 2003, soon after the drug wasapproved by the US Food and DrugAdministration (FDA). Infusion treat-ment is currently administered at theMetabolic Genetics Service at the KPLos Angeles Medical Center—KPSC’s state-of-the-art center fordiagnosis and management of meta-bolic disorders—under the directionof Rebecca Mardach-Verdon, MD.Infusion therapy is available also atthe KP Bakersfield and San DiegoMedical Centers. Now, more thantwo years after FDA approval of thedrug, several patients are beingtreated with this enzyme replacementtherapy, and reports have describedreduction or elimination of neuro-pathic pain, retardation of cardiacinvolvement, and improved abilityto resume work and social activity.

A KP multidisciplinary Fabry Dis-ease Advisory Panel including ex-perts from the genetics, cardiology,neurology, nephrology, ophthalmol-ogy, and gastroenterology depart-ments meets regularly to discuss andcreate management guidelines andto review nonclassic cases of Fabrydisease. Treatment of this diseaseillustrates the potential for treat-ments derived from expandedknowledge about the genetic basisfor disease and developed throughnew technology for pharmaceuticaldevelopment. Indeed, the story ofFabry disease illustrates how ad-vances in genetic technology havetransformed management of thiscondition from simply offering in-

This genetic mutation causes defi-cient activity of the alpha galactosi-dase enzyme. This deficiency resultsin progressive accumulation ofglycosphingolipids, especially invascular endothelium, leading toischemia and infarction of smallvessels and resultant renal, cardiac,and cerebrovascular dysfunctions.

In 1978, when Dr Shinno coun-seled a young woman whosebrother and a maternal uncle hadFabry disease, doctors could offersuch women little other than theinformation that they had a 50%chance of being a carrier of the con-dition. At that time, Fabry diseasecould be diagnosed in the woman’sbrother by using enzyme analysisof leukocytes to identify alpha ga-lactosidase deficiency, but this di-agnostic test could not reliably di-agnose the carrier state. Prenataldiagnosis using enzyme analysiscould be used to detect an affectedmale fetus, but no treatment (otherthan kidney transplantation) wasavailable for any affected sons thewoman might bear.

By the early 1990s, scientists hadmapped the gene for Fabry disease,and DNA analysis was available toinform women whether or not theywere carriers of the disease. If re-sults of DNA analysis were nega-tive, the woman had no need toworry about bearing sons destinedto have the disorder; if results ofthe test were positive, the womancould have prenatal diagnosis us-ing sequence analysis, which coulddetect nearly 100% of mutations inthe GAL gene.2

By 2003, medical geneticists couldinform a carrier patient that enzymereplacement therapy (a drug spinofffrom identifying the gene) was avail-able for her affected sons to helpprevent renal failure, cardiac andcerebrovascular sequelae, and pain.

At KP, careful evaluation and se-

Table 1. Scope of KPSC Regional Genetic servicesPrenatal/Reproductive Genetics testingGenetic ScreeningNeonatal/Pediatric GeneticsAdult Genetics (including Cancer and Neurogenetics)Metabolic GeneticsCraniofacial ServiceGenetic Testing Laboratory

Table 2. KPSC Regional Genetics mission statementThe primary aim of the KPSC Regional Genetics Program isto help individuals and families faced with genetic disordersto live and reproduce as normally as possible. Our goal is toensure that high-quality services are available and accessibleto all patients who require care. We strive to reducemorbidity and mortality, to alleviate the suffering associatedwith genetic and congenital disorders, to improve health andpregnancy outcomes, and to optimize life options for peopleaffected by a genetic disorder.3

Genetic Services in the KP Southern California Region: Delivering the Promises of Tomorrow Today

New Technology


health systems

formation (ie, about risk of diseaserecurrence) to accurate diagnosisand carrier testing and, finally, touse of enzyme replacement to treatand prevent complications.

Genetic Testing,Screening, andCounseling

Genetic testing analyzes humanDNA, RNA, genes, chromosomes, ora combination of these structures todetect heritable or acquired geno-types, mutations, phenotypes, orkaryotypes that can cause a specificdisease or condition. Genetic test-ing also analyzes human proteinsand certain metabolites, which arepredominantly used to detect heri-table or acquired genotypes, muta-tions, or phenotypes. Many differ-ent types of genetic tests arecurrently available (see Table 3).

Most genetic testing in KPSC isconducted at our state-of-the-artRegional Genetic Testing Labora-tory. During the past year, the labo-ratory conducted more than 12,000cytogenetic tests, 14,000 moleculartests, and more than 20,000 bio-chemical tests. In addition, eachyear the laboratory conducts rev-enue-generating tests, including ap-proximately 56,000 maternal serumalpha-fetoprotein (AFP) tests reim-bursed by the California ExpandedAFP Screening Program. The bio-chemical genetics section of the labo-ratory also provides services (eg,analysis of amino acids, organic ac-ids, tandem mass spectrometry) toother KP Regions, including North-ern California and Hawaii. Since1991, the number of cancer cytoge-netic tests performed at the KPSCRegional Genetic Testing Laboratoryhas increased by more than 500%,the number of fluorescent in situhybridization (FISH) procedures hasincreased by nearly 2000%, and thenumber of cytogenetic studies of pre-

basis of genetic linkage studies ofpopulations, not studies of risk inindividual persons. This type ofpopulation testing has social andethical consequences that extendbeyond medical management andreveals information that affects notonly the patient but also the patient’sblood relatives. For this reason, ge-netic counseling is always an inte-gral part of genetic testing. At KPSC,an outstanding team of 22 geneticcounselors work alongside SCPMGmedical geneticists to provide pedi-gree collection and risk assessment;education about genetic diseasesand genetic testing options; discus-sion of options for disease manage-

natal specimens has remained fairlyconsistent. Moreover, during thepast five years, the Regional GeneticTesting Laboratory has seen a dra-matic decrease in the number ofmolecular tests sent to outside labo-ratories while the number of inhouseDNA tests has increased even moredramatically (Figures 1 and 2).

Genetic tests are often more com-plex than other types of medicaltests. Testing for genetic suscepti-bility to disease (eg, examination ofbreast cancer susceptibility genesBRCA1 and BRCA2) is inherentlycomplex because of its probabilis-tic and familial nature. Tests of thistype identify empirical risks on the

Table 3. Types of genetic testsDiagnostic Tests: Used to confirm or exclude suspected genetic conditions (eg,Duchenne muscular dystrophy) in symptomatic persons of any age.Predictive Tests: Offered to asymptomatic persons concerned about possiblesusceptibility to a genetic disorder. Two types:

• Presymptomatic, where eventual development of symptoms is certain, eg, Huntington disease.

• Predispositional, where eventual development of symptoms is likely but notcertain, eg, inherited susceptibility to breast and ovarian cancer.

Carrier Tests: Used to identify healthy persons who have a genetic mutation coding foran autosomal or X-linked recessive disorder which puts their children at risk for havingthe disorder. Carrier tests may be conducted in persons with a family history of thecondition or in ethnic groups known to have a higher carrier rate for the condition (eg,cystic fibrosis).Prenatal Tests: Used to diagnose genetic conditions in the fetus. Offered to pregnantwomen who, because of any conditions (maternal age, personal or family history,ethnicity, suggestive results of either multiple-marker screening or fetal ultrasound), areat increased risk for having a child with a genetic condition oe congenital defect.Newborn Screening Tests: Used in newborns to determine whether they are atincreased risk for specific genetic conditions that usually need immediate treatment.Pharmacogenetic Tests: Used to determine how a person’s genetic makeup may affectthat person’s reactions to specific drugs. These tests may help clinicians to prescribedrugs that are most effective and cause the least side effects.Preimplantation Genetic Diagnosis (PGD): Used to test embryos for genetic disordersbefore transfer of the embryo to the uterus. PGD has limited application and isconsidered on a case-by-case basis.

Table 4. Most common cancer susceptibility syndromesSyndrome Gene Cancer TypesHBOC BRCA1

BRCA2breast, ovarian, prostate, othersbreast (male and female), ovarian, pancreas, others

Li-Fraumeni p53 breast, brain, adrenocortical, sarcoma, leukemia, others FAP APC colorectal, duodenal, thyroid, othersHNPCC MLH1

MSH2MSH6

colorectal, endometrial, stomach, ovary, other s

Cowden PTEN hamartoma of skin, breast, thyroid, oral mucosa, and intestine


Special Feature


health systems

ment, treatment, and surveillance;psychosocial support; and casemanagement.

The KPSC Genetic Screening Pro-gram administers the California Ex-panded AFP Screening Program aswell as the Regional Cystic Fibrosis(CF) Program and the NewbornScreening Program. In California, allpregnant women are offered pre-natal “multiple marker screening”through the California ExpandedAFP Program. The current panelreports a detection rate of 70% forDown syndrome and detection rates

ranging from 85% to 97% for neuraltube defects (depending on the typeof neural tube defect). “Quad”screening, which adds anotheranalyte to the assay, is under de-velopment and is expected to sub-stantially improve prenatal detectionrates for Down syndrome over thecurrent “triple screen.” Prenatal CFcarrier screening is offered towomen on the basis of theirethnicity or on request. KP mem-bers who receive positive test re-sults are immediately referred for ge-netic counseling to help them

understand their risks, evaluate theiroptions for additional testing, andmake informed medical and per-sonal decisions about having addi-tional genetic tests.

KPSC also participates in the Cali-fornia Newborn Screening Pro-gram,4 which has for many yearsbeen screening newborns for phe-nylketonuria (PKU), sickle-cell ane-mia, congenital hypothyroidism,and galactosemia. Since its incep-tion, the program has screened vir-tually all babies born to KPSC mem-bers. The program was expandedin 2005 to screen for more than 40additional disorders through use oftandem mass spectrometry. Amongthe disorders detected by thismethod are medium-chain-acyl CoAdehydrogenase (MCAD) deficiencyand glutaric acidemia type I (GA1).

Cancer GeneticsFor decades, physicians have been

able to identify families that haveclearly hereditary patterns of can-cer; however, physicians had littleto offer these families other than rec-ommending vigilance toward allfamily members without knowingwho was (or was not) at risk. Thatsituation changed in the past de-cade, thanks to the discovery andmapping of several genes associatedwith susceptibility to cancer. Com-mercial testing for familialadenomatous polyposis (FAP, themost thoroughly characterized he-reditary form of colorectal cancer)was first made available in 1995 andwas closely followed by testing forBRCA1 and BRCA2 (breast cancersusceptibility genes 1 and 2)—test-ing which first became available in1996—and testing for hereditarynonpolyposis colorectal cancer(HNPCC). Opportunities for com-mercial and research testing forother cancer syndromes continue toevolve (see Table 4). KP has always

Figure 1. Graph shows number of samples sent by KPSC Regional GeneticsTesting Laboratory for DNA testing outside KP during years 1991 through2005. Graph produced by Michael Bucher, and used with permission.

Figure 2. Number of inhouse DNA tests done at KPSC Regional GeneticsTesting Laboratory during years 2000 through 2005. Graph produced byMichael Bucher, and used with permission.


New Technology


health systems

been a leader in the area of cancergenetics and was one of the firsthealthcare organizations in the na-tion to address the issues related toBRCA1/BRCA2 testing. In 1997, theNational KP Guidelines for BRCACounseling and Testing5 wereamong the first such guidelines de-veloped in the United States. Ge-neticists and genetic counselorsfrom KPSC were key contributorsto development of that guideline,and today these professionals con-tinue to provide comprehensive riskassessment, genetic testing and in-terpretation, and management infor-mation to patients who are at riskfor hereditary cancer susceptibility,as well as to their families.

Diagnosis and management ofFAP are excellent examples of howgenetic technology has substantiallychanged the way that hereditarycancer susceptibility is diagnosedand treated today. FAP is an auto-somal dominant condition whichaffects approximately 1 in 5000 per-sons and is characterized by devel-opment of numerous (often morethan 1000) colon adenomas; virtu-ally all affected patients are at riskfor having colorectal cancer by age40 years. Before 1995, diagnosis ofFAP was based on family history ofeither polyposis, early colon can-cer, or both, and sometimes basedon presence of extracolonic char-acteristics (eg, congenital hyperpig-mentation of retinal epithelium).Because of the early manifestationsof the disorder, all children of af-fected parents were scheduled forannual endoscopic examinationbeginning around ten years of age.6

Because each child had a 50%chance of being affected, half of thechildren receiving endoscopy hadthe procedure unnecessarily. Aftergenetic testing became available andthe family mutation could be iden-tified, children at risk could be

tested; and only those carrying thefamily mutation would need to bescreened for colon cancer. This ge-netic testing technology thus sparesunaffected children from being testedand allows families and thehealthcare systems to focus their re-sources where they are most needed.Thanks to recent developments inmolecular diagnostics, the rate of de-tecting the mutations in FAP familieshas increased from about 80% (inthe 1990s) to 90% today.7

The Vision ofPharmacogenetics andPharmacogenomics: TheRight Drug for the RightPatient

Pharmacogenetics is the study ofvariations in DNA sequence relatedto drug action and disposition andincludes study of the enzymes in-volved in drug metabolism as wellas the transporters involved in theabsorption, distribution, and excre-tion of drugs. Pharmacogenomics isthe study of all genes that affect thebody’s response to drugs;pharmacogenomics is thus the in-

tersection of pharmacology andgenomics. Although the termspharmacogenomics and pharmaco-genetics are often used interchange-ably, pharmacogenomics is abroader term because it applies toall genes.

Pharmacotherapy forHeritable Disorders

Recombinant versions of enzymeshave been developed for treatingseveral heritable disorders of lyso-somal storage. Enzyme replace-ment therapy is available for pa-tients with Gaucher disease, Fabrydisease, and some forms ofmucopolysaccharidosis (MPS).Other forms of enzyme replace-ment therapy may soon be ap-proved for treating Pompe diseaseand another type of MPS (seeTable 5).

Throughout California, semian-nual collaborative videoconferenceshave been held by KP geneticistsand other specialists (eg, cardiolo-gists, neurologists, nephrologists,ophthalmologists, and gastroenter-ologists) who treat these patients.

Table 5. Enzyme Replacement Therapy commercially available or pending FDA reviewEnzyme Disorderimiglucerase ( Cerezyme)a Type 1 Gaucher disease laronidase (Aldurazyme)a Mucopolysaccharidosis I (MPS I)agalsidase beta (Fabrazyme)a Fabry diseasegalsulfase (Naglazyme)a MPS VI (Maroteaux-Lamy syndrome)alpha-glucosidase Pompe diseaseiduronate-2-sulfatase MPS II (Hunter syndrome)

Table 6. Minimum requirements for obtaining family medical historyObtain family history information on at least three generations.Ask about all individuals in both sides of the patient’s family and recordpregnancy history, including losses/stillbirths/neonatal deaths, age atdiagnosis of significant disease, current age (or age at—and causeof—death).Ask about history of mental retardation or developmental delay, birthdefects, known genetic disorders.Record ethnicity and race. Record consanguinity.

a Commercially available in the United States as of late 2005.


Special Feature


health systems

Videoconference participants re-view the newer enzyme replace-ment products as well as issues sur-rounding therapy. This interactiveapproach provides an optimumperspective on complex diseases,enables sharing of information, andhelps clinicians who are makingtreatment decisions regarding en-zyme replacement therapy.

The Promise ofPersonalized Medicine

News articles have heralded theapproach of personalized medicine,a vision of the future wherein typeand dose of medication will be cho-sen on the basis of each patient’sown genetic profile as determinedby pharmacogenetic pretesting. Thisenvisioned future will probably oc-cur in small steps, because testingis not yet widely available for mostgenetic variants and because out-come data must first be collected toguide prescription adjustmentsbased on pretesting. This futuristicmodel of personalized medicinemust also account for multiple fac-tors that can affect gene expression.

Pharmacogenetic informationhas already been added to theFDA-approved labeling of somemedications. Many others will fol-low, adding new facets to treatmentdecisions in individual cases. Inaddition, pharmacogenomic analy-sis conducted during the drug de-velopment process will result inmore accurately targeted drugs withmore limited toxicity. This achieve-ment may bring new therapies tothe consumer market, because im-proved efficacy and lessened toxic-ity could justify FDA approval ofdrugs which could not have beenapproved for less-well-defined tar-get populations.

During the past five decades, re-search has led to considerable in-crease in knowledge concerning the

metabolizing enzymes affected bypolymorphisms of single genes.Examples of these enzymes include:

• N-acetyltransferase (NAT2), re-lated to alterations in pharma-cokinetics of isoniazid, hydrala-zine, procainamide, and sul-fonamides

• cytochrome-P450 isoenzymes,such as CYP2D6, CYP2C19,and CYP2C9, which affect me-tabolism of many drugs

• UDP-glucuronosyl transferases(UDP-GT), which has anisoform (UGT1A1) that con-verts the active metabolite ofirinotecan to an inactive glu-curonide.

Patients with one of these poly-morphisms may be at increased riskfor adverse reactions or for ineffi-cacy of the substrate drugs whenthese drugs are used at usual doses.

With new pharmacogenetic appli-cations and expanded informationabout associations between drugtherapy and genetic variations, thechallenge presented to KP includesthe need for careful, evidence-basedevaluation regarding use of phar-macogenetic testing in drug therapy.This evaluation will require the co-ordinated efforts of physicians, clini-cal laboratory staff, and pharmacystaff. In most instances, we will findvalue in development of evidence-based guidelines, educational tools,and internal KP review by the Bio-technology and Emerging Pharma-ceutical Technology AssessmentCommittee (BEPTAC), physiciancommittees, and the Pharmacy andTherapeutics Committee.

Genetic Testing andDrug Therapy

At least two types of genetic test-ing will be used in pharmacogeneticapplications that affect choice ofdrug therapy.

One such type of testing measures

genetic variation in a disease, suchas mutations in tumor tissue. Oneof the best-known examples of genetesting related to drug therapy istesting of tumor tissue in metastaticbreast cancer patients as a determi-nant of whether trastuzumab(Herceptin, Genentech, South SanFrancisco, CA) might be effective.Overexpression of the HER2 proteinhas been found in some human pri-mary tumors and has been identi-fied in 25% to 30% of patients withbreast cancer. Available methods oftesting include an immunohis-tochemical (IHC) assay to test foroverexpression of HER2 protein anda FISH test using a DNA probe todetermine HER2 gene amplification.Testing has become both a standardfeature of treatment plans and req-uisite for use of trastuzumab in aspecified subset of patients diag-nosed with metastatic breast cancer.

The other type of genetic testingis testing for genetic variations in anindividual person. An example ofsuch variation is the gene variant forUGT1A1 enzyme, which converts theactive metabolite of irinotecan(Camptosar; Pharmacia, Peapak, NJ),indicated for metastatic colorectalcarcinoma) to an inactive metabolite.This polymorphism (UGT1A1*28)leads to decrease in UGT1A1 enzymeactivity, which in turn leads to in-creased irinotecan toxicity (eg, severeneutropenia). About 10% of NorthAmericans are homozygous for thepolymorphism and are at increasedrisk for this toxicity. Another 40%of the North American populationare heterozygotes and may alsohave some increased risk for toxic-ity. The FDA has recently added thisinformation to the irinotecan prod-uct label.8 Oncologists, pharmacists,laboratory personnel, and geneti-cists are interacting to determinehow to use this pharmacogeneticinformation most effectively.


New Technology


health systems

The Family MedicalHistory: A Timeless Tool

Although genetic technology con-tinues to evolve at an unprec-edented pace, the family medicalhistory remains a valuable clinicaltool in delivery of genetic servicesto our patients. Indeed, one fore-cast has stated that “Personal andfamily [medical] history will continueto be the key indicator for clinicaluse of genetic tests.”9:p7 Collectionand interpretation of information onfamily medical history is essentialfor several purposes: to identifypersons at risk for genetic condi-tions, to determine genetic testingoptions, to interpret results of ge-netic tests, and to choose appropri-ate options for clinical case man-agement. The FAP examplepresented above is a perfect illus-tration of how knowing a patient’sfamily medical history affects diag-nosis and management of a geneticcondition.

Physicians in all specialties willface increasing demands “to explorefamily [medical] history, explaingenetic testing options, and sepa-rate genetic hype from reality fortheir patients—roles for which phy-sicians currently receive little or notraining.”10:p10 Recently, several pro-fessional organizations have focusedon increasing genetic competencyamong primary care practitioners.The National Coalition for HealthProfessional Education in Genetics(NCHPEG) has defined core com-petencies in genetics for all healthprofessionals and has developededucation tools to promote integra-tion of genetics into healthcare prac-tice.11 The American Academy ofFamily Physicians chose genomicsas their Annual Clinical Focus (ACF)for 2005 and invited Francis Collins,MD, Director of the Human Ge-nome Project, to kick off the pro-gram; and the CDC declared

Thanksgiving 2004 as “Family His-tory Day” to launch its Family His-tory Initiative.12

The family medical history shouldinclude information on at least threegenerations from both sides of thefamily (see Table 6). Physicians mustrecognize that family history is dy-namic. As relatives age, they maybe diagnosed with new disordersthat were not part of the originalhistory collected for the patient. Fordata on family medical history tobe accurate, it must be updatedregularly. Collecting and updatinginformation on family medical his-tory should not be the sole respon-sibility of primary care practitioners,however. Because some KP mem-bers rarely see a primary care prac-titioner, all clinicians should seizethe opportunity to collect and up-date information about their pa-tients’ family medical history.

KP HealthConnect will provide anopportunity for collecting and track-ing some data on family medicalhistory. Moreover, a KP interregionalcommittee of genetics specialists iscurrently exploring options for de-veloping expanded databases offamily medical history and pedigree.

We hope that these initiatives willallow family history interpretationsoftware to become widely availableto assist primary care practitionersin identifying patients at risk for ge-netic conditions and to improveclinical care of these patients. Untilthose tools are universally available,clinicians should familiarize them-selves with some of the more com-mon “clues” that suggest the needfor a referral to the genetics service(Table 7).

Present and FutureEvaluation of GeneticTechnology at KPSC

The KPSC Regional Genetics De-partment works closely with manyother departments and processes toensure that the following occur:

• Decisions regarding introduc-tion of new genetics technol-ogy are evidence-based

• All aspects of service qualityand cost are considered dur-ing the planning and imple-mentation process

• An ongoing management struc-ture for existing technologiesis provided. Groups who in-teract with the KPSC Regional

Table 7. Genetic “red flags” in the family medical historyChildren with birth defects, developmental delay, unexplained shortstature, clinically significant hearing loss, unusual dermatologic conditions, ambiguous genitalia, or tumors with possible hereditarycomponent (eg, retinoblastoma, Wilms’ tumor)Family history of mental retardation, birth defects, or known geneticdisorders (eg, muscular dystrophy, hemophilia, neurofibromatosis)Family history of multiple pregnancy losses, stillbirths, or unexplainedneonatal deathConsanguinityEvidence of autosomal dominant (vertical) transmissionEvidence of autosomal recessive (horizontal) transmissionThree or more relatives (on same side of family) with same disorder (eg, colon cancer)Early age at diagnosis of common cancer (eg, breast or colon cancer atage <50 years)Multiple primary cancers in same individualConstellation of tumors consistent with specific cancer syndrome (eg, breast and ovary, or colon and endometrium, in the same side of the family)


KP HealthConnectwill provide anopportunity forcollecting andtracking somedata on familymedical history.

Special Feature


health systems

Genetics Department includeNational KP and KPSC Medi-cal Technology Assessmentand Deployment Committees,the Biotechnology and Emerg-ing Pharmaceutical Technol-ogy Assessment Committee,the Regional Laboratory, andthe Research and EvaluationDepartment.

Advances in genetic technologyare changing the traditional patient-doctor paradigm. Because of cur-rent genetic technology and predic-tive testing, medical management isnow available for some conditionsbefore they are diagnosed in a pa-tient, and diagnosis is possible formany conditions for which no effec-tive treatment currently exists. Inboth situations, genetic counselingof patients is imperative for helping

them and their families to understandthis complex information. In the fu-ture, evolving genetic technology willallow physicians to manage theircases on the basis of each patient’sindividual genetic makeup, the dis-orders to which these patients arepredisposed, and how these patientsrespond to treatment.

The impressive power of genetictechnology brings with it an equallyimpressive three-part responsibility:equitable access, clinically respon-sible care, and timely use of genetictechnology for patients who maybenefit from it. Collecting, docu-menting, and acting on informationabout each patient’s family medicalhistory are key factors in this equa-tion. The physicians and counselorsat the KPSC Regional Genetics De-partment are already delivering on

the promises of genetic technologyand will continue to combine pow-erful, state-of-the-art medicine witha personal touch and with the sameexcellence that exemplifies geneticservices in each KP region. ❖

References1. Human Genome Project information

[home page on the Internet]. [update2004 Oct 27; cited 2005 Oct 26].Available from: www.ornl.gov/sci/techresources/Human_Genome/home.shtml.

2. Desnick RJ, Astrin KH. Fabry disease[monograph on the Internet]. Seattle(WA): University of Seattle; 2005.[cited 2005 Oct 26]. Available from:www.genetests.org.

3. Bass H, Broome D, Jamehdor M,Mardach R, Rainey E, Shinno N.SCPMG charter of genetic services.[Pasadena (CA)]: Kaiser Permanente,Southern California Permanente

Glossary• Genetics is the study of single genes and their effects.• Genetic Medicine includes the diagnosis and treatment of conditions caused by mutations in a single gene

(eg, Huntington disease) or chromosomal abnormality (eg, Down syndrome). Genetic counseling, genetictesting, and genetic-disease management are services that have been associated with genetic medicinepractice.

• Clinical geneticists are Board-certified or Board-eligible physicians who have completed a fellowship ap-proved by the American Board of Medical Genetics. The American Board of Medical Genetics, recognizedby the American Board of Medical Specialties in 1991, certifies physicians in clinical genetics along withphysicians and PhDs in clinical biochemical genetics, clinical cytogenetics, and clinical molecular genetics.In the past, clinical geneticists were interested primarily in dysmorphology and evaluation of children withbirth defects, mental retardation, or both. Although this interest continues to be a part of their practice,clinical geneticists now engage in a wide range of clinical endeavors involving patients of all ages.

• Genetic Counselors are medical professionals trained in all areas of medical genetics who have completeda master’s degree program accredited by the American Board of Genetic Counseling and who are Board-certified or Board-eligible. In addition to collecting and interpreting information of a patient’s family history,genetic counselors educate and counsel patients about genetic disorders, inheritance patterns, genetic test-ing options, interpretation of test results, and the medical and social implications of genetic disorders. Ge-netic counselors work under the supervision of, and in collaboration with, clinical geneticists. Geneticcounselors provide preconception and prenatal genetic counseling to determine family history of birth de-fects or inherited conditions, possible teratogenic exposure, consanguinity, suspected personal or familyhistory of cancer susceptibility, and other conditions.

• Genomics is the study of the whole genome—how individual genes interact with each other and how theymay interact with the environment to spur development of disease. When genomics is fully developed as afield, genetics will be a subset of genomics, and genetic medicine will be part of the prevention, diagnosis,and treatment of all disease, not just genetic disorders.13


New Technology


health systems

Medical Group; 2001.4. California Newborn Screening

Program [homepage on the Internet].[Sacramento (CA): CaliforniaDepartment of Health; 2004; cited2005 Oct 26]. Available from:www.dhs.ca.gov/pcfh/GDB/html/NBS/Mainmenu.htm.

5. Southern California PermanenteMedical Group. Department ofClinical Analysis. Breast and ovariancancer: referral to genetic counselingfor inherited susceptibility[monograph on the Intranet].[Pasadena (CA): Southern CaliforniaPermanente Medical Group,Department of Clinical Analysis;[cited 2005 Oct 26]. Available from:http://cl.kp.org/pkc/scal/cpg/cpg/html/BRCA.html (passwordprotected).

6. Giardiello FM, Brensinger JD,Petersen GM. AGA technical reviewon hereditary colorectal cancer andgenetic testing. Gastroenterology2001 Jul;121(1):198-213.

7. Solomon C, Burt RW. APC-associated polyposis conditions[monograph on the Internet]. Seattle(WA): University of Seattle; 2005.[cited 2005 Oct 26]. Available from:www.genetests.org.

8. Camptosar [manufacturer’s label][Web page on the Internet]. NewYork: Pfizer; [updated 2005 Jul; cited2005 Oct 26]. Available from:www.pfizer.com/pfizer/download/uspi_camptosar.pdf.

9. The future of genetic testing:technology forecast report[monograph on the Internet]. SanFrancisco (CA): HealthTech; 2004[cited 2005 Oct 26]. Available from:www.healthtech.org/redesign/research/tfr/docs/06-The_Future_of_Genetic_testing.pdf(password protected).

10. Kary W, Raymond B. Genomics:current issues and the policylandscape. In: Kaiser PermanenteInstitute for Health Policy, The KaiserPermanente Federation. Roundtable

discussion: genomics and healthpolicy. Oakland (CA): KaiserPermanente Program Offices; 2004.p 2-27.

11. National Coalition for HealthProfessional Education in Genetics[homepage on the Internet].Lutherville (MD): NCHPEG; [cited2005 Oct 26]. Available from:www.nchpeg.org.

12. US Department of Health & HumanServices. US Surgeon General’sFamily History Initiative [homepageon the Internet]. Washington (DC):US Department of Health & HumanServices; [updated 2004 Dec 29;cited 2005 Oct 26]. Available from:www.hhs.gov/familyhistory/.

13. Khoury MJ. Genetics and genomicsin practice: the continuum fromgenetic disease to geneticinformation in health and disease.Genet Med 2003 Jul-Aug;5(4):261-8.


WonderWonder was the motive that led people to philosophy.

Philosophy is to the cure of the soul what medicine is to the cure of the body.Wonder is a kind of desire in knowing.

It is the cause of delight because it carries with it the hope of discovery.

—Thomas Aquinas, circa 1225-1274, Italian Catholic philosopher and theologian

Special Feature


health systems

Presented as Kanter M, Schottinger J, Odell R. “New technologiesin health care: an evidence-based approach to evaluating newtechnologies,” at the Kaiser Permanente Care Management Insti-tute and The Permanente Journal Evidence-Based Medicine Sym-posium, Costa Mesa, California, December 3-4, 2004.

IntroductionKaiser Permanente (KP) has a robust process for evaluat-

ing, deploying, and monitoring new types of medical tech-nology, including devices, equipment, diagnostics, andprocedures. This process provides guidance and manage-ment of new and existing medical technology to ensurethat physicians of the Southern California PermanenteMedical Group (SCPMG) can provide state-of-the art care.The success of the process depends on participation ofa variety of internal professional and physician experts aswell as other internal groups, such as the InterregionalNew Technologies Committee, Laboratory Committees,and Pharmacy Committees.

The process of managing medical technology usesthree teams of physicians and support staff: the Medi-cal Technology Assessment Team (MTAT), the MedicalTechnology Deployment Strategy Team (MTDST), andthe Regional Product Council (RPC). The medical tech-nology management process seeks to evaluate medi-cal technology in a timely manner, using principles ofevidence-based medicine and focusing on efficacy,safety, and expected improvement in health outcomes.The evaluation process also provides analytical andtactical support to SCPMG physicians by assisting themwith systematic, well-thought-out deployment of medi-cal technology. The final component of the processconsiders benchmark standards to coordinate purchaseof the technology while ensuring that KP leverages itscollective purchasing power, and provides appropri-ate vendor support.

Over the past two decades, the process of managing

new technology in the KP Southern California Regionhas evolved continuously. Initially, in 1983, a MedicalTechnology Committee was formed to evaluate requestsof local medical centers for regional approval to pur-chase capital medical equipment. At that time, muchfocus was directed on new types of imaging technol-ogy, such as computed tomography (CT) or magneticresonance imaging (MRI).

In 1995, the Technology Assessment and Guidelines(TAG) Unit was developed to support the committeeby providing evidence-based evaluation of new tech-nology. In 1998, the California legislature enacted theFriedman-Knowles Act, which set the stage for inde-pendent medical review of coverage decisions for indi-vidual health plan enrollees. The Medical TechnologyInquiry Line was created in the KP Southern CaliforniaRegion as a one-stop location for giving clinicians promptaccess to objective, evidence-based medical informationon new technology. With the support of the PermanenteFederation, this service was expanded to include sup-port for KP regions outside California.

In 2000, a process called the Medical TechnologyManagement Process was implemented to connect thediscipline of evidence-based evaluation of medical tech-nology with a strategy for planned equipment purchaseand deployment. Figure 1 shows the groups currentlyparticipating in this process, the components of whichinclude assessing and deploying medical technologyas well as responding to inquiries about it.

Technology AssessmentThe Medical Technology Assessment Team (MTAT)

performs critical analysis of published, peer-reviewedmedical literature to evaluate the evidence supportinguse (or avoidance) of specific types of technology formedical diagnosis or treatment. Assessment of new tech-

Kaiser Permanente Southern California RegionalTechnology Management Process: Evidence-BasedMedicine OperationalizedBy Joanne Schottinger, MDRichard M Odell

Joanne Schottinger, MD, (left) is an oncologist and Assistant Medical Director at the SouthernCalifornia regional offices and is responsible for technology assessment, biotechnology, andclinical practice guidelines. E-mail: [email protected] M Odell, (right) is Director of Medical Technology Assessment and Research Supportservices. E-mail: [email protected].

The medicaltechnology

managementprocess seeksto evaluate

medicaltechnology in atimely manner,using principles

of evidence-based medicineand focusing onefficacy, safety,and expected

improvement inhealth

outcomes forKP members.

New Technology


health systems

nology includes describing the specific health problem,the population of concern, the new technology, any al-ternative interventions, and the desired health outcomes.The medical problem of interest is described preciselyand systematically with input from clinicians practicing inspecialties relevant to the specified condition.

One of the analytical staff uses PubMed (an onlinebibliographic resource) to search the medical literature.The published medical literature is searched also to iden-tify any previous assessments that may have been con-ducted by other organizations that use evidence-basedmethodology (for example, the Emergency Care ResearchInstitute, Blue Cross/Blue Shield, or Hayes, Inc, an inde-pendent assessor of health technology). Information issought also from government agencies, such as the USFood and Drug Administration (FDA), National Insti-tutes of Health (NIH), National Cancer Institute (NCI),Centers for Disease Control and Prevention (CDC), andfrom medical specialty societies.

The MTAT carefully evaluates the quality of availableevidence by thoughtfully considering such factors asnumber of studies and subjects, quality of investiga-tion (Figure 2),1 consistency of study results, certaintyand magnitude of possible benefits and harms, and num-ber of potential candidates for a specified intervention.

Stating the rationale for its conclusion, the MTAT devel-ops and forwards to interested specialty groups a rec-ommendation based on the sufficiency of the evidence.

Technology DeploymentTechnology whose use is supported by available evi-

dence is also recommended by MTAT to the MedicalTechnology Deployment Strategy Team (MTDST), whichconsiders the logistics of deployment, including fore-casting the need and uses for the technology, develop-ing a business case for its use, determining requirementsfor training and credentialing staff who will use the tech-nology, and defining processes for monitoring the qual-ity of the technology’s outcomes. The Regional ProductCouncil (RPC) is responsible for acquiring, standardiz-ing, and budgeting for medical equipment. The RPCcommunicates with KP’s geographic service areas inSouthern California.

This process of evaluating, recommending, planning,acquiring, and monitoring use of new medical tech-nology is tied together and is administratively coordi-nated by the Joint Chairs Committee (a group whichincludes the Chair and Cochairs of the MTAT, MTDST,and RPC). The Joint Chairs Committee ultimately makesregionwide recommendations about new technology

Medical Technology

Assessment Team

(MTAT)assess all medical

technologies

Medical Technology Assessment

Regional Product

Council (RPC)forecast, deploy allexisting equipment,products, devices

NPO / SCM

Clinical Technology Committees (CTC)

multidisciplinary groupsprovide clinical expertise, benchmarking, standardization

eg, Anesthesia, Eye Care, Imaging/PACS, Ob/Gyn, Patient Monitoring, Respiratory, Urology

Clinical Services Engineering / Medical Physics for imaging technologies

Medical Technology

Deployment StrategyTeam (MTDST)

develop deploymentstrategy; plan qualitymonitoring process

Strategic Business Initiatives andClinical Strategy Consulting

communicate communicate

Southern California Systems andCapital Approval Council (SCAC)

medical services delivery strategies, IT systemsand capital planning

Capital and Planning

SCPMGMedical

Directors &Medical GroupAdministrators

KFH/HPService AreaManagers &Directors of

Hospital Ops

Med Tech“Joint Chairs”

Figure 1. Diagram illustrates the KP Southern California Region technology management process.

Kaiser Permanente Southern California Regional Technology Management Process: Evidence-Based Medicine Operationalized

Special Feature


health systems

after carefully consulting with KP internal experts, chiefsgroups, regional clinical committees, and clinical tech-nology committees. At their meetings, the medical direc-tors and medical group administrators receive regularupdates on new technology, including capital require-ments as well as implications for future space planning.

Responding to Inquiriesabout Technology

Physicians or Member Services Representatives with aspecific patient case question or leaders with ques-tions about new technologies can easily access infor-mational resources on new technology by contactingthe KP Southern California Region Technology InquiryLine at 626-405-5138 or by sending an electronic in-quiry to Med-Technology-AGU, Scal (KP e-mail) [email protected] (Internet access). Ques-tions can range widely—from the newest technologyfor targeted cancer therapy or drugs still in clinical trialsto the oldest technologies—and ask, for example, “Whatis the role of leeches in medical therapy?” and “How canwe acquire leeches appropriate for medical use?”

In response to the inquiry, the technology assess-ment group sends an electronic file containing severalcomponents:

• a summary and analysis of published information• a reference list with published abstracts obtained

from MEDLINE• assessments obtained from other evidence-based

organizations, if available; and• information on FDA/Medicare coverage.

The inquiry line receives about 700 inquiries per year,about a third of which originate from outside California.Maintaining assessments and responses in a databaseenables most inquiries to be answered within 24 hours.

The KP InterregionalNew Technologies Committee

Technology that may have programwide applicationis also assessed by an interregional KP group, the In-terregional New Technologies Committee. This group,chaired by the Permanente Federation Associate Execu-tive Director for Quality and Program Improvement, in-cludes physician-representatives from each KP region,Program Offices, the Care Management Institute (CMI),and from Kaiser Foundation Hospitals benefits and regu-latory services, legal counsel, public affairs departments,and ethics advisors. The INTC tracks emerging technol-ogy as it is developed for entry into the marketplace.

On the basis of the published literature reviewed, theINTC can issue any of three types of recommendation:

• Sufficient evidence shows that use of the technol-ogy is medically appropriate for select patients

• Insufficient evidence exists for the committee todetermine whether use of the technology is medi-cally appropriate for any patient; or

• Sufficient evidence shows that use of the technol-ogy is generally not medically appropriate for anypatient.

Recommendations and discussion of the rationale fornew technology discussed by the INTC are availableon the clinical library Intranet site, http://cl.kp.org/. Thesematerials are filed under Clinical Practice Guidelines asthe last item (New Clinical Technologies) and can besearched either chronologically or alphabetically. Table1 lists some recent examples of technology reviewedby the INTC along with its recommendations.

Evaluation of New DrugsAssisted by monographs prepared by KP National Drug

Information Services, the KP Pharmacy and TherapeuticCommittees use an evidence-based approach to assess thesafety and efficacy of new medications. Individual clini-cians can obtain literature searches and information aboutnew medications from the Drug Info line (available byphone in the KP Southern California Region), electroni-cally at Drug-Info-Inquiry (available through KP e-mail), [email protected] (accessed over the Internet).

The KP Biotechnology and Emerging Pharmaceuti-cals Technology Advisory Committee (BEPTAC) wasformed in response to the exploding growth of newtypes of medication, including human proteins, mono-

Systematic reviewsand meta-analyses

Randomized controlled double-blind studies

Figure 2. Diagram shows pyramidal hierarchy of evidenceused by clinicians, researchers, and administrativedecisionmakers to evaluate medical technology forpossible use in the KP Southern California Region.(Reproduced by permission of the publisher from: SUNY Down-state Medical Center, Medical Research Library of Brooklyn. SUNYDownstate Medical Center evidence based medicine tutorial [homepage on the Internet]. [Brooklyn (NY): SUNY Downstate MedicalCenter]; 2005 [updated 2004 Jan 6; cited 2005 Nov 14]. Availablefrom: http://library.downstate.edu/EBM2/contents.htm.1


New Technology


health systems

clonal antibodies, growth factors, immunomodulatorydrugs, and chemotherapeutic agents. Although expen-sive, these drugs often represent major advances in treat-ing the diseases for which the new medications are ap-proved. Monitoring these medications is challenging alsobecause they may have more widespread potential ap-plications that have not yet been well studied; and thatneither the safety of these medications, often approvedafter review of very limited clinical trials, nor the ad-verse reactions they cause, may not yet be completelyunderstood. This concern is illustrated by the recentwithdrawal of natalizumab from the market after pro-gressive multifocal leukoencephalopathy developed insome patients who had received the drug as treatmentfor multiple sclerosis or Crohn’s disease.2-4

Challenges to Useof New Medical Technology

Tension in evidence-based technology managementis presented mostly by the statement that “there is in-sufficient evidence showing that this intervention ismedically appropriate for patients.” Because the pro-cess tries to “stay ahead of the curve,” many assess-ments of medical technology initially include this state-ment, often reflecting existence of lag time betweendata collection, its presentation at specialty societymeetings, and publication of the evidence in peer-reviewed medical journals. In some cases, the technol-ogy that appears in a publication is already outdatedand has been replaced by newer methods. Frequently,assessments must be updated and the medical litera-ture monitored until the technology “matures” or untilhigh-quality investigational trials are completed.

A good current example of this sequence of events ispresented by virtual colonoscopy as used for detectingpolyps and colorectal cancer. The medical communityeagerly awaits the results of ongoing large randomizedcontrolled trials to determine the utility of this technol-ogy compared with standard visual colonoscopy.5

Another reason for concluding that a recommenda-tion is supported by insufficient evidence may be thatdifferent studies present conflicting evidence. In addi-tion, other reasons may be found for recommendingagainst use of medical technology: existing publishedstudies may be methodologically weak or include toosmall a study cohort; the magnitude of the benefit maybe small; or no comparison has been made with exist-ing technologies and therefore no evidence has beenpresented showing that the newer technology improvesupon the older technology. In these instances, one pos-sible solution is to deploy the new technology at KP as

Table 1. Recent recommendations of the KP Interregional New Technologies Committee regarding several new types of technology

Evidence sufficient to recommend use of these technologies in selected patients• Vagal nerve stimulation for patients with intractable epilepsy• Wireless capsule endoscopy for evaluation of Crohn’s disease • Artificial lumbar disc replacement for single-level vertebral disease• Bone morphogenic proteins for spinal fusion surgery• Laparoscopic hysterectomy for benign uterine conditions

Evidence insufficient to recommend use of these technologies • Vagal nerve stimulation for treating depression• Electrical stimulation and electromagnetic therapy for healing

of chronic wounds • Islet cell transplantation for patients with type I diabetes • Robot-assisted prostatectomy

part of a research protocol or as a quality pilot projectdesigned to collect data for responding to unansweredquestions about whether the technology deployed withinKP has improved treatment outcomes. If the technologyis thus deployed as part of a research protocol, we cancontribute to the health of our communities also by con-tributing to the peer-reviewed medical literature or bypublishing our own results. With our organization’s size,the interests of our clinicians, the strength of our re-search departments, and especially the power of anelectronic medical record, the future holds much prom-ise for us to lead in the most effective use of newmedical technology. ❖

References1. SUNY Downstate Medical Center, Medical Research Library

of Brooklyn. SUNY Downstate Medical Center evidencebased medicine tutorial [home page on the Internet].[Brooklyn (NY): SUNY Downstate Medical Center]; 2005[updated 2004 Jan 6; cited 2005 Nov 14]. Available from:http://library.downstate.edu/EBM2/contents.htm.

2. Kleinschmidt-DeMasters BK, Tyler KL. Progressive multifocalleukoencephalopathy complicating treatment withnatalizumab and interferon beta-1a for multiple sclerosis. NEngl J Med 2005 Jul 28;353(4):369-74. Epub 2005 Jun 9.

3. Langer-Gould A, Atlas SW, Green AJ, Bollen AW, PelletierD. Progressive multifocal leukoencephalopathy in a patienttreated with natalizumab. N Engl J Med 2005 Jul28;353(4):375-81. Epub 2005 Jun 9.

4. Van Assche G, Van Ranst M, Sciot R, et al. Progressivemultifocal leukoencephalopathy after natalizumab therapyfor Crohn’s disease. N Engl J Med 2005 Jul 28;353(4):362-8. Epub 2005 Jun 9.

5. Mulhall BP, Veerappan GR, Jackson JL. Meta-analysis:computed tomographic colonography. Ann Intern Med2005 Apr 19;142(8):635-50.


Special Feature


health systems

Update on Interventional NeuroradiologyBy Amon Y Liu, MD

IntroductionInterventional neuroradiology—a relatively new medi-

cal subspecialty known also as endovascular neurosur-gery—treats cerebrovascular, head and neck, and spinaldisease by using minimally invasive techniques.Interventional neuroradiology was originally developedin the 1980s by neuroradiologists and neurosurgeons. Sincethat time, dramatic advances in interventionalneuroradiology have been made possible by similarly rapidadvances in medical technology, such as neuroimaging(particularly digital subtraction cerebral angiographyand angiographic road-mapping), and development ofrevolutionary medical devices. Many medical condi-tions which could not be treated effectively 15 yearsago can now be treated curatively using currentendovascular techniques. Indeed, even within the fieldof interventional neuroradiology, new technology anddevices introduced within the past five years have al-lowed interventional neuroradiologists to increase thenumber of life-threatening cerebrovascular diseaseswhich can be treated effectively.

This article provides a brief overview of the histori-cal basis for interventional neuroradiology, current treat-ment options for different types of cerebrovascular dis-ease, and anticipated future developments in the field.This article also discusses current status and future plansfor the Interventional Neuroradiology program at Kai-ser Permanente (KP) Medical Center in Redwood City,California.

Historical Basis of InterventionalNeuroradiologyDiagnostic Neur oradiology

Diagnostic neuroradiology is a subspecialty of radi-ology. The first report of cerebral angiography (visual-ization of the cerebral vascular anatomy) in a livinghuman subject, in 1927,1 described a small surgical inci-sion made in the neck to puncture the common carotidartery, after which radiopaque contrast material was in-jected as a bolus for serial filming of the cerebral arteries

and veins. In the ensuing decades, cerebral angiogra-phy advanced considerably in accuracy, efficacy, andsafety. Direct surgical incision was replaced by percuta-neous direct carotid puncture, a procedure which hassubsequently been supplanted by percutaneoustransfemoral catheterization (ie, insertion of a catheterthrough the common femoral artery after percutaneousneedle puncture) and use of safer radiopaque contrastmaterials for cerebral angiography. In addition, modernmechanical devices for injecting contrast material, ad-vent of digital subtraction angiography, new techniquesfor obtaining high-speed serial films, and manufactureof modern high-performance catheters also have con-tributed to the evolution of cerebral angiography as animaging modality which is safe and effective when usedby experienced operators.

Concurrent with these developments, noninvasiveadvanced technology such as ultrasound, computedtomography (CT), and magnetic resonance imaging(MRI) have sometimes allowed interventionalneuroradiologists to make more accurate diagnoses andto plan endovascular interventions without making askin incision to see inside the body. Further improve-ments in noninvasive imaging equipment and power-ful computer processors have led to new techniquesfor visualizing the cerebral vasculature using CT or MRI.These techniques—computed tomographic angiogra-phy (CTA) and magnetic resonance angiography(MRA)—are now often used to screen patients for sus-pected cerebrovascular disease. These techniques re-duce (but do not eliminate) the need for diagnosticcerebral angiography, which currently has greatest sen-sitivity for detecting subtle abnormalities or diseases ofthe small and distal cerebral vessels.

Interventional Neur oradiologyInterventional neuroradiology is a radiologic subspe-

cialty which was introduced in the 1980s to helpneuroradiologists and neurosurgeons to find effec-tive techniques for treating patients for whom tradi-

Amon Y Liu, MD, is a radiologist in the Department of Radiologyand Neurosurgery at the KP Redwood City Medical Center inNorthern California. E-mail: [email protected].

CME

Emergence ofinterventional

neuroradiologyhas marked a

transition fromthe radiologist’straditional roleas a consultant:Interventional

neuroradiologistsserve not onlyas consultants

but as clinicianswho assume anactive role andresponsibility in

treatment.

New Technology


health systemsUpdate on Interventional Neuroradiology

tional treatments (ie, open brain surgery) were nei-ther possible nor feasible. Conditions precluding tra-ditional treatment included giant cerebral aneurysm,surgically inaccessible aneurysm, large arteriovenousmalformation, c l inical ly s ignif icant medicalcomorbidity, or a combination of these conditions.Introduction of cerebral angiography provided anavenue for achieving more effective treatment forpatients with these conditions.

Through the 1980s, neurointerventional techniqueswere considered largely experimental and were doneonly for patients who had no other treatment options.In the late 1980s and early 1990s, two key develop-ments in angiographic equipment—digital subtrac-tion angiography and roadmap fluoroscopic imag-ing—permitted dramatic growth of interventionalneuroradiology. Digital subtraction angiography initiallyhad resolution inferior to that of cut-film angiographybut allowed more rapid decision making duringangiographic procedures by eliminating the need forusing time-consuming, conventional film processingafter each angiographic injection of contrast material.Roadmap fluoroscopic imaging has allowedinterventional neuroradiologists to obtain angiographicimages of a blood vessel, lesion (eg, cerebral aneu-rysm), or both by injecting only a small amount ofcontrast medium and to maintain this angiographicimage on the fluoroscopic monitor while superim-posing live fluoroscopic (x-ray) images on theangiographic image. In essence, by givinginterventional neuroradiologists a “roadmap” of theblood vessel and lesion, this imaging technique hasenabled these specialists to treat the lesion. For ex-ample, a “roadmap” can be used to guide a catheter tothe proper location within a blood vessel so that mate-rials can be deployed to treat a cerebral aneurysm. The“roadmap” also enables interventional neuroradiologiststo then inflate and deploy a balloon within the aneu-rysm to occlude it . Indeed, interventionalneuroradiology would be impossible without the ad-vent of roadmapping.

Equally important for advancement of interventionalneuroradiology were the rapid technological improve-ments in each successive generation of medical de-vices and materials. In general, therapeutic proceduresin interventional neuroradiology are done through amicrocatheter measuring between .013 and .021 inchesin diameter. The microcatheter is inserted coaxiallythrough a larger catheter (the “guide” catheter, mea-suring approximately 2 mm in diameter) placed in thegroin. Under fluoroscopic (x-ray) guidance, the

microcatheter is threaded through the blood vesselsleading into the brain. Depending on the disease pro-cess being treated, any of several devices or materialsmay be deployed or injected through the microcatheter.

Despite its strong roots in the field of radiology,interventional neuroradiology has evolved into a dis-tinct medical discipline that combines elements of ra-diology and neurosurgery. Emergence of interventionalneuroradiology has marked a transition from theradiologist’s traditional role as a consultant:Interventional neuroradiologists serve not only as con-sultants but as clinicians who assume an active roleand responsibility in treatment. As interventionalneuroradiology continues to evolve, radiologists as wellas a growing number of neurosurgeons have enteredthe field. The American Society of Interventional andTherapeutic Neuroradiology was formed in 1992 as thegoverning body for this multidisciplinary field.

Current Treatment Options inInterventional Neuroradiology

The minimally invasive procedures used byinterventional neuroradiologists accomplish a widevariety of treatments (some of which are described inthis article) designed to provide pain relief as well asto correct life-threatening conditions. Such conditionsinclude aneurysm (treated by inserting platinum coilsinto the aneurysm bulge to promote clotting and toprevent rupture), abnormal, enlarged cerebral arteries(treated by injecting embolic material into a arterio-venous malformation to prevent life-threatening hem-orrhage), and stroke (treated either by delivering “clot-busting” drugs directly to the site of blockage or byusing microdevices specificallydesigned to retrieve clots). As al-ternatives to invasive surgery,these forms of therapy are oftenadvantageous because they canlower the risk to patients,shorten hospital stays, and has-ten recovery. Endovascular tech-niques also allow treatment ofmany lesions which could notbe treated with open surgery.

Similarly, interventional neuro-radiologists use endovascularand other percutaneous tech-niques to treat some types ofhead and neck disease (for ex-ample, embolic or sclerosingagents are injected to treat carotid

Roadmap fluoroscopicimaging has allowed

interventionalneuroradiologists to obtainangiographic images of ablood vessel, lesion … orboth by injecting only a

small amount of contrastmedium and to maintain thisangiographic image on thefluoroscopic monitor while

superimposing livefluoroscopic (x-ray) imageson the angiographic image.

Special Feature


health systemsUpdate on Interventional Neuroradiology

blowout syndrome, epistaxis, and facial hemangioma)and some types of spinal disease (for example, a “glue”is injected to treat spinal arteriovenous malformation,or cement is injected into a fractured vertebra to treatpain caused by fracture).

Treatment of Cer ebral AneurysmsInitially, only aneurysms described as giant (> 2.5

cm) or otherwise inoperable were treated usingendovascular techniques. These aneurysms were treatedby inflating and detaching small silicone or latex bal-loons within the aneurysm in the hope that filling theaneurysm would prevent its rupture. Other aneurysmswere treated, where possible, by using balloons todeliberately occlude the blood vessel both proximaland distal to the aneurysm.

The early 1990s brought a revolutionary advance tointerventional neuroradiology: the Guglielmi Detach-able Coil, GDC (Boston Scientific, Natick, MA). Thisdevice is an electrolytically detachable platinum coilwhich can be delivered into a cerebral aneurysm topromote clotting within the aneurysm. If satisfactorypositioning of the coil cannot be achieved, it can bewithdrawn through the microcatheter. Currently,interventional neuroradiologists planning treatmentof aneurysms can choose from among several typesof FDA-approved coils: bare platinum coils, 2- and3-dimensional coils, aneurysm-conforming coils,bioactive coils, and hydrogel-coated coils. Thesecoils differ from one another in performance char-acteristics, advantages, and disadvantages. Whenused in the appropriate setting, these newer-gen-eration coils are expected to improve the stabilityof aneurysm coiling and thereby reduce the needfor repeat embolization.

The International Subarachnoid Aneurysm Trial(ISAT)2 was designed to compare the efficacy of aneu-rysm coiling versus open surgery in patients with rup-tured aneurysms. In 2002, investigators showed thatpatients who were treated with coil embolization hadimproved outcomes compared with patients who re-ceived open surgery.2

The next revolutionary advance in endovascular treat-ment of cerebral aneurysms came in 2003 with the in-troduction of the first stent approved by the FDA forintracranial use. The Neuroform stent (Boston Scien-tific, Natick, MA) facilitates treatment of wide-neckedcerebral aneurysms by bridging the neck of the aneu-rysm with a very thin meshwork which prevents coilloops from prolapsing into the parent vessel and therebyreduces the risk of a treatment-related stroke.

Treatment of Cer ebral V asospasmInterventional neuroradiologists are also frequently

called upon to treat cerebral vasospasm, one of thedevastating sequelae of aneurysmal subarachnoid hem-orrhage. Endovascular treatment of vasospasm mayinclude use of a microcatheter for intraarterial injectionof vasodilating agents, or balloon angioplasty of theintracranial vessels.

Treatment of Cer ebral ArteriovenousMalfor mations and Dural ArteriovenousFistulae

These types of vascular malformations can often causedebilitating symptoms such as headaches or pulsatiletinnitus (“ringing or buzzing in the ears”) and can causelife-threatening intracranial hemorrhage. Depending onthe type of arteriovenous vascular malformation in-volved, interventional neuroradiologists can very ef-fectively treat these lesions by injecting embolic agentssuch as polyvinyl alcohol (PVA) and n-butyl cyanoacry-late (colloquially known as “glue” and approved bythe FDA in 2003) into arteries supplying the lesions. InAugust 2005, the FDA approved Onyx (Micro Thera-peutics, Irvine, CA), a nonadhesive liquid embolic sys-tem composed of ethylvinyl alcohol dissolved in dim-ethyl sulfoxide, for preoperative and radiosurgicalembolization of arteriovenous malformations. Othertypes of vascular malformation can be treated usingplatinum coils placed through a transvenous approach.

Treatment of Intracranial and ExtracranialAther oscler osis

Increasingly, interventional neuroradiologists are alsotreating these conditions by using endovascular tech-niques, such as balloon angioplasty, stenting, or bothtechniques. In patients who have symptomatic intrac-ranial atherosclerosis and who have suboptimal resultsof medical management using antiplatelet agents oranticoagulants, stroke is highly likely to develop shortlyafter this medical treatment;3,4 in such cases, use ofintracranial angioplasty, stenting, or a combination ofthese techniques can make the disease less debilitatingby improving cerebral perfusion, by reducing the riskof thrombotic/embolic events, or by both actions. TheFDA has recently approved the first intracranial stent,the Wingspan (Boston Scientific, Natick, MA), for usein atherosclerotic disease, further raising the prospectsfor improved outcomes in affected patients. Stentingof the extracranial carotid and vertebral arteries hasalso advanced greatly. Carotid endarterectomy doneby an experienced surgeon remains a highly effective

The Neuroformstent (Boston

Scientific,Natick, MA)facilitates

treatment ofwide-necked

cerebralaneurysms bybridging theneck of the

aneurysm witha very thinmeshwork

which preventscoil loops fromprolapsing into

the parentvessel and

thereby reducesthe risk of atreatment-

related stroke.

New Technology


health systems

method of treating symptomatic carotid stenosis, andmost interventional neuroradiologists reserve stentingfor patients who are poor candidates for carotid endar-terectomy. (In these patients, the procedure is precludedby recurrent postendarterectomy stenosis, radiation-induced stenosis contralateral carotid occlusion, high-cervical stenosis, or clinically significant medicalcomorbidity). However, multicenter randomized clini-cal trials, such as the Carotid Revascularization Endar-terectomy vs Stenting Trial (CREST),5 are well under-way to determine whether carotid stenting done byexperienced operators is superior, equivalent, or infe-rior to endarterectomy for treating carotid stenosis. Earlyresults of this study have been encouraging for stenting.

Vertebr oplastyIn many cases, painful spinal compression fracture

(osteoporotic or traumatic), isolated vertebral bonemetastasis, and vertebral hemangioma can be treatedeffectively with vertebroplasty when the pain is not re-lieved by analgesic medications. In such cases, a largespinal needle is guided percutaneously into the frac-tured bone under x-ray guidance, and a bone cementmixture is then carefully injected into the bone to treatthe fracture. In approximately 90% of appropriately se-lected patients, the pain is either partially or completelyrelieved after completion of this procedure.6 Many pa-tients who receive the procedure can safely eliminateor substantially reduce their use of pain medication.

Future Developments inInterventional Neuroradiology

The rapid pace of technological innovation ininterventional neuroradiology makes this a very excit-ing field. Although we cannot precisely predict whatnew devices may become available in the next fiveyears, we can certainly expect continued improvementin successive generations of the coils and stents usedfor treating aneurysms. The Onyx liquid embolic sys-tem (Micro Therapeutics, Irvine, CA) has also been usedsuccessfully in clinical trials to treat selected cerebralaneurysms,7,8 and the manufacturer is expected to seekFDA approval for this indication within the next two tothree years. This embolic material may ultimately beused in conjunction with coils or may in some casesreplace use of coils for aneurysm treatment.

In August 2004, endovascular treatment of acuteischemic stroke was advanced substantially by FDAapproval of the Merci Retriever device (ConcentricMedical, Mountain View, CA). The device is de-signed to restore flow to the brain by retrieving

embolic material (or blood clot) within an occludedcerebral vessel. Nonetheless, the device is only ap-proximately 50% effective in appropriately selectedpatients.9 Further improvement in this and othersimilar devices is anticipated.

Continuing improvement in imaging technology is alsoexpected to enhance the capabilities of interventionalneuroradiologists. Angiographic equipment improve-ments in image resolution, 3-D imaging, and imaging ofsoft tissue all will help interventional neuroradiologiststo make more effective treatment decisions.

The Interventional NeuroradiologyProgram at the KP Redwood CityMedical Center

The Interventional Neuroradiology program at theKP Redwood City Medical Center is led by Amon YLiu, MD; Gwinette Cowan, RN (Manager, InterventionalServices); and Beverly Land, RN (InterventionalNeuroradiology Nurse Coordinator) and includes a teamof six angiography technologists and five staff nurses.In September 2005, the team was joined by a secondneurointerventionalist, Sean P Cullen, MD.

The goals of the Interventional Neuroradiology pro-gram at the KP Redwood City Medical Center are

• to extend the range of cerebrovascular and headand neck diseases that can be effectively treated;

• to improve rates of morbidity and mortality asso-ciated with treating cerebrovascular and head andneck disease; and

• to improve continuity of care and to reduce treat-ment delays in the KP Northern California Region.

As the regional service center for the neurosciences,the KP Redwood City Medical Center has been able toform this cohesive team, which uses a multidisciplinaryapproach to treating patients diagnosed with neurologi-cal disease. With regard to patients with cerebrovascu-lar disease in particular, specialists in interventionalneuroradiology, neurosurgery, and neurology-criticalcare work closely with each patient to determine thebest course of treatment and management. At present,the Interventional Neuroradiology service can provideall FDA-approved treatments that do not require par-ticipation in clinical trials (except treatments for acuteischemic stroke, which are treated on a case-by-casebasis). Participation in selected clinical trials is consid-ered if a potential benefit to a patient can be estab-lished. The service expects to offer complete coveragefor acute ischemic stroke upon certification by theAmerican Stroke Association as a comprehensivestroke center. ❖

Update on Interventional Neuroradiology

Special Feature


health systems

References1. Lowis GW, Minagar A. The neglected research of Egas

Moniz of internal carotid artery (ICA) occlusion. J HistNeurosci 2003 Sep;12(3):286-91.

2. Molyneux A, Kerr R, Stratton I, et al; InternationalSubarachnoid Aneurysm Trial (ISAT) Collaborative Group.International Subarachnoid Aneurysm Trial (ISAT) ofneurosurgical clipping versus endovascular coiling in 2143patients with ruptured intracranial aneurysms: a random-ized trial. Lancet 2002 Oct 26;360(9342):1267-74.

3. Hass WK, Easton JD, Adams HP Jr, et al. A randomized trialcomparing ticlopidine hydrochloride with aspirin for theprevention of stroke in high-risk patients. TiclopidineAspirin Stroke Study Group. N Engl J Med 1989 Aug24;321(8):501-7.

4. Thijs VN, Albers GW. Symptomatic intracranial atheroscle-rosis: outcome of patients who fail antithrombotic therapy.Neurology 2000 Aug 22;55(4):490-7.

5. Hobson RW 2nd, Brott T, Ferguson R, et al. CREST: carotidrevascularization endarterectomy versus stent trial.Cardiovasc Surg 1997 Oct;5(5):457-8.

6. Hacein-Bey L, Baisden JL, Lemke DM, Wong SJ, Ulmer JL,

Cusick JF. Treating osteoporotic and neoplastic vertebralcompression fractures with vertebroplasty and kyphoplasty.J Palliat Med 2005 Oct;8(5):931-8.

7. Song DL, Leng B, Zhou LF, Gu YX, Chen XC. Onyx intreatment of large and giant cerebral aneurysms andarteriovenous malformations. Chin Med J (Engl) 2004Dec;117(12):1869-72.

8. Molyneux AJ, Cekirge S, Saatci I, Gal G. CerebralAneurysm Multicenter European Onyx (CAMEO) trial:results of a prospective observational study in 20 Europeancenters. AJNR Am J Neuroradiol 2004 Jan;25(1):39-51.

9. Smith WS, Sung G, Starkman S, et al; MERCI TrialInvestigators. Safety and efficacy of mechanical embolec-tomy in acute ischemic stroke: results of the MERCI trial.Stroke 2005 Jul;36(7):1432-8. Epub 2005 Jun 16.

Suggested Reading• Nelson PK, Kricheff II, editors. Neuroimaging Clin N Am

1996 Aug;6(3) [entire issue].• Rosenwasser RH, editor. Neurosurg Clin N Am 2000

Jan;11(1) [entire issue].

Update on Interventional Neuroradiology

The MysteriousThe most beautiful thing we can experience is the mysterious.

It is the source of all true art and science.

—Albert Einstein, 1879-1955, physicist, 1921 Nobel Laureate in Physics

New Technology


health systems

Implementation of a Teleradiology Systemto Improve After-Hours Radiology Servicesin Kaiser Permanente Southern California

By Bruce HornDanny Chang, MD

Julian Bendelstein, MDJo Carol Hiatt, MDAbstract

Kaiser Permanente Southern California (KPSC) has implemented ateleradiology service to provide after-hours radiology services to its 11 medi-cal centers from 7:00 pm to 7:00 am each day of the week. Features of theservice include a Web application that is used to manage the workflowassociated with teleradiology exams and to provide reports of theteleradiologists’ findings to referring clinicians. Currently, two teleradiologistswho can be located at any KPSC facility (varies from day to day) are used toprovide preliminary interpretations of CT, MRI and ultrasound exams. How-ever, the service is scalable and could be easily reconfigured to accommo-date additional teleradiologists if needed. The service also includes a qual-ity monitoring system that tracks significant discrepancies between theteleradiologist’s findings and the subsequent final report of a medical center’sstaff radiologist. Clinicians who utilize the teleradiology service have beenhighly satisfied with the responsiveness of the service—median time be-tween performance of an exam and availability of a wet read is 19 minutes.

a page and when s/he arrived atthe medical center produced inevi-table delays in providing radiologyconsultations to EDs. In most cases,the radiologist was needed only toprovide image interpretation, not toperform the exam.

The Chiefs discussed a variety ofoptions, including providing eachon-call radiologist with the abilityto view exams and transmit inter-pretations from home. This andother potential solutions did notprove to be feasible for various rea-sons, including: concern over thequality of images viewed on home

computers, the challenge of re-motely supporting a variety ofhome systems and the SouthernCalifornia Permanente MedicalGroup compensation structure. Af-ter much discussion, the Chiefs,with the support of administration,elected to implement ateleradiology system that wouldstation a radiologist in a centrallocation to provide image interpre-tation for CT, MRI and ultrasoundexams from 7:00 pm to 7:00 amseven days a week for all KPSouthern California medical cen-ters. “Wet read” reports would becommunicated via fax to the re-ferring ED.

However, when working out thefinal details of the implementation,two important changes were made.First, the single central location planwas abandoned. The radiologistsstrongly preferred an alternativeoption that provided the ability toaccess the teleradiology studies fromany of KPSC’s 11 medical centers.This alternative permitted eachteleradiologist to work from his/herhome medical center, or another ifmore convenient. This change wasmade due to concerns about thewillingness of radiologists interestedin working a teleradiology shift to

For several years, the SouthernCalifornia Chiefs of Radiology ex-plored various technology optionsto improve the efficiency of after-hours services. Until 2002, on-callradiologists at each of the 11 medi-cal centers provided after-hours ra-diology services for their local Emer-gency Departments (ED) in KaiserPermanente Southern California(KPSC). This process had been inplace for many years and reflectedthe medical group’s political struc-ture (essentially 11 separate groupsof radiologists). The time lag be-tween when a radiologist received

Bruce Horn, (top, left) is the Director of Medical Physics for the Southern California PermanenteMedical Group. E-mail: [email protected].

Danny Chang, MD, (top, right) is an interventional radiologist, Chief of Radiology at Riverside Medical Center,Physician-in-Charge teleradiology program and Regional Chief of Radiology, SCPMG. E-mail: [email protected].

Julian Bendelstein, MD, (bottom, left) is the Chief of Radiology in San Diego, CA. E-mail: [email protected] Carol Hiatt, MD, MBA, (bottom, right) is Assistant Medical Director, Business Management, for SCPMG and

chairs the National Product Council. E-mail: [email protected].

Special Feature


health systems

travel to a central location (for ex-ample radiologists who normallyworked in San Diego to travel morethan 125 miles to Pasadena). Doingso offered the advantage of havingthe teleradiologist work in a famil-iar setting, using familiar equipmentand traveling no more than for atypical workday. Second, the planto communicate the teleradiologist’sfindings via fax was replaced by aWeb application that would providethe ability to track a request forteleradiology services throughoutthe entire process, as well as com-municate the findings to the refer-ring site.

WorkflowTwo different components of

teleradiology needed to be managedas part of the workflow (Figure 1):information and images. Informa-tion workflow begins with the EDinitiating a request for an exam.Required information during thisfirst step includes the patient’s name,medical record number, date ofbirth, clinical reason for the exam,radiology exam requested, andname and contact information of theclinician who needs the results.Next, a radiologic technologist per-forms the requested exam. At thecompletion of the exam, the tech-nologist can add comments to theinformation record that could beuseful to a radiologist interpretingthe exam (eg, technologist’s impres-sions during an ultrasound exam areparticularly helpful to radiologistsremotely reading the resulting im-ages). The technologist documentsthat the exam has been performedand the images sent to theteleradiologist. Step three is theteleradiologist reading the exam anddocumenting his/her preliminaryfindings (“wet read”). The Web ap-plication makes these available tothe referring site where the clinician

or staff, who originally requested theexam, views the findings as thefourth step. Any user can view theup-to-date status for each exam (re-quested, performed, read). In addi-tion, the Web application alertsteleradiology support staff when thereferring site has not accessed theinterpretation after 30 minutes sothat they can follow-up with the site.

Images are the second componentof the teleradiology workflow. Im-ages produced during an exam needto be delivered to the teleradiologistfor interpretation. Because the lo-cation of the teleradiologist variesfrom day to day, there was concernthat images could be frequently

misrouted to the wrong location iftechnologists had to check sched-ules and send the completed exam’simages directly to the teleradiologist.This design would also have re-quired that each possibleteleradiologist location (at least 11sites) be configured on each of the50+ possible imaging systems usedfor the exams. For these reasons, acentral image router serving all ofSouthern California was installed.Exam images are communicated viaDigital Imaging and Communicationsin Medicine (DICOM) from the origi-nating imaging system (eg CT scan-ner) to the router. DICOM is a non-proprietary industry standard forcommunicating images in digitalform between medical devices. Therouter then automatically sends theimages directly to the workstation atthe location of the teleradiologist forthat day. Changes in teleradiologistlocation are easily accommodated bychanging the destination configura-tion of the router.

Initial Launch,Expansion andScalability

EDs in 5 of the 11 medical cen-ters in Southern California were in-cluded in a pilot of the teleradiologyservice in August 2002 so that theprocess could be refined beforeexpanding the service to the entireRegion. As the remaining six medi-cal centers were brought online, theworkload grew to the point that asingle teleradiologist was no longersufficient. Furthermore, althoughoriginally designed to support theEDs, workload increased substan-tially due to addition of urgent af-ter-hours inpatient and some out-patient studies. The design flexibilityof both the image router and theWeb application accommodated thisincrease in workload with the ad-dition of a teleradiologist.

Implementation of a Teleradiology System to Improve After-Hours Radiology Services in Kaiser Permanente Southern California

ReferringDepartmentRequests

TeleradiolgyExam

RadiologyTech

Performs Exam

TeleradiologistProvides“Wet Read”of Images

ReferringDepartment

ViewsTeleradiolgist’s

Findings

Figure 1. Teleradiology examworkflow.

New Technology


health systems

In this expanded model, the Re-gion was divided into two groups,with a teleradiologist assigned toeach group. Medical centers wereassigned to a group on the basis oftheir historical workload so that thetotal workload for each groupwould be roughly equal. Thismethod of balancing the workloadamong teleradiologists also insuredthat multiple exams performed onthe same patient during a shiftwould be read by the sameteleradiologist. The image routersends the exam to the workstationof the appropriate teleradiologiston the basis of knowledge of themedical center from which theexam was submitted. Conse-quently, each teleradiologist onlysees a worklist of the exams re-quested by the medical centers inhis/her group.

The ability to have multiple group-ings for workload division and toroute images on the basis of theirsource allows the teleradiology ser-vice to expand as workload grows inthe future and more teleradiologistsare needed. The design will also sup-port variable shift schedules shouldthese be developed.

Monitoring QualityOne of the concerns that surfaced

during the development of theteleradiology service was how tomonitor the quality of theteleradiologists’ findings when theteleradiologist was, in most cases,providing preliminary reads of examsoriginating from medical centers otherthan his/her own. To address this is-sue, the Web application used to sup-port the exam workflow was en-hanced to include a post-exam qualitymonitoring process. Since theteleradiology findings are only “wetreads,” all teleradiology exams aresubsequently interpreted by a staff ra-diologist at the originating medical

center. The local staff radiologist’sinterpretation is the official diagnos-tic report for the exam. This prac-tice is identical to that used for anypreliminary interpretation.

The first step in the quality moni-toring process is comparison by thestaff radiologist of the teleradiologist’spreliminary findings with his/her of-ficial diagnosis for the same exam.The staff radiologist uses the Webapplication to enter whether there wasa significant difference in findings andto add any pertinent comments.

The designated QA radiologist foreach medical center performs thesecond step in the process. Thisradiologist reviews each exam notedto have a significant difference ininterpretation between theteleradiologist and staff radiologist.The QA radiologist also uses theWeb application to enter whethers/he agrees that a significant differ-ence in findings exists and to recordpertinent comments.

The third process step is per-formed by four radiologists whomeet quarterly to collectively reviewthose teleradiology exams for whichboth the interpreting staff radiolo-gist and the medical center’s QA

radiologist agreed there was a sig-nificant difference from theteleradiologist findings. The conclu-sions of this group of four are re-corded in the Web application andthe teleradiologist is notified of anyexam for which the group agreedthere was a significant differencebetween the group’s findings afterreviewing the actual images and theoriginal teleradiology findings.Quality statistics for eachteleradiologist are maintained in thisfashion for all exams.

Staff SupportDuring each teleradiology shift,

regional staff is on duty and imme-diately available via telephone tosupport the teleradiology workflow.Typically, requested support con-sists of determining the cause of anydelays that may occur in perform-ing or interpreting requested examsand following-up on exams withcompleted findings that have notbeen viewed by the requesting de-partment within a reasonableamount of time. The goal is to as-sure that clinicians are aware of theteleradiologist’s findings. This staffis also responsible for implement-


Sidebar: Teleradiology statistics

Statistics for the six months of teleradiology activity from March 1 to August 31, 2005:Average number of exams per 12-hour shift: 125Annualized number of exams per year: 46,000Number of teleradiologists per shift: 2

Proportion of exams by imaging modality:CT: 80%Ultrasound: 19%MRI: 1%

Proportion of teleradiology requests by referring department:ED: 85%Outpatient: 9%Inpatient: 6%

Median delay from exam performed to teleradiologist wet read: 0:19 (hrs:min)Median delay from exam requested to teleradiologist wet read: 1:17 (hrs:min)Busiest teleradiology hours (based on time read): 8:00 PM to midnight (50% of exams)

Special Feature


health systems

ing a manual method of communi-cating teleradiology results if theWeb application fails. In the eventof technical problems with the Webapplication or with the image router,staff can contact on-call imagingtechnical support staff.

Regional staff support the qualitymonitoring process and collect theimages for the exams that need tobe reviewed for the third processstep, compile the group’s findingsand provide communications of thefindings to teleradiologists.

Future DirectionsAs the teleradiology workload in-

creases, methods to incrementallyincrease capacity in an efficientmanner continue to be investigated.Rather than simply adding anotherteleradiologist for an entire 12-hourshift, it may be advantageous to addteleradiologist capacity only duringthe peak hours of activity (seesidebar: Teleradiology Statistics).For example, three teleradiologists

could be scheduled for the firsthalf of the shift and two for theremainder of the shift.

Another process improvementunder investigation is provision ofthe complete official diagnostic find-ings by the teleradiologist, rather thanonly reporting preliminary findingsas is currently the case. Several op-erational and technical challengeswill need to be adequately addressedin order to implement this changein teleradiology practice: a)teleradiologist staffing will need tobe adjusted to allow for the longerinterpretation times required for fi-nal reports as compared to prelimi-nary findings; b) conversion of theimaging modalities to a filmless en-vironment will need to be completeacross the Region in order to sup-port efficient retrieval of prior examsrequired to support final reports; andc) the dictation/transcription processfor radiology reports will need to bemodified to accommodate any radi-ologist providing a report for any

medical center from any location.

ConclusionThe KPSC teleradiology service

has improved Radiology’s supportof EDs by significantly decreasingdelays in providing after-hours in-terpretation of CT, MRI, and ultra-sound exams. The Chiefs of Emer-gency Medicine have beenenthusiastic about the prompt ser-vice that minimizes the time requiredfor clinical management decisions inEDs, enhances throughput and helpsimprove ED capacity. The servicehas also made it possible to moreeffectively manage the Region’s col-lective radiologist resources and toprovide a process to assure the on-going quality of those services—de-velopments that have produced ahigh level of confidence in the re-sults among emergency physicians.In addition, radiologists have expe-rienced an improved quality of lifedue to the significant reduction of“callbacks” when on call for theirmedical centers. ❖


To WinPick battles big enough to matter, small enough to win.

—Jonathan Kozol, b 1936, non-fiction writer, educator, and activist


CC

C U

pdateBetween November 2004 and January 2005, the In-stitute for Culturally Competent Care (ICCC) conducteda needs assessment survey to identify perceived needsfor education and training in the area of culturally com-petent care, as well as preferred methods to receivethat education and training. Among targeted recipi-ents were physicians, physician assistants, osteopaths,nurse practitioners, nurses, pharmacists, and dieti-cians. The Colorado Region opted out of the assess-ment survey because it was preparing to conduct itsown survey in the near future. The Southern Califor-nia and Northwest Regions participated through repre-sentatives because each Region had recently conductedsimilar surveys.

Respondents were almost exclusively physicians(MDs). The possible reasons for this include: 1) keyregional diversity contacts had primarily MD e-maillists and/or are accustomed to surveying physicians;2) the lack of appropriate contacts with access to RNe-mail lists; 3) historically, RNs are less likely to re-spond to these types of survey requests; and 4) RNUnion concerns.

Survey QuestionsTo address the stated twofold purpose of the survey,

the following questions were asked:1. Would you be interested in attending (additional)

culturally competent care training if convenientlyoffered in your Region?

2. If YES to No. 1, what topics would you like to seeaddressed? (Five options were provided in addi-tion to an “Other” category, which included a nar-rative box.)

3. How do you prefer to receive training or informa-tion on culturally competent care? (Eight optionswere provided in addition to a “Combination ofthe above” or “Other” category, which included anarrative box. Choices included: Printed material,

Institute for Culturally Competent Care:Clinicians’ Needs Assessment 2005

Web-based training, video vignettes, e-mail,videoconference, grand rounds, workshops, CDs/DVDs, combination of above, and other.)

4. Would you be interested in receiving CME/CEUcredit for attending training in culturally compe-tent care?

5. Specifically, are you interested in receiving CME/CEU credit for training on the basis of the infor-mation in the Provider Handbook series on cul-turally competent care?

6. If YES to question No. 5 on CME/CEU credit fortraining on the basis of information in the hand-books, how would you like the training delivered?(Please select no more than three choices: Readthe handbook and answer multiple-choice ques-tions, grand rounds, CD/DVD, workshop, Web-based training, and other.)

7. Identify your job or position. (Seven options wereprovided in addition to an “Other” category, whichincluded a narrative box.)

8. Please identify your Region.

Perceived NeedsNationally, 73% (n = 879) of respondents indicated

that they would be interested in attending additionalculturally competent care training if conveniently of-fered. The lowest interest rate was in Ohio (70.5%),with the Northwest and Southern California at 100%.The area of greatest interest was “crosscultural com-munication skills with culturally diverse populations”(74%). The other two areas of greatest interest were“understanding health beliefs and practices” (68%) and“how to best use interpreter services” (49%).

Respondents indicated particular interest in learningabout two broad population areas: Latinos (also iden-tified as Hispanics, Mexicans, Central Americans, LatinAmericans, and Spanish language) and Asian and Pa-cific Islanders (also identified as Chinese, Vietnamese,

culturally competent care update

Gayle Hunt (left) is the Project Manager and Acting Director for theInstitute for Culturally Competent Care. E-mail: [email protected].

Saleena Gupte, DrPH, MPH, (right) is a Consultant with the Institute forCulturally Competent Care. E-mail: [email protected].

By Gayle HuntSaleena Gupte, DrPH, MPH



SE Asian, East Indian, Pacific Islanders, Pakistani, Mien,Korean, Cambodian, Laotian).

Training PreferencesWhen responding regarding the preferred method of

training, respondents were requested to select up tobut not more than three choices from a list. The mostoften chosen responses were grand rounds, workshops,and printed materials (see Table 1). Significant num-bers (>300 responses each) also responded affirma-tively to the use of new technologies (videoconferencesand Web-based training). Of the 50 who wrote in todescribe a combination or alternative option, the mainmessage was the importance of offering CME credit.This was also reflected in the responses to the ques-tion of interest in receiving CME/CEU credit for train-ing in culturally competent care.

Provider Handbook SeriesICCC produces a Provider Handbook Series, which

speaks to the requested areas of interest for training/learning needs and population groups. Culturally Com-petent Care Training may be modeled from informa-tion in the Handbook Series in order to meet providers’needs, including the provision of CME credit. The sur-vey, however, indicated a general lack of familiarity

Institute for Culturally Competent Care: Clinicians’ Needs Assessment 2005

with this series, indicating the need to promote theHandbook Series to increase awareness nationally.

SummaryICCC has much to glean from the six questions posed

in this survey. Together with regional diversity educa-tors, ICCC has multiple opportunities to impact thequality of culturally competent care delivered by all itsclinicians. Results will help inform the Institute for Cul-turally Competent Care’s ongoing priorities and strate-gic initiatives. ❖

Table 1. How do you prefer to receivetraining?

Training preferencesNo. of timesmentioned

Ground rounds 462Workshops 410Printed material 407Video conference 366Web-based training 337Video vignettes 263E-mail 184CDs/ DVDs 175Combination of above or other 50

A Better WorldYou cannot hope to build a better world without improving the individuals.

To that end each of us must work for his own improvement,and at the same time share a general responsibility for all humanity,

our particular duty being to aid those to whom we think we can be most useful.

—Marie Curie, 1867-1934, Polish chemist and early pioneer in the field of Radiology,1903 Nobel Prize Laureate in Physics, 1911 Nobel Laureate in Chemistry


AbstractAn innovative partnership with the Kaiser Permanente (KP)

Institute for Culturally Competent Care (ICCC) has enabledthe KP School of Anesthesia (KPSA) to become one of thefirst nurse anesthetist programs in the western United Statesto incorporate a formal cultural competence curriculum intoits educational program. Housed administratively in theCalifornia State University system since 1981, KPSA is afully accredited, 24-month program that educates registerednurses to become certified registered nurse anesthetists(CRNAs). The collaboration between the ICCC and KPSArepresents a unique opportunity to enhance the care stu-dent nurse anesthetists provide in ten Southern CaliforniaKP hospitals. In addition to serving KP patient populations,students travel to 12 affiliated hospitals in urban and ruralareas. The partnership also benefits KP: Upon graduation,80% to 90% of the student nurse anesthetists in each gradu-ating class join the diverse KP workforce. This article de-scribes the genesis, evolution, and potential impact of thisongoing collaboration to reduce health disparities.

The Need for Cultural CompetencyCurricula at the Kaiser PermanenteSchool of Anesthesia

The patient population in the Kaiser Permanente (KP)Southern California Region comprises approximately100 distinct cultural groups. The major ethnic commu-

A Successful Partnership to Help ReduceHealth Disparities at Kaiser Permanente:The Institute for Culturally CompetentCare and the Kaiser Permanente Schoolof Anesthesia

nities in the area include African American, ArmenianAmerican, Central American, Chinese American, EastIndian American, Filipino American, Mexican Ameri-can, Jewish American, Japanese American, KoreanAmerican, and Vietnamese American. Aware of the di-versity in the patient population in Southern Califor-nia, the faculty at the KP School of Anesthesia (KPSA)concluded that principles of culturally competent careshould be incorporated into the didactic curriculum toenhance students’ opportunities to deliver high-qualitycare and establish effective cross-cultural communica-tion with patients.

To reach this educational goal, KPSA enlisted the par-ticipation and support of KP’s Institute for CulturallyCompetent Care (ICCC). ICCC provides consultation anddevelops tools, training, and educational resources forclinicians to develop and enhance their cultural compe-tency in order to increase their patients’ compliance withtreatment and positively impact the health outcomesof patients during the clinical encounter.

The KPSA faculty envisioned cultural competencytraining as enhancing student nurse anesthetists’ abil-ity to provide holistic, high-quality anesthesia care andto exhibit awareness, knowledge, understanding, andrespect regarding cultural differences and similaritiesduring the perioperative period. The faculty decidedthat the scope of the training would frame “culture” as

By Nilda Chong, MD,MPH, DrPHSassoon M Elisha, CRNA,MS, EdDMaria Maglalang, RN, MN, NPKaren Koh, MPH, DrPHi


Nilda Chong, MD, MPH, DrPH, (top, left) is a nationally recognized leader in culturallycompetent care and multicultural health. She is the former Director of the Institute for

Culturally Competent Care. E-mail: [email protected] M Elisha, CRNA, MS, EdD, (top, right) is a clinical and academic educator

at the Kaiser Permanente School of Anesthesia. E-mail: [email protected] Maglalang, RN, MN, NP, (bottom, left) is the Clinical Videoconferencing Consultant from theDistance Learning Program, Cross-Regional Patient Care Services. E-mail: [email protected].

Karen Koh, MPH, DrPHi, (bottom, right) is a Consultant at the Institute for CulturallyCompetent Care. E-mail: [email protected].

CC

C U

pdate



encompassing racial, ethnic, religious, and social is-sues, thereby modeling the definition proposed by theUS Department of Health and Human Services Officeof Minority Health.1

Three cornerstones guided the collaborative planningprocess undertaken by ICCC and KPSA. First, the chang-ing demographic profile of the United States requireshealth care staff to have a basic understanding of con-ceptual issues regarding cross-cultural communicationand basic knowledge of health beliefs and practices ofculturally diverse populations. Second, cultural com-petence can enhance clinicians’ opportunities to de-liver high-quality care to patients from diverse culturalbackgrounds. Finally, the collaboration represented astrategic opportunity to help decrease racial and eth-nic health disparities.

Developing and ImplementingCulturally Competent Curriculaat KPSA

Theoretical and practical aspects of patient care areincorporated into every accredited nursing educationalprogram in the US. From human anatomy and physiol-ogy to pharmacology and pathophysiology, a majorgoal of nurse anesthesia education is to provide stu-dents with a solid theoretical foundation. Of criticalimportance is integration of theoretical concepts intoclinical practice, which has been the focus of nursingeducation. Distinct educational opportunities for cul-tural competency knowledge and skills acquisition havenot traditionally been formally integrated into nursingeducation curricula.

The KPSA cultural competency curriculum consistsof four modules and was developed from the 16-hourcultural competence training curriculum created for KPhealth care clinicians by ICCC. Through collaborationwith the KP Distance Learning Program, the KPSA cur-riculum was customized for integration into the exist-ing KPSA nurse anesthesia program. Because applica-tion to clinical practice is a key component indeveloping cultural skills, the four modules are inter-woven throughout the nurse anesthesia curriculum. Thismethodology allows students ample time to apply andpractice the module concepts during clinical rotations.At the conclusion of the four-module training sessions,student nurse anesthetists become formally certified inculturally competent care.

During the first semester of each academic year, theInstitute staff deliver Module 1: Introduction to Diver-sity and Culturally Competent Care and Module 2:Cultural Awareness. Through facilitated class discus-

sions and learning exercises, students learn how torecognize and deal with the biases and preconcep-tions they have formed throughout their childhood andadulthood experiences.

Building upon the first two modules, KP content ex-perts present Module 3: Cultural Knowledge to the stu-dents in the second semester. This module focuses oncultural beliefs, health practices, and nuances of spe-cific social and cultural groups and includes informa-tion on African Americans, Latinos, Asian and Pa-cific Islander populations, LGBT (lesbian, gay,bisexual, and transgender) populations, and personswith disabilities. ICCC’s Provider Handbook Serieson Culturally Competent Care 2-6 serves as a majorresource for the students: Each handbook is devotedto a specific sociocultural group. Students who com-plete Module 3 are assigned to select a patient whoseculture differs from their own and to record clinicalencounters that occur during the clinical rotations; thisserves as preparation for the case presentation eachstudent is expected to conduct at the conclusion of thenurse anesthesia program.

During the last semester, students participate in Mod-ule 4: Cultural Skills, a highly interactive module thatfocuses on cross-cultural communication. A major com-ponent of this module is the individual student casepresentation and discussion with peers.

Successes and ChallengesAn obvious challenge encountered when implement-

ing the cultural competency curriculum has been stu-dents’ uneasiness with discussing cultural values dif-ferent from their own. Some resistance to change hasbeen encountered in the form of some students ques-tioning the need for cultural competency when theirjobs involved “minimal interaction with patients” and“putting people to sleep for a living.” On the success-ful side, many students value the utility of the culturalknowledge and skills gained as well as appreciate theinsight gained from identifying their own biases andpreconceptions around diversity issues.

The KPSA cultural competence program continuesto evolve. Since 2004, for example, students have re-ceived didactic training sessions on culture and ex-pressions of fear and pain, leading students to under-stand that these cultural differences exist not only amongpatients but also among health care providers. In addi-tion, more specificity has been added to the culturalcompetency training curriculum, such as how to workwith interpreters.

The partnership between KPSA and ICCC reflects

A Successful Partnership to Help Reduce Health Disparities at Kaiser Permanente:The Institute for Culturally Competent Care and the Kaiser Permanente School of Anesthesia

… studentshave received

didactic trainingsessions onculture and

expressions offear and pain,

leadingstudents to

understand thatthese cultural

differences existnot only among

patients butalso amonghealth careproviders.



leadership in delivering health care that is both evi-dence-based and built on understanding the healthbeliefs and practices of our culturally diverse mem-bership. Training programs such as the four-moduletraining curriculum in culturally competent care canfacilitate development of cultural awareness, knowl-edge, and skills for the lifelong journey toward cul-tural competence. Most importantly, the KPSA-ICCCpartnership reaffirms KP’s commitment to help reducehealth disparities. ❖

AcknowledgmentThe Medical Editing Service of The Permanente Medical

Group Physician Education and Development Departmentprovided editorial assistance.

References1. US Department of Health and Human Services, Office of

Minority Health. National standards for culturally andlinguistically appropriate services in health care: finalreport [monograph on the Internet]. Washington (DC): USDepartment of Health and Human Services, Office ofMinority Health; 2001 [cited 2005 Dec 22]. Available from:www.omhrc.gov/omh/programs/2pgprograms/finalreport.pdf.

2. Kaiser Permanente National Diversity Council; KaiserPermanente National Diversity Department. A provider’shandbook on culturally competent care: African Americanpopulation [monograph on the Intranet]. 2nd ed. [Oakland

A Successful Partnership to Help Reduce Health Disparities at Kaiser Permanente:The Institute for Culturally Competent Care and the Kaiser Permanente School of Anesthesia

(CA)]: Kaiser Permanente; 2003 [cited 2005 Dec 22].Available from: http://diversity.kp.org/docs/pdf/providers_handbook_african_american.pdf.

3. Kaiser Permanente National Diversity Council; KaiserPermanente National Diversity Department. A provider’shandbook on culturally competent care: Asian and PacificIslander population [monograph on the Intranet]. 2nd ed.[Oakland (CA)]: Kaiser Permanente; 2003 [cited 2005 Dec22]. Available from: http://diversity.kp.org/docs/pdf/providers_handbook_asian_pacific_islander.pdf.

4. Kaiser Permanente National Diversity Council; KaiserPermanente National Diversity Department. A provider’shandbook on culturally competent care: Latino population[monograph on the Intranet]. 2nd ed. [Oakland (CA)]:Kaiser Permanente; 2001 [cited 2005 Dec 22]. Availablefrom: http://diversity.kp.org/docs/pdf/latino_handbook2ed.pdf.

5. Kaiser Permanente National Diversity Council; KaiserPermanente National Diversity Department. A provider’shandbook on culturally competent care: lesbian, gay,bisexual and transgender population [monograph on theIntranet]. 2nd ed. [Oakland (CA)]: Kaiser Permanente; 2004[cited 2005 Dec 22]. Available from: http://diversity.kp.org/docs/pdf/handbook_lgbt.pdf.

6. Kaiser Foundation Rehabilitation Center; Kaiser PermanenteNational Diversity Council; Kaiser Permanente NationalDiversity Department [monograph on the Intranet]. Aprovider’s handbook on culturally competent care:individuals with disabilities. [Oakland (CA)]: KaiserPermanente; 2004 [cited 2005 Dec 22]. Available from:http://diversity.kp.org/docs/pdf/disability_handbook_final.pdf.

MutualityAll men are caught in an inescapable network of mutuality.

—Martin Luther King, Jr, 1929-1968, Baptist minister,civil rights activist, 1964 Nobel Laureate for peace


soul of the healer

“The Monks”

oil on canvas

18x20

By Ming Jing (Mike) Wang, MD

Dr Wang is an anesthesiologist at the KP Santa Clara Medical Center.He is a self-taught artist working with oil, acrylic, and water media.

Dr Wang focuses his artistic work on human faces and figures,portraying people’s emotions in a realistic manner. This painting is part

of a group of paintings inspired by the lives of Tibetans Dr Wangencountered in his recent travel to Tibet. More of Dr Wang’s work

can be seen on his Web site: www.mwangmd.com.


Spirit


W

Writing and Telling Our Clinical Storiesto Improve the Art of Medicine

hy do doctors and nurses write stories? And why tell them to agroup of unfamiliar colleagues?People write to learn from theirexperiences, to express the mean-ing of their life’s work. Although weremember our stories, we may notunderstand them until we writethem on paper, move them out intothe world.

Origin of Spirit SectionIn this issue we publish a large

collection of original stories, poems,and essays by Kaiser Permanentedoctors and nurses, written eitherduring the five Narrative Medicineconferences and workshops ThePermanente Journal (TPJ) spon-sored in 2004-5, or the TPJ Port-land and Oakland quarterly writ-ing groups in 2005. Barry Lopez,an Oregon naturalist, wrote in hisNative American tale, Crow andWeasel, “The stories people tellhave a way of taking care of them.If stories come to you, care forthem. And learn to give them awaywhere they are needed. Sometimesa person needs a story more thanfood to stay alive. That is why weput these stories in each other’smemory. This is how people carefor themselves.”1

Relevance of StoriesReading and writing stories of

clinical encounters with patients orcolleagues can improve the diagnos-tic and communication componentsof physicians’ and nurses’ clinicalcompetence. Physicians and nurses

counts illuminates more of our col-lective lives as patients and physi-cians, expanding our felt under-standing of human frai l ty,compassion, strength, love, fear,hatred, and ill will.”3

Abraham Verghese, MD, MFA, aNew York Times best-selling author

and practicing inter-nist, gave the key-note address at ourfirst writing confer-ence. He wrote inAnnals of InternalMedicine, “A sensefor the stories un-

folding before us will perhapsallow us to be more conscious ofbringing people to the epiphaniesthat their stories require … [W]ewill remember the voice of thepatient, even though it is the voiceof medicine that we record in thechart. … We should be not just‘doctors for adults’1 but also min-isters of healing, storytellers,storymakers, and players in thegreatest drama of all: the story ofour patients’ lives as well as ourown.”4

Spirit: The PermanenteLiterary & Arts Journal

TPJ has produced three supple-ments thus far: Weight Manage-ment, HealthConnect, and Evi-dence-Based Medicine. From thisissue we will produce a fourth,somewhat different one. We willcollect the stories, poems, essays,published in this section, with aspiritual symposium, commentary,

Tom Janisse, MDEditor-In-Chief

encounter many dilemmas in theirpractice: moral, ethical, legal, so-cial, human rights, religious, eco-nomic, and personal values. Sto-ries can help with understandingand finding solutions, to integrateand organize complicated situa-tions, and to clear the mind. Writ-ing stories can alsopositively impactphysician mentaland spiritual health.Writing is a power-ful tool to discovermeaning and to pro-mote self-under-standing, and because psychologi-cal conflicts are linked to specificchanges in our bodies, narrativewriting can be of therapeutic valueto physicians.2

Physician Authorson Writing

Kate Scannell, MD, internist withThe Permanente Medical Groupand author of “The Death of theGood Doctor,” keynotes our writ-ing workshops. She wrote in An-nals of Internal Medicine, “Writingand speaking about doctoring cansave your life. By this I do not meanthat they can prolong life, but,rather, that they can prove deeplyenlivening. Giving language towhat we witness lifts into personaland, sometimes, public conscious-ness the otherwise unarticulatedexistential dimensions of experi-ence that permeate our work—whether we name them or not.Consciously narrating these ac-

“Sometimes aperson needs astory more than

food to stayalive.”


Spirit


other new stories, and art into anannual periodical, called “Spirit:The Permanente Literary & ArtsJournal.” When published in Sum-mer, 2006, it will be our secondbook. The first book, published in2005, was Soul of the Healer: TheArt & Stories of The PermanenteJournal: The First Seven Years. Mo-tivated by our readers’ comments,we created this book to bring to-

gether our art and stories they sayare so beautiful and uplifting.

The editors hope you enjoyreading your colleagues’ never-before-told stories and poems, andthat they bring you health. Writeand tell us one of your stories, andplease attend one of our writinggroups, or tell us of your interestin starting your own. ❖

Restoring Our Humanity:Our Intention to Heal

References1. Lopez B. Crow and weasel. San

Francisco: North Point Press; 1990.2. Pennebaker JW. Opening up: the

healing power of expressingemotions. New York: The GuilfordPress; 1997.

3. Scannell K. Writing for our lives:physician narratives and medicalpractice. Ann Intern Med 2002 Nov5;137(9):779-81.

4. Verghese A. The physician asstoryteller. Ann Intern Med. 2001Dec 1;135(11):1012-7.

commentary

Being a doctor can be such a lonely place to inhabit. Our task-oriented approaches to patient carecan all too often reduce us to feeling more like two-dimensional characters in someone else’s storythan three- and four-dimensional people in our own meaningful lives. Never has there been a timein the history of medicine when physicians have had a greater need to find meaning in what theydo. When we translate clinical experience into written narratives, we bring to life the physician-patient relationships in which we live. The act of writing helps us to restore our own humanity, andthe act of seeing ourselves with our patients on the written page reminds us of what led most of usinto medicine in the first place. These stories both humanize the physician-patient encounter andmake physicians feel more like the human beings they are than the “human-doings” they some-times become. And it is only through being more fully human ourselves that we may conveyconvincingly to patients our intention to heal. ❖

Fred Griffin, MD

Fred Griffin, MD, is a psychiatrist and a professor at the University of Alabama Schoolof Medicine. Dr Griffin has written extensively on literature in medicine, the use ofwriting in psychoanalysis, and the physician-patient relationship. He presented to andattended the TPJ writing workshop in Atlanta, Georgia in October 2005.


Spirit


Does Anyone Have a Case?The Balint Group Experience

By Cecilia Runkle, PhDLaura Morgan, MD

Eric Lipsitt, MDSommers, DrPH, author of the Practice Inquirymethod, attended a Balint Leaders Intensive coursein Portland, Oregon.

The IntensiveOver a four-day period, we participated in seven Balint

groups, with opportunities to co-lead. Each session wasfollowed by a one-hour debriefing of the group’sinteraction: what was observed in the leaders’ andgroup’s behavior? Did facilitators provide a safe en-vironment for presentation and discussion? Whatcould leaders have done to improve the way in whichthe group addressed both the clinician’s and patient’sperspectives? What occurred unexpectedly and howwas it handled? One session was videotaped. Laterin the day, the group observed and commented onfacilitators’ interventions.

The ValueThe practice of medicine is often referred to as the

“art of medicine.” Our experiences in participating inand co-facilitating Balint groups reflect this adage. Af-ter a case is presented and clarifying questions an-swered, the presenter listens while the group verballyshines a light on the case from many perspectives.Gradually, the picture becomes three-dimensional, withmany shades and possible meanings. The presenter isthen invited back into the group discussion, free toview the picture of their case from new directions.Sometimes, a presenter will put further touches on thepicture; sometimes one will paint it over completely;sometimes one will simply contemplate a new picturethey’d not been aware of before. In all cases, for allparticipants, there is a change in perception that leadsto finer practice of the art of medicine.

So begins another Balint group for clinicians. Us-ing a case presentation model in a facilitated dis-cussion format, clinicians are invited to explore theclinician-patient dynamic. The deceptively simpleprocess can enable clinicians not only to learnmore about the perspectives of the patient butalso to foster greater satisfaction in the practiceof medicine. This is one possible method of prac-tice-based learning that we are exploring to rein-vigorate our vocation.

Since the 1950s, Balint groups have been used inmedical schools, residency programs, and amongpracticing clinicians worldwide. Recent articles docu-ment the value of these groups in preparing clini-cians for practice as well as provoking insight, per-sonal growth and sat isfact ion among thoseclinicians who have been practicing medicine forsome time.1-3 According to the American BalintSociety Mission Statement, the goal of the BalintGroup experience is “for the participants to trans-form uncertainty, confusion and difficulty in thedoctor-patient relationship into understanding andmeaning that nurtures a more therapeutic alliancebetween clinician and patient.”4

For over two years now, the Department of Medi-cine at Kaiser Permanente (KP) Oakland has spon-sored a hybrid Balint/Practice Inquiry group forphysicians, which combines evidence-based medi-cine with the traditional Balint approach. Everytwo weeks, a drop-in discussion is held, withlunches and meeting space provided by the de-partment. Recently, Eric Lipsitt, MD, and LauraMorgan, MD, from the KP Oakland Medicine De-partment, with Cecilia Runkle, PhD, from RegionalPhysician Education and Development and Lucia

Cecilia Runkle, PhD, (top) is a Program Coordinator/Trainer for Group Health Permanente. She is a formerSenior Training and Development Consultant with TPMG’s Physician Education and Development Department. In

her spare time, she enjoys writing haikus, reading mysteries, and race walking. E-mail: [email protected] Morgan, MD, (left) is a family physician working in primary care in the Northern California Region

for the past 13 years. She has authored Surviving and Thriving at Kaiser Permanente, a manual forphysicians, and continues to seek ways to improve the quality of professional life for her peers.

Eric Lipsitt, MD, (right) is an internist and is Oakland’s elected representative on the TPMG Board of Directors.He is also the Chair of the Physician Health & Wellness Committee in Oakland. E-mail: [email protected].

Creating meaningful reflectionand dialogue for expression

and renewal

Experiences


Spirit


Finding Meaning in MedicineBy Laura Morgan, MD

Since January of 2004, an extraor-dinary series of physician gatheringshas been taking place at our homeseach month. Most participants arefrom the Kaiser Permanente (KP)Oakland Medicine Department, butthe group has grown to include phy-sicians from the Oakland communityand other KP facilities as well.

After a reasonably priced, catereddinner and homemade dessert(there’s stiff competition for bestbaked goods between two of us),we settle down to discuss the night’s“theme.” We follow a format cre-ated by Rachel Remen, MD, authorof Kitchen Table Wisdom.

We contribute writings, drawings,songs, photos, objects or a groupexercise that expresses our “take”

on a specific topic as it relates toour practice of medicine. This week,the theme is “silence.” Last monthit was “listening.” In prior months,the themes have ranged from “cel-ebration” to “loss.”

Through these gatherings, origi-nal writings have emerged, such asRoger Baxter’s haikus, which ap-peared in The Permanente Journalin the Summer 2004 issue. Storiesof our experiences with patientseasily fit a “narrative medicine” de-scription. If shy or unprepared,group members may simply contrib-ute their attention to their peers.

Distinct from the case-based col-league groups discussed above,“Meaning in Medicine” dinners arepurely for clinician renewal. Most

of us practice in busy isolation, takecare of everyone but ourselves, andhave little time for reflection. Thesegatherings have created community,self-awareness, and a base of sup-port for needed change in our pro-fessional and personal lives (not tomention hilarity and occasionalrowdiness!).

Initiation and logistics are not dif-ficult but require either one consis-tent host(ess) or an agreement torotate homes. A simple e-mail toyour facility or department can iden-tify interested colleagues.

For further information, youmay contact me or better yet, see“MeaninginMedicine.org,” orRache l Remen ’ s Web s i te :www.rachelremen.com. ❖

In the community of shared experience, with sensi-tive and strong facilitation, we learn to support andtrust each other. Cases with “risky” content, such asdoubt about our medical knowledge, difficulty settinglimits, or negative feelings toward patients, becomenormalized and safe to share and thus better under-stood. In this community, we heal ourselves while wepractice the art of healing others. We believe that Balintgroups provide a forum for the kind of professionaldevelopment that leads to spontaneous personaliza-tion of care. We hope to share our enthusiasm andsupport for initiating this process with all interestedcolleagues.

If you’re interested in starting a Balint group, pleasecontact Laura Morgan at [email protected]. ❖

References1. Turner AL, Malm RL. A preliminary investigation of Balint

and non-Balint behavioral medicine training. Fam Med2004 Feb;36(2):114-22.

2. Johnson AH. The Balint movement in America. Fam Med2001 Mar;33(3):174-7.

3. Adler HM. The sociophysiology of caring in the doctor-patientrelationship. J Gen Intern Med 2002 Nov;17(11):883-90.

4. The American Balint Society [homepage on the Internet].The American Balint Society; [updated 2005 May 5; cited2005 May 19]. Available from: http://familymed.musc.edu/balint/mission.html.

Creating meaningful reflectionand dialogue for expression

and renewal

Experiences


Spirit


Things Happen in the ParkBy Steve Long, MD

A boy yelled, “Stop crying!”As I turned toward him, he pushed his sister. She landed, hard, bouncing on the

cement.Then she stood, head bowed, facing him.“Why are you f…ing crying?” he shouted. He was thirteen or fourteen, big, sitting on

a park bench, a cast on his leg, crutches at his side. His face was red, his hair short.The girl, maybe five, had flat blond curls, and pale skin.“Why can’t you be happy like all the other kids here? Look around. They’re all

happy. Everyone here is happy but you. Stop your f…ing crying.” He screamed in herface.

I couldn’t hear her response. An old gentleman and his wife were sitting on thebench facing the boy. They had a black terrier.

The boy yelled, “Well then go swing on the swings. Have fun.” The girl stood still,unmoving, with her head down.

In the twenty seconds this all took place, I had managed to convince myself that myangry stare was somehow going to make a difference.

The old man stood up. His wife stared off into space. The man and his dog walkedaway.

“Stop your crying,” yelled the boy.I stared.A young woman walked up from behind the bench. “Where’s your parent?” she

asked, calmly. She was plain, thin, with glasses and mousy hair.“My dad’s at work.” The boy replied.“Where’s your mom?” The woman asked.“My mom abandoned me.” The boy said.At this point my daughter asked me to pick her up. The woman kneeled beside the

boy. I couldn’t hear anything else said. I carried my daughter to another part of thepark. She played while I watched.

After awhile, the boy stopped staring straight ahead and looked at the young woman.The woman took the sister to the slides. The woman again knelt next to the boy,

then disappeared from my view, then came back to sit, at a slight distance, with herown group of friends.

The boy continued to sit on the bench, staring straight ahead. His sister was gone.As my daughter played, I kept looking back. I wanted to go up to the woman, to

thank her. To tell her she is brave and smart and wise.“Time to go find mom,” I said.I carried my own daughter to our car, carefully strapped her into her car seat, and

we drove away. ❖

Steve Long, MD, is an otolaryngologist at Northwest Permanente. He has a wife,Wendy, and two children, Zaidie and Eli. He enjoys film as well as writing.

The product of an automaticwrite-for-ten-minutes workshop exercise

Quick Writes


Spirit


For CarlBy Barbara Gardner, MD

We were in my exam room, whereI most always see my patients. Thiswas probably the fourth or fifth timeI’d seen Carl. He was always intense,yet despite his intensity, there wasa softness to his eyes. I could imag-ine him having thoughtful discus-sions with his middle-school stu-dents. His voice was soft, but directand clear and firm.

Life LessonBy Shawna L Swetech, RN

7:15 am. I am sitting at the nurse’s station, get-ting report on my group of patients for the shift.Oh, no—this one is going to be a challenge: 55-year-old male, admitted with Stage IV decubitusulcer and septicemia. History: paraplegic x23years from a gunshot wound to the spine, withsubsequent bilateral AKA, multiple surgeries, andcolon cancer two years ago with colostomy place-ment. He has a suprapubic catheter, triple lu-men central line catheter, extensive Q shift dress-ing changes, and is on bed rest in supine positiononly. God, how awful. I can’t imagine any qual-ity of life worth waking up to, day in and dayout, after all of that. Life is hard enough as it is.Now, the poor soul has weeks of around-the-

clock antibiotics and more surgery to deal with.8:15 am. I’m at the door to his room now, initial

assessment time. Knock, knock, I say as I peekaround the curtain, clipboard clutched against mychest. There, floating atop the fluid air mattress, isthe upper half of a body: the entire lower portionof the bed is empty. I expect to see a man with asad, broken spirit—or at least someone with achronic, sour disposition, rightfully earned fromall those years of misery. But no. An infectioussmile quickly spreads across his face when he seesme. In fact, he exudes a palpable joy that radiatesinto the room like a warm light. I am stunned.

This man is not just my patient; today, he ismy teacher. ❖

We finished talking about the lat-est tack his treatment would take, andfor once he didn’t seem to have anendless stream of questions.

Instead, he sat and thanked me foralways taking the time to answer hisquestions, and said he really appreci-ated it, it made him feel well cared for.

I thanked him. If he only knewwhat a struggle it sometimes was for

me talking to him. He had a bad dis-ease, a malignant brain tumor, and Icertainly wanted to take good careof him. I had struggled to make itappear that I had all the time in theworld to talk to him.

He subsequently died. The imageof his tweed coat, his mustache, hisclear gaze, and his words of thanksremain. ❖

Barbara Gardner, MD, (right) has worked as a neurologist with PMG in Sacramentofor 20 years, and is also doing work in palliative care. She is married with threechildren and has many outside interests, which she juggles with variable success.Shawna L Swetech, RN, (not pictured) is a medical/surgical nurse at the KP SantaRosa Medical Center. She has been studying and writing poetry for five years. MsSwetech finds the magnificence of the human spirit a constant source of inspiration.


Quick Writes


Spirit


MountainBy Laura L Wozniak, LCSW

Everyone who sits on my couch sees ablack and white print of the valley I livedin as a teenager viewed from our moun-tain. It hangs out of my line of sight, be-hind me and over my head. I forget it isthere most of the time, but it was a gift tomy Dad toward the end of his life from oneof his art students. They were as eager forhis praise as I was-and less frustrated. Abovethe print hung a ceremonial eagle feathergiven to me by a Native American elder. Ithought it looked great flying above theaerial view. More importantly, it remindedme of hope and higher powers.

Frank sat there today, looking past me ashe dredged up words from his own valley ofphysical pain and depression. There was amountain of trouble for this man. He was atribal policeman laid low; a revered youthhockey coach stopped cold; a mountain ofstrength to his family, now dependent. Maybehe was a cooling volcano looking for justone reason to glow again.

I remember the mountain I saw risingfrom the shore of the Connecticut Riveracross the road from my house as a teen-ager. Mount Sugarloaf looked huge be-cause it was so steep and loomed instriped sunset colors above the flatnessof shade tobacco fields and wide water.Pocumtuck tribal history said it was thebody of a menacing giant beaver killedby a god, but when I was a teenager youcould drive up and park on top with yourboyfriend. From my window I could seethe lookout tower and all the places where

the fence leaned out dangerously.Looks deceived. The mountain was made

of arkose- coarse sandstone. A handholdturned into handful of miniature rocks ofpink, red and gray and ochre yellow. Eachbit beautiful and nothing that you wantedto keep in the end. Mount Sugarloaf gotsmaller every year. It was earth science infast forward, but it still so dominated hu-man scale that I knew my grandchildrenwould gasp to see it just as I had when wemoved there.

I saw Mount Sugarloaf every morning andevery day. It stands over my mother’s oldgarden bordered with chives and marigoldsto repel pests. It stands over the tiny Christ-mas tree farm my Dad planted in front ofour house—now tall and shadowing thelong driveway. It was my point of refer-ence—always there when I needed to takethe long view.

I looked up after my Dad died at homeand Mount Sugarloaf was still there whenhis ashes came back in a cardboard box. Theashes looked liked tiny pale rocks- nothingthat could hold together in the shape of atall, tall man with a giant presence.

I got up at the end of the hour withFrank. He moved slowly, so I had time tolook around. I was searching for one morething to say or do to ease his life. My handflew up and I spoke without hesitation.“Please take this eagle feather. It is meantfor an elder.” I think of him now everytime I see the pinhole in the wall abovemy Sugarloaf view. ❖

Laura L Wozniak, LCSW, is a therapist in the Mental Health Department at BeavertonClinic as well as the Team Supervisor for the Westside Clinics. She is delighted to be

married to Ken and has two wonderful sons, aged 19 and 21. She takes care of herselfwith ballet classes, gardening and great friends. She thanks her first clinical supervisor,

Julia Kling, MSW, who taught her compassion and courage nearly 30 years ago.


Quick Writes


Spirit


One of Our StoriesMight, Beauty, and Machine Take Flight for “Right” and “Only”:

Is This Story Too Big to Hear?

By Tom Janisse, MD

High over heads at the World Health Congress, beautydazzles and drugs, as does sleek black tech.Washington, DC

“Please do not vandalize this phone booth. I haveno place else to change clothes.” —SupermanVolcano, California, population 100

One hour before the green flag Tony’s orange, 20, Home Depot Chevy issecond pole. A brilliant racer, True Speed author, he wins at Indy, wins theyear, and signs my Stewart hat.Michigan International Speedway

“The Sphere,” a bronze sculpture in the plaza’sfountain buried at the World Trade Center, risesaltered, a peace monument awaiting return.Battery Park, NYC


Spirit


Doctoring My DoctorBy Tom Janisse, MD

I got the call at sundown on Fridayfive minutes before walking out the doorfor my first free weekend in three weeks.The ER doctor on the phone said he hada patient with acute radicular low backpain, and hoped I could help. The pa-tient, he said, was Dr Peter Devereaux,one of our internists, who, on exam andimaging, was free of spine abnormalities.He said he knew that I, as an anesthesi-ologist, was an expert, and did I think anepidural steroid injection would work?

I gulped, more anxious than I wouldhave guessed to perform a spinal proce-dure, which I had done a thousand times,on a colleague. Afraid for a moment I couldhurt another doctor, I wondered what ifhe was the one-in-a-thousand patient?

What if, while he lay helpless on a whitesheet in the fetal position I advanced the14 gauge metal behemoth through theskin and toward the spinal cord in searchof the tiny, potential epidural space, andthe needle slipped and I lacerated a lum-bar spinal nerve, irreparably.

“Sure,” I said, “I’d be glad to take careof him.”

When Peter hobbled in, I was at onceanxious and confident, concerned and

certain, of my skill. He smiled, and saidhe was so grateful I would help, andhappy that I was the doctor on-call whowould perform the spinal procedure hedreaded.

“Well, how was that Peter?” I said, with-drawing the needle. I had performed aflawless epidural puncture and injecteddexamethasone and lidocaine bathing thespinal roots to shrink and numb them.

He sat up on the gurney, turned hishead side to side, looking into the emptycorners of the Recovery Unit and outthe windows, now black pictures of nightlights, and said, “You know, I think I’mstarting to feel less pain already. Yes,the pain is definitely better.”

“Great,” I said, my heart rate plummet-ing. “Peter, I have a request.” I had justreceived a letter at home from our Phy-sician Health Committee encouragingeach of our medical group to find a per-sonal physician (like patient, like doc-tor): “Would you be my personal physi-cian?” I said. “Turns out, I don’t have adoctor. I was one of the 25% of ourHealth Plan member population whowas unassigned and unbonded.”

“I’d consider it an honor,” Peter said. ❖

Tom Janisse, MD, founded Peninhand Press in 1977, in Volcano, California, and has published: short stories—All Stories, All Kinds; California oral history—The Argonaut Mine Disaster; and poetry books—the volcano

review 1-6, Peninhand, Falstaff Medical Poetry I and II, and Notes of a Cornerman. His published works include:a poem, “Dying Distant,” in the New England Journal of Medicine, and a story, “Bring the Bottles,” in the

book Emergency Room: Lives Saved and Lost: Doctors Tell Their Stories. E-mail: [email protected].


Quick Writes


Spirit


EvanescenceBy Mason Turner-Tree, MD

The cold, damp institutional concrete leapt at me like a prisoner attackingwith a fork, ready to extract my radial artery and bite it in half. Fear perme-ated the minimal throng of people who were just moments before en-sconced in laughter, joviality, and irresponsibility. The vague camphor smellwent unnoticed until a polyester protector reminded us that the room waslast occupied in the early 1960s. Suddenly, as she inhaled deeply, we allfollowed suit, as if our individuality had been stamped into an 8x8 cell witha regulation coiled, uncomfortable bed and an assaulting jumpsuit. Sud-denly, the camphor flowed over me, not in my lungs, but on my skin,across my eyes and through my hair. The collective shudder was morefrightening than the camphor. A shared soul is less easy to tolerate than adistant smell leaching from walls that contained such misery. I peered tomy companion, hesitant to break the collection of souls marching along-side the polyester protector. It was night. Bleak, cold, wet, and exhaustingnight. As I broke the camphoria and touched my companion, the bare bulbblew. An echoed scream blinded us, until we realized that it was blackness,not loudness that had burned the retina of our collective. I pulled to thewindow, and looked at the marshmallow skyline, enveloped by black,moonlit tar. Suddenly, it was 1960-something, and I was trapped. Impris-oned not by concrete walls, but by loneliness and isolation. The smell ofchocolate now filled my lungs, but never made it to my brain, stopped onits marginal path by the bleakness of my soul. Snuffed by the camphoria.Blinded by the pale green that I could feel pressing against me. Relief wasusurped when a bowl of light fell upon that very same pale green. Thepolyester protector squashed the collective with her bowl of chocolate-scented fragrance. I stood alone, so close to the moonlit tar that fear perme-ated my olfactory senses and dragged me, quicksand-like, into the roilingpot of tar, studded with the white, fluffy figures that seemed like heaven.They too, were imprisoned by the sticky filth around us. Suddenly, a sol-vent hand touched my shoulder, and the collective was gone. The palegreen marshmallows were sucked into the moat, and a radiant dragonappeared to damselize me. In the distance, I heard, “That was the room,where Robert “The Birdman” Stroud died …”

Mason Turner-Tree, MD, earned his AB degree in psychology from Dartmouth College andcompleted his medical degree at the University of Texas Southwestern Medical Center/ ParklandHospital in Dallas, TX. He joined The Permanente Medical Group as an associate physician in theDepartment of Psychiatry at San Francisco Medical Center and in Addiction Medicine at theChemical Dependency Recovery Program in July 2003. He is currently working on his first novel.In his spare time, he also enjoys playing classical piano and attending opera.


Quick Writes


Spirit


MiracleBy Vicky Van Dyke, CNM

“Do you have privileges at the hospital yet?” I lookedup from my computer charting to see my colleague,Julie, standing in the doorway. “Yeah, I was on call lastweekend, why?” “Well, I’m supposed to be on call to-night and I just found out that the medical staff officedidn’t finish processing mine. Now it’s past five o’clockand it can’t get done today.” The impact of what shewas saying hit me—we had to have someone availablefor the laboring women who would surely be arriving atthe hospital all night. Our obstetric group had just movedfrom a hospital that closed to a new facility. All of themembers of our group were experienced, competentpractitioners but all hospitals have a checklist of infor-mation that has to be completed before they allow apractitioner to care for patients. Only a few members ofour 11-person group had gotten through the process.

I thought through the reasons I might not be able todo it. Tired from a long day at the office didn’t count inthis situation. No previous engagements for the evening.No young children at home requiring care. I hadn’tbeen on call the night before. I didn’t even have theexcuse that too many patients would have to be movedfrom my next day’s schedule—I was scheduled to dosome work for our marketing department and there-fore did not have any patients to be rescheduled. Isighed inwardly. “Sure, I can do it. I’ll just finish uphere and head on over.” She looked relieved. “Thanks,I’m not scheduled again for a while, so I should beable to get it straightened out.”

As I walked through the door of the hospital, I no-ticed a large group of people gathered outside the doorof one of the rooms, some crying, some looking angry.Further down the hall, a small group of nurses wastalking with great animation.

Arriving at the call room, I changed quickly into scrubsand went looking for the people who had been on callthat day so they could “sign out”—tell me which patientswere ours to care for and what their condition was.

I found my friend and colleague, Kristy, standing withthe group of nurses. “You’re probably going to be sorry

you volunteered for this. You’re walking into a powderkeg.” That could mean anything when you’re talking aboutcaring for laboring women. Kristy and I walked own thehall to find a private place to discuss the patients.

“We’re not terribly busy,” she said, “Only one personin labor, but she’s a doozy. She and the family arepretty upset at all of us.”

“Why?” I asked.“Lots of reasons. Have you heard about Camie

Bentley?” The name did sound familiar. Then I remem-bered—the patient screaming at my colleague with theoffice next to mine a few months ago. Dan had beenupset enough about the interaction that he’d talkedabout it for days after. Apparently he had been dis-cussing a 20-week ultrasound report that showed thatCamie’s baby had a serious birth defect calledancephaly. This means that most of the brain is absent.Babies with this disorder rarely survive more than afew days after birth and most die within minutes. Car-rying a baby destined to die is a burden few womenwant to shoulder. Dan had started to arrange a termi-nation of the pregnancy, assuming that this was whatthe patient would want. She had become hysterical. Adevout, “born again” Christian, she did not believe inabortion for any reason. The last words I heard her saywere, “You don’t know everything. Tests can be wrong.They told my cousin her baby would be deformed andhe was all right!” With these words she had stormedout of the clinic. Dan and his nurse had contacted hernumerous times since, but she refused to come in forany more prenatal care, not wanting to discuss the is-sue any further. And now she was in labor. I sensedthings weren’t going well here, either.

Kristy continued. “She came in contracting on herown and has been insisting on having continuousmonitoring. We don’t want to do that, because we don’twant to have to do a crash c-section if we see distress.”“That seems sensible—this situation is difficult enoughwithout subjecting the mother to the pain and poten-tial danger of a c-section,” I answered. I, too, was mak-

Victoria Van Dyke, CNM, graduated from the University of Washington in Women HealthCare and OHSU in nurse-midwifery prior to joining KP ten years ago. She had a private

practice and ran a prenatal clinic for medically indigent women. In addition to attending birthsand providing prenatal care, she also enjoys working with women across the lifespan.

Written over time,read at our writers’ group,

revised from group feedback

Narratives


Spirit


ing the assumption that the mother’s safety should bethe primary concern when survival for the baby wasimpossible. However, when Kristy explained the fullnature of the conflict between the woman and herhusband and the medical team, it was obvious thatwhat seemed sensible to us was only making the familyangry and alienated. Complicating things further, inaddition to her family, the patient had her ministerand a ten-person prayer support group in the room.None of them were talking to the daytime medicalteam any more, stating that they did not trust themand they had been waiting for our “change of shift”to have a new person to deal with. Kristy finished upwith “That patient’s husband is in Holly’s office andhe wants to talk to you.”

I took a deep breath. I consider myself a spiritualrather than a religious person, having difficulty find-ing any church that “felt right.” But I had been raisedin a fundamentalist Christian family and know a lotabout the common beliefs. I encounter patientswhose belief structure impacted their decision mak-ing all the time and generally have no difficulty find-ing a treatment plan that was respectful of their faithand safe for the fetus. This isn’t all that common,unfortunately. Many highly trained, scientific medi-cal practitioners find their rationale impossible to un-derstand and try to direct them more. The night prom-ised to be a challenge, but less for me than others inmy group. I decided it was good that I was going tobe the one here.

I went first to meet with the father of the baby,David. I’m a small woman, and David was only slightlytaller than me, slender and muscular, wearing cowboyboots and a big buckle. His dark eyes were flashingand his face flushed.

“Hi, I’m Vicky. I’m the midwife on call tonight. I hearyou’ve been having some troubles. Why don’t you tellme what’s been going on?”

The story poured out of him. They did not believethat the fetus would be born with the predicted severelife-threatening defect. “We’re expecting a miracle. We’reexpecting God to heal our little girl tonight. That’s whatwe are all praying for and we believe that God an-swers prayers. So we want her to get the best possiblecare. We want her to be treated like the healthy, valu-able child of God she is and for everything possible tobe done to save her. Is that so unreasonable?” He looked

exhausted and on the verge of tears as he pleadedwith me. I thought about it. As he explained the situa-tion from his perspective, I could see why they weredemanding care for their child. We all, instinctively,want to do everything for our children. A mother my-self, I could understand that. I told him so.

“Well, you know, David, I agree with you that therewill be a miracle here tonight. I’m not sure I believe itwill be the same one you are expecting but I do be-lieve that we will experience a miracle. And I want togive you the same care I would any other family inlabor. But I do have to let you know, I’m not a fan ofcontinuous monitoring in any situation. Over the yearsit’s been shown to increase the c-section rate withoutreally improving outcomes for babies. I think the laborwould go faster and therefore be easier on both yourwife and daughter if she was up walking and we lis-tened to the baby’s heart rate intermittently. Intermit-tent monitoring is an accepted obstetric practice.”

“What about resuscitating her after she is born?” he asked.I answered, “That’s not as clear cut to me but I’m

willing to respect whatever decision you and Camiemake. I just want you to have all the facts. Have youever seen a full neonatal resuscitation before?” Hehadn’t. “They can be pretty brutal. The baby is whiskedaway from the parents, a tube is placed down the throatand another into the stomach. An IV is started in theumbilical vein and medicines are given. It is almost al-ways necessary to breathe for the baby with a bag andmost need chest compression. I know you believe shewill be healed and not need this but what if it turns outGod intends a different miracle tonight? Is this how youwant to spend the precious few moments you will shareof her life?” I could tell he hadn’t thought of this. “Wouldyou explain all of this to my wife?” Of course I would. Isensed the tension that I had first felt from him drainingaway and he seemed calmer and more ready to facethe rest of the labor, whatever it brought us.

I entered Camie’s room. It was darkened; there wassoft music playing and clusters of people with theirheads down and their hands clasped were murmuringprayers. A man who was introduced as the ministerwas standing at the head of the bed, one hand on aBible and the other on Camie. She was working withthe contractions and appeared to be coping well withthem. “Camie, I think you should listen to what themidwife has to say,” David started.



Narratives


Spirit


“Hi, I’m Vicky and I’m coming on to take care ofyou tonight. David’s been telling me about your dif-ficulties today and I’m wondering if you’d like tohear my opinion of what we should do.” She lookedat David and he nodded. I repeated my belief thatcontinuous monitoring was not necessary to protectthe baby. Again, I said I believed there would be amiracle, but I wasn’t sure what it would be. There isa miracle at every birth and I wanted her to have themost healing birth possible. She agreed with me andwe took the monitors off. She went to sit with herprayer partner, and they began to pray in earnest,with Camie stopping from time to time to breathethrough a contraction. I went out to tell her nursethat we would be using the intermittent protocol andthat the family was deciding about the level of re-suscitation they would want.

I went back into the room, partially for labor supportand partially to get a sense of who was there and whattheir roles would be. The minister and her prayer part-ner seemed focused on Camie and genuinely involvedin supporting her. Her husband seemed loving, and theyseemed connected as a couple and trusting of each other.The reactions of the church members varied—someseemed there for moral support, some to watch the show,others mainly seemed there to share every horrible birthstory they had ever heard. I see that often with laboringwomen and I wonder at the cruelty of it.

The night wore on, and Camie made steady laborprogress. She refused all pain medication, fearingit would compromise the baby. We talked a lot inthose hours about her faith and the experience ofthe pregnancy. Finally, I broached the subject ofresuscitation after the birth. “If she is ancephalicand your moments with her are going to be lim-ited, how do you want us to spend them?” I couldsee her mother’s heart struggle, then answer, “I wanther life to be gentle. I want her to feel our lovingarms and hear our words. Don’t resuscitate any morethan drying and suctioning her.” I nodded. That feltright to me, too.

The birth of a full term ancephalic presents othercomplications that we hadn’t talked about but were atthe back of my mind. Without a full scalp, it is oftendifficult to distend the mother’s tissue enough to havethe head come through the birth canal. Women pushto exhaustion. The risk of having the shoulders get

stuck is higher. I’d never done this before and was alittle nervous. My backup MD, at home, hadn’t either.

Throughout the evening, there had been a video cam-era filming parts of the birth. Many of my colleaguesdon’t allow cameras to film deliveries but I usually do.For some people this is an important way to be able tomake peace with their birth experience. I was prettysure that was going to be necessary here.

About midnight, it was time to push. We gathered,me to coach her, the minister to bless her and the con-gregation to pray for the miracle. She pushed with astrength and determination that I had to think wasotherworldly. It took hours. Finally, the head was lowenough that I could feel it. It was ancephalic—shouldI tell them? I decided to. “The head I am feeling isshaped in a way that leads me to believe that yourbaby will be ancephalic.” The praying intensified.Camie’s eyes met mine and I could tell she was readyfor whatever the next few moments gave her. We satin a halo of light from the exam light, the rest of theroom darkened. The soft sound of hymns around us,I reached in, hooked my fingers around the little armsand pulled the baby forward into the world. Otherthan the lack of fullness at the back of her head, shewas a beautiful little girl. I laid her on her mother’sabdomen and she cradled her gently. “Welcome tothe world, Hope” she said. I felt the umbilical pulse—life-giving blood continued to flow from her motherbut the baby made no effort to breathe. Her eyeswere open and she appeared to look at her motherand father. “Camie, if I cut the cord, it will stop theflow of oxygen from you to her and that is what iskeeping her alive. It will stop on its own soon, but Iwant you to have her as long as possible.” She nod-ded and continued to explore her baby. The cordcontinued to pulse for what seemed to me a verylong time, then got weaker and weaker. Hope closedher eyes. Her mother kissed her and I cut the cord.

I looked up at the quiet crowd. They were silent, notknowing what to say or do. Who does? Words came tome. “There was a miracle in this room tonight. Themiracle I saw was the amazing power of Love. Thankyou for letting me be a part of it.” The church mem-bers slowly drifted away, leaving Camie, David, Hope,and the minister. I left, too, to give them some privacy.Walking out of the light into the hall, it seemed like Iwas walking into a different world. ❖



Narratives


Spirit


1970By Les J Christianson, DO

Verl was born in 1970. He thinks there is somethingabout 1970 that has made him different from his broth-ers. Not: Oh, isn’t it unfortunate that in 1970 my neu-rons got scrambled while incubating in my mother’swomb?

But rather, What is it about 1970 that made me sodifferent from my brothers? I wish I wasn’t born in 1970.

He has said that many times. But who knowswhether his neurons were fried in utero or whethermy mother simply did not get the Rhogam shot whenshe should have. My parents were young and scaredand this was rural North Dakota. I think all we knewwas that there was a new arrival in our house thatkept having seizures. Those images are some of myearliest memories. Verl, having one of his seizuresnext to the TV. Maybe even under the TV with hislegs sticking out like the Wicked Witch of the Westexcept that Verl was not crushed because the TVwas on four legs.

Two months after Verl moved in with me, and mywife, Kris, I woke up one morning at 3 or 4 am tovery bizarre sounding noises coming from Verl’s roomdown the hall. Kris was in Chicago visiting her fam-ily so it was just Verl and me. It was April 2000. Iwent into his bedroom and my first thought was IsVerl possessed by the devil? His breathing sounded

very noisy and labored and he sounded as if he weremaking grunting animal-like noises. One of his armswas stiff and it was extended into the air. He couldnot respond to me. He seemed asleep but not asleep.I called 911 because I was scared and because Iwasn’t sure what else to do other than sit next tohim on the bed.

When the crew arrived Verl was coming out of itbut was still pretty confused and couldn’t walk on hisown. We stood him up and half-walked/half-carriedhim into the hallway where he pissed in his under-wear. They took him to Kaiser Sunnyside MedicalCenter because that’s the location where I worked atthe time and because I had enrolled Verl as a KPmember when he moved here. I thought it would bebetter for Verl to be enrolled in the Health Plan whereI worked. A nervous control thing on my part.

Pulling out of the driveway to follow the ambulance,I couldn’t control my tears crying most of the way there.Twelve miles. Sobbing is probably more accurate. Butit’s only a seizure. Seizures don’t seem to kill manypeople. The threat to life seems to be somewhere be-tween sneezing and a heart attack. But his seizure scaredme. I think I was crying because he seemed so help-less and vulnerable and so much like a child—hewas starting to seem like my child. ❖

Les J Christianson, DO, is a general psychiatrist with NorthwestPermanente, practicing at Eastman Parkway Campus.



Narratives


Spirit


InsightBy Kurt Smidt-Jernstrom, MDiV, MA

ting people to move,” and this in turn, en-abled her to foster the semblance of controlin her life. Judy abhorred uncertainty and ten-tativeness, and resented having to wait foranything or anyone.

A recent divorce had left her feeling em-bittered. Furious about the settlement, sheblamed the judge for being biased and notunderstanding the rationale of her side of thesuit. One of Judy’s colleagues argued the caseand was quite persuasive Judy thought. Thewhole contentious process created a deepresentment in her that grew as time passed,as if it were something alive inside of her.

After the divorce was finalized, Judy be-came sullen and irascible. At work, the leastfrustration provoked her and she lashed outat whomever was closest, which created re-sentment and anxiety among her colleagues.At some point, she began to have a sensethat something was amiss, something washappening with or to her, but it was all sovague. She had been feeling under theweather: a cold, a fever, a slight discomfort—or rather a sense of fullness in her abdomen—none of which were going away. She wasfinding it difficult to concentrate on her workso she decided to get to the bottom of it alland see the doctor. The appointment wasinconclusive; the doctor wanted her to re-turn for a test. She became suspicious. Whynot just prescribe some medication and bedone with all of this? Why was it taking solong to figure out what’s wrong?

At a follow-up appointment she was toldthe diagnosis: a tumor was growing on oneof her ovaries, and it was uncertain if, or howfar it had spread. “Tumor? You mean can-cer?” She was not aware of raising her voice.

Rattled, she left quickly without making anydecisions about the next step.

A few days afterward, Judy vaguely recalledthe doctor having mentioned SURGERY say-ing that the need was URGENT. She was un-successful in attempting to compartmental-ize these troublesome words. They would notremain in her mental file cabinet that shecould open and close at will. Finally, in or-der to settle the matter, she decided to callthe doctor. Presenting the evidence, the doc-tor convinced Judy of the need for surgery,and she reluctantly scheduled time off fromwork. She thought: Why does it feel as if I’madmitting that I’m wrong?

As I sat beside her, listening to her recol-lections, I noticed that the tone in her voicewas changing. I sensed in it something likeregret. When I asked her how the surgerywent, she replied thoughtfully, “Fine, I guess,but it seems the cancer has spread. She lookeddown and then looked directly at me. “I havea question for you. Do you think …” shebegan, “… that anger can cause cancer?”

Momentarily taken aback by her question,I wondered: Is she really seeking a medicalanswer to this question, or is there somethingon a deep level that is working its way intoher consciousness?

“Are you wondering if perhaps your angermight have caused your cancer?” I asked.

She fought back tears as she began re-counting instances in her life when her an-gry outbursts had alienated others—family,coworkers, friends. Her illness was forcingher to confront the limits of her control, andwhen she allowed herself to think about itall, she could begin to see the destructive-ness of her anger. ❖

“I asked to see you over an hour ago!” shecomplained as I entered her room and intro-duced myself. Judy looked slightly older thanher 44 years with thick gray hair that hadbeen styled short in preparation for the sur-gery. A volatility that had plagued her mostof her life, manifested itself in the furrows onher brow. Annoyed that she was missing workbecause of her surgery—to remove a tumorthat had engulfed an ovary—and aggravatedby the pain she was experiencing, she tyran-nized the nursing staff activating the call lightcontinuously as if the mere act of pushing onthe device would palliate her impatience.

“I came as soon as I could,” I replied, try-ing not to become defensive. “Anyway, I’mhere now.”

“I can’t reach anyone on this phone! What’smore, the doctor says I’m ready to leave thehospital tomorrow. I am not ready to leaveyet.” The tone of her voice betrayed a hint ofsomething besides frustration … anxiety, per-haps. I pulled up a chair next to her bedsidetable and sat down.

She recited a litany of unmet expectations:family and coworkers not visiting more of-ten, hospital staff seemingly unable to figureout what she needed, even God had let herdown. “What kind of God allows a person toget cancer?” she demanded to know. Judywas angry with the hospital staff; angry ather illness and the limitations it had imposedon her, angry with her family and coworkers,and angry with herself. She had always beenable to wield her anger effectively; and itbothered her that lately her anger had seemedto be losing its power. She had used it tobreak through institutional as well as rela-tional barriers—“getting things done,” “get-

Kurt Smidt-Jernstrom, MDiV, MA, is currently a chaplain at KaiserSunnyside Medical Center in Clackamas, Oregon. He has previously

worked as a pastoral counselor with KP Northwest Hospice.



Narratives


Spirit


SilenceBy Laura Morgan, MD

Maggie taught me about silence.Three years ago, with a nasty caseof laryngitis, I went to clinic asusual and let patients know that Iwould be essentially silent dur-ing their visit. Most appointmentswent smoothly, in fact, moresmoothly and quickly than usual,which should have been a hint.But Maggie’s visit, to this day,stands out in my memory mostpowerfully.

I knew her as a type 1 diabetic,accident-prone, morbidly obese,self-deprecating woman wholived in a trailer with her chroni-cally ill, demented mother andher troubled sister and niece.Every previous visit with her hadbrought reports of conflict, in-jury, frustration, poverty, andsometimes theft. On the day oflaryngitis, I resigned myself tolisten passively instead of ac-tively trying to make a differencefor the better in this unfortunatewoman’s life.

I indicated to her that I wouldn’tbe able to speak during our visitand, with that, she was off andrunning. For the first time sinceour first visit, ten years ago,Maggie told me the story of herabusive father, her “silent” mother,her deliberate decision to gainweight in order to repulse herfather’s advances after she heardhim express an aversion towardfat women. She told me about pro-tecting her younger sister, withwhom she was now living, by of-fering herself as bait to her fatheruntil her sister was old enough todefend herself. She imitated thewords and voice he used to ini-tiate physical contact and how, tothis day, despite his death, she canstill hear his voice.

I think it took her all of ten min-utes to explain her life to me. Sheexpected nothing in return but myattention. She left the office inwhat seemed a remarkably light-ened mood and told me it was

the best visit she had ever hadwith me.

Since that day, Maggie is still mypatient, now taking two hours totravel by bus one way to my newoffice. She never complains aboutthe distance and she’s never late.

Since that day, Maggie exercisesand diets on her own and has lostover 100 pounds. She is highlycompliant with her medicationregimen and her chronic diseaseis in optimal control. She has notfallen down or injured herself ac-cidentally again. Maggie placedher mother into skilled nursingcare, helped her sister raise herdaughter, set and enforced behav-ioral guidelines in their home, andbecame a fine seamstress. I trea-sure the pillow she made for me;I try to imagine placing it firmlyover my mouth whenever I feelthe urge to tell someone how tolive without first understandingsomething of his or her life. ❖

Laura Morgan, MD, is a family physician working in primary care in the NorthernCalifornia Region for the past 13 years. She has authored Surviving and Thriving atKaiser Permanente, a manual for physicians, and continues to seek ways toimprove the quality of professional life for her peers.



Narratives


Spirit


Harpooning the VeinBy Shawna L Swetech, RN

Are they prominent and soft, or finelike dark thread? Are they hiddenbeneath spongy layers of adipose?And the skin, is it thick like tanned leather,or thin like a white veil separatingthe inner and outer worlds?Should I use a tourniquet?Will the vein distend and harden,roll from the needle’s probe?Or will binding pressure burstthe thin blue line, ecchymosispurpling the tissues.

Take a deep breath, I say,imagine your vein is a caterpillar,fat and juicy. I swipe antisepticacross the target, twirl the steelstylette in the cannula.Please, God.Please let me get in, first stick.I can’t think of this as real now,can’t think of causing pain, injury.The angiocath becomes a harpoon,the arm a lifeless fish.

I pierce the flesh —Don’t move now! and waitfor crimson flashback in the needle’s hub.Score, there it is. I hook up tubing,chevron the paper tape over and under,place a see-through dressing.Blue lights flash, the IV pumpbeeps to life.

Yes. I have been granted the power again.

Shawna L Swetech, RN, is a medical/surgical nurse at the KP Santa Rosa MedicalCenter. She has been studying and writing poetry for five years. Ms Swetech finds

the magnificence of the human spirit a constant source of inspiration.


Spirit


The Wheezing Cherub,Her Earth Grandmama,

and OUR LOSSESBy Ed Ruden, MD

Natalie is my sonorous Wheezer—The Orchestra in her chest is rarelyin Tune—Alveolar AnxietyShe will come in with Raucous Cacophony andappear to have just finished a 50-yard dashunsuccessfullyI Treasure her serendipitous visitsRosey Cheeks, the Thickest Light Brown Ponytail,Those Gifted Round EyesThe Heavenly Angel Reads to US while beingNEBBED with OUR Misty Solutions to relieve theFrothy Rigid PUlmonary MILKSHAKE …BOOKS Of Joy, OF HOPE, of HUGS and Kisses, ofTeddy Bears and Soft, Fluffy Creatures ONE wouldlike to crawl into bed with when our Bones are dampand achingGrandmama is Her most capable Caretaker since theyoung one’s earliest yearsSuch a Tragedy—MOM’s death from a LymphomatousLecher in her primeThe mid-50s SAVIOR is a bundle of nurturing energy,a 60s lady grown wise, mellow, with Rainbowvestments and Iridescent fingernailsI unveil the recent Demise of my own FatherWe weep together and Breath out Long Serene, UnobstructedExhalations to Placate our Grief …

Ed Ruden, MD, has been a pediatrician with Northwest Permanentefor the past seven years. He enjoys writing snippets as an aide to innerreflection, preventing burnout, connection with families.


Spirit


The Young Father’sImperfect Gift of Life

By Ed Ruden, MD

He gave part of his liver to his Infant Son …I was there at the Start of this Ugly Bilious DiseaseUnfortunate “Draw of the Straw” plagued by Biliary AtresiaPaternal “Fois Gras” Sucked out … but nurturing the young babe andrecapturing this childhood vigor and joyYet, the Sequellae of the Donor Impairs DAD’s life AbysmallyRobbing the prime of Paternal 20sHOLES/CAVITIES/Abdominal Fenestrations years after “The Taking”Haunt himSwiss Cheese of the Peritoneum and Rectus AbdominusThis Vaporizes his Vitality—Suspends his LIFENonetheless, I know you Treasure the Gift you Gave and I honor youIn your Ultimate HOLY Sacrifice …

HypochondriacalAtopic Derm Adolescent

By Ed Ruden, MD

His body is like crocodile skin – every Angstrom of itA scaley mass of crustaceous keratinA warty six-foot toad of a teenIntense use of fluoridated steroid ointments,Petrolatum baths, antihistamines q4h, andNewer Immunmodulator agents have little effect on his intense pruritisThe true cause of his eczema lies not in the superficial layers of his body;but deep in his somaticizing mindThe “boy” tortures himself from withinPerseverating in his brain about this malady or that“If only there were another blood test,” “A Radiographique”“A serum porcelain level to pinpoint my illness!”He stammers/agitatesI present this theory – “The mind-skin” gap!If you “soothe” your mind, you will surely “soothe”your alligator dermisIn theory, he takes it in but never really engulfs the reality of his tortured cerebrumFitfully, the young lad wallows in his “crustiness” and painstakinglyrelentlessly scratching as he exits my exam room!


Spirit


Poetic MomentsBy Cecilia Runkle, PhD

Yellow green leaf dropsThin stalks, white bark, like slow rainStill, no whisper

Light glances red maple leavesGreen intertwined with redNot Christmas, just nature

Red maple on burnt coalsDead yet still beautifulA life after death?

DisbeliefBy Kurt Smidt-Jernstrom, MDiV, MA

Doubting the diagnosisshe listened apprehensivelyfor the soundsof marrow explodingdeep in her bones,portending the disintegrationof her life.

Hearing nothingand buoyedby an infusion of packed cellsshe insistedthat it wasa mistake.

Cecilia Runkle, PhD, is a former Senior Training and Development Consultant with TPMG’s PhysicianEducation and Development Department, Northern California Region. She joined Kaiser Permanentein 1981 and in her spare time enjoys writing haikus, reading mysteries, and race walking.Kurt Smidt-Jernstrom, MDiV, MA, is currently a chaplain at Kaiser Sunnyside Medical Center inClackamas, Oregon. He has previously worked as a pastoral counselor with KP Northwest Hospice.


Pay-for-Performance: At Last or Alas?By Michael J Pentecost, MD

hat a lovely phrase … pay-for-performance.For those who toil harder, work smarter,

go the extra mile, satisfy customers, followthe rules, comply with regulations—the sur-est incentive of all—more money on payday.

The underlying principle of pay-for-per-formance compensation, now the rage inhealth care, is the creation of financial in-centives that reward quality-improving,cost-saving, and more efficient behavior bymedical professionals.

For many in health care, the question is notwhy now, but rather what took so long withthis pay-for-performance? Isn’t it about timethat someone recognized the quality work ofphysicians and hospitals? After all, for yearseveryone has known that a fee schedule thatrewards volume will result in … more vol-ume. Therefore, isn’t it a no-brainer that apayment mechanism that compensates clini-cal excellence will lead to better quality?What’s not to like?

Barely five years old, a myriad of differentpay-for-performance strategies have alreadyspread from New England to California, andthe notion has been embraced by hospitals,physicians, health plans, and employers, par-ticularly large corporations. Medical journals,management literature, the lay press, govern-ment leaders, and CEOs all tout the conceptas a solution to the ills of health care.

But does pay for performance, long themantra of corporate America, offer a realisticmeans for improving quality and efficiencyin health care? Or is this another ill-conceivedstrategy that falls flat on the way from benchto bedside? Will pay for performance be theanswer to national concerns regarding risinghealth care costs and uneven quality in medi-cine? Or will this payment mechanism founder

in a sea of complexity, imperfect data andprovider pessimism?

Pay-for-performance made it to Main Streetcommerce in the 1990s when it emerged asthe model for executive compensation, es-pecially in publicly traded, for-profit compa-nies. The idea was logical enough: seniormanagement would have their pay (in theform of salary, equities, or bonuses) tied toquantitative outcomes such as earnings orstock price—presumably a win-win strategyfor shareholders and company officials.

Though mentioned in health care manage-ment circles as early as 1985, the pay-for-per-formance movement did not really get goinguntil the creation of the Leapfrog Group in2000. Prompted by the 1999 Institute of Medi-cine report1 about the parlous state of qualityin American medicine, companies such as Gen-eral Electric, IBM, General Motors, and Boeinglaunched Leapfrog with an original missionof disseminating information about qualityand fashioning a payment mechanism thatrewarded value and efficiency.

Leapfrog quickly settled on three standardsfor judging hospitals: computerized physicianorder entry, full-time intensivist staffing of ICUs,and referral to hospitals with high-volume sur-gical practices. Hospital compliance with thesevoluntary standards is published annually inthe group’s Hospital Quality and Safety Survey.

While tangible benefits for complying withthese guidelines have been limited, somehospitals in New York have been given bo-nuses for meeting the standards, and in Se-attle employees have had copayments waivedat cooperating institutions.

A second major project began in 2003 whenPremier, Inc, a medical center purchasing al-liance, partnered with Medicare in a pilot

health policy in focus

Michael J Pentecost, MD, is the Chief of Radiology in the Mid-Atlantic Region.He is also Director, Institute for Health Policy in Radiology at the American College

of Radiology in Reston, Virginia. E-mail: [email protected].

project to improve quality in more than 300member hospitals. The trial involves follow-ing patients with myocardial infarction, kneeand hip replacement, congestive heart fail-ure, community acquired pneumonia, andcoronary artery bypass surgery.

As an example, in orthopedic surgery pa-tients, outcomes such as antibiotic usage inthe perioperative period, post-operativebleeding, and readmissions within 30 dayswill be measured. In coronary artery bypasspatients, rates of internal mammary grafts andinpatient mortality will be assessed.

For the first time, there was an explicit fi-nancial incentive for participation. Hospitalsin the top 10% will receive an additional 2.0%in payments, the second 10% will earn anextra 1.0%, while the lowest 10% can bedocked as much as 2.0%.

Bridges to Excellence, originated by Gen-eral Electric in 2003, goes one step furtherthan Leapfrog by creating a financial bonussystem for physicians, at least as pertains tocaring for patients with diabetes and heartdisease. By adhering to National Committeefor Quality Assurance guidelines, a physiciancan earn $80 for diabetic and $160 for heartpatients per year. The guidelines are straight-forward—for example, monitoring lipids,blood pressure and renal functions in patientswith diabetes; smoking cessation; andantithrombotic use in cardiac patients.

From its origins in New England, Bridgeshas now spread across the country as theproduct has been licensed nationally to in-surers including BlueCross BlueShield, Cigna,and United Healthcare.

While all these initiatives provided a boostfor the pay-for-performance movement, thewhole landscape for physicians was jolted

W

CME


health policy in focusPay-for-Performance: At Last or Alas?

recently when the 2000-pound gorilla,namely Medicare, got into the game. On Feb-ruary 1, 2005, Mark McClellan, MD, aneconomist/internist and the Director of theCenter for Medicare and Medicaid Services(CMS), announced that ten physician groupswould be enrolled in a pay-for-performancetrial, dubbed the Medicare Physician GroupPractice Demonstration.2

These practices included the GeisingerHealth System in Pennsylvania, Dartmouth-Hitchcock in New Hampshire, Deaconess Bill-ings in Montana, Forsyth in Winston-Salem,the University of Michigan Faculty GroupPractice, and others. Unlike the Premier ex-periment, which involved only technical orhospital fees, this new venture would putphysician revenue at risk.

Each group will have a different area ofconcentration. For instance, Geisinger willemphasize the use of its electronic medicalrecord to improve access to health care in-formation among Medicare beneficiaries inrural Pennsylvania. Other participants will op-timize treatment of patients with diabetes,congestive heart failure, hypertension andCOPD utilizing means such as home care,preventive health, and disease managementprograms.

Other programs have arisen that share asimilar philosophy. In California, the Inte-grated Healthcare Association, formed in 1994by six health plans encompassing over sevenmillion members, is unique in its incorpora-tion of patient satisfaction into the bonus for-mula for its pay-for-performance initiative. In2004, more than $50 million was distributedon the basis of clinical quality (50%), patientsatisfaction (40%) and computer investments(10%). (Kaiser Permanente initially played anadvisory role only, because the medical groupincentive payments did not fit with its inte-grated health plan-medical group structure.However, the two California PermanenteMedical Groups began reporting data on clini-cal and satisfaction measures to the IHA ini-tiative in 2005 and 2006.)

Hospital Compare, a cooperative effort ofCMS, the Department of Health and HumanServices, and the Hospital Quality Alliance,was introduced in April 2005 to provide the

public with quality metrics from every Ameri-can hospital on their outcomes in patientswith myocardial infarction, congestive heartfailure, and pneumonia.

So as all these projects show, the pay-for-performance movement is not only alive andwell, it’s growing. Nonetheless, legitimateconcerns have arisen, generally centered onthe programs’ effectiveness, durability andfairness. Such issues include:

Stifling InnovationIn nonmedical industries, with their vastly

larger experience, one of the major worriesabout pay-for-performance programs hasbeen about overvaluing the status quo andunderinvesting in new initiatives.3 A companymight find it easy to measure and reward es-tablished, easily quantifiable outputs such assales, but what about strategic planning ornew product development? A medical prac-tice can easily tabulate the RVUs for routineCTs of the abdomen, but who pays for thetime and effort to develop virtualcolonoscopy? Are the short-term gains of in-creased activity in these conventional areascoming at the expense of a company or medi-cal practice’s future?

Undervaluing TeamworkThe new Medicare Physician Group Prac-

tice Demonstration proposes paying physi-cians more for better results in treating pa-tients with congestive heart failure, asthma,diabetes, depression, and other conditions.And in the descriptions of the individualproject goals, much emphasis is placed oncollaborative care. Yet no mention is madeabout compensating other members of thehealth care team—not nurses, technologists,therapists, pharmacists—no one but physi-cians. In a profession where virtually no taskis performed alone, how will this be justi-fied? What will be the impact on the moraleand professionalism of valued colleagues?

Exploiting the SystemIn the Hospital Compare database, facilities

are compared on the basis of the time betweenthe diagnosis of pneumonia and the initiationof antibiotic therapy. Who makes the call on

the diagnosis of pneumonia? The paramedic?Senior resident? Attending? Does someone inthe emergency room trigger a stop watch? Whatabout patients with other infections? Will hos-pitals shortchange other patients with urinarytract infections, meningitis, or bronchitis in theirrace to beat the clock?

Although this may seem like a frivolousscenario, teasing out a subgroup of patientsfor analysis does raise questions about ex-trapolation of the data to an entire hospitalpopulation.

Selection BiasBenchmarking, which is at the core of pay-

for-performance, is not without its limitations.As discussed recently by Denrell,4 in the ab-sence of a carefully monitored setting suchas a controlled experiment, corporate data isfrequently not collected in a rigorous man-ner. Quite the contrary. In commerce, suc-cessful businesses are happy to answersurveys about their triumphs, but the un-successful companies—those whose ideasfailed—are out of business and no longeraround to respond. So, like Lake Wobegon,only above-average results are tabulated.

In medicine, this phenomenon correspondswith the well-accepted fact that investigatorsfrequently do not publish negative results.

FragmentationMost community physicians practice at more

than one hospital, and nearly all participatein multiple insurance plans. As noted byEpstein, et al,5 if only 1% of an internist’s pa-tients were in the Bridges to Excellence pro-gram, the annual bonus would be $1265,hardly worth the paperwork necessary toenroll. If each pay-for-performance programnecessitates an incompatible information sys-tem, this could pose an insurmountable bur-den, particularly to small practices.

Winners and LosersBehind the headlines about pay-for-perfor-

mance, some morning-after realities are notso pleasant, specifically zero-sum accounting,better known as winners and losers.6 Whileeveryone’s first take may be more money forbetter results, with budget neutrality that also


health policy in focusPay-for-Performance: At Last or Alas?

means less money for those on the wrongside of the bell curve.

For example, in the Premier trial, hospitalreimbursements could vary from plus 2.0% tominus 2.0%. If Medicare patients were a thirdof hospital admissions, as is frequently the case,being on the wrong side of that swing couldbe disastrous, especially in an industry where4% margins are the stuff of dreams.

Further, will the very hospitals strugglingto keep up with information system invest-ments and human resource needs be the onesreceiving less compensation? Very likely—thereby raising a multitude of questions aboutequity and access over the long term.

Provider AcceptanceThe Leapfrog Group was the first out of the

blocks in the pay-for-performance movement,so their standards would seem likely to be themost accepted. Perhaps, but a query into hos-pitals within 100 miles of downtown Washing-ton, DC reveals only two institutions, JohnsHopkins in Baltimore and Christiana in Dela-ware, that had fully responded to their surveys.

Why so limited? In a recent analysis,7

Galvin, et al, identified a number of factorsincluding the voluntary nature of hospitalsurveys and the unrealistically high expec-tations by Leapfrog’s founders. Further, com-puterized physician order entry andintensivist staffing are expensive and, with-out tangible returns, hospital executives were

reluctant to invest in these programs. And isit realistic to expect that low-volume surgi-cal hospitals are going to rush to answer asurvey that recommends diverting their patientsto a higher-volume facility?

Impact on the DisadvantagedSocioeconomic status has been shown to

have a strong correlation with HEDIS scores.8

That is, the poor are much more likely tohave lower baseline scores on measures suchas breast, cervical, and colorectal cancerscreening, hypertension control, and immu-nization rates. From so far back in the pack,how likely is it that these populations willmeet the lofty targets of most pay-for-per-formance programs? No doubt, very improb-able. And where is the fairness in financiallypunishing the physicians and hospitals whocare for these patients?

The arguments for pay-for-performance arepersuasive, and few believe that trials of themethodology are out of order. But many out-puts of the health care industry are difficultto define, much less measure. The everydaybazaar of a hospital represents a delicate equi-librium between business and benevolence,empiricism and instinct, complexity and sim-plicity. The current metrics of pay-for-perfor-mance are, by any standard, rudimentary—so elementary as to raise doubts about theirreal impact or the long-term buy-in by physi-cians and hospitals. ❖

Edited and reprinted from the Journal of the Ameri-can College of Radiology, V2(8), Pentecost MJ, Pay forperformance: At last or alas?, 655-8, ©2005, with per-mission from American College of Radiology.

References

1. Institute of Medicine, Committee on Quality ofHealth Care in America. Kohn LT, Corrigan JM,Donaldson MS, editors. To err is human:building a safer health system [monograph onthe Internet]. Washington (DC): NationalAcademic Press; 2000 [cited 2005 Feb 23].Available from: www.nap.edu/openbook/0309068371/html/.

2. Wessel D. Rx for health care may includecarrots. Wall Street Journal 2005 Feb 3;Sect A:2.

3. Day JD, Man PY, Richter A, Roberts J. Has payfor performance had its day? McKinseyQuarterly [serial on the Internet]. 2002 [cited2005 Dec 21];(4). Available from:www.mckinseyquarterly.com.

4. Denrell J. Selection bias and the perils ofbenchmarking. Harv Bus Rev 2005Apr;83(4):114-9.

5. Epstein AM, Lee TH, Hamel MB. Payingphysicians for high-quality care. N Engl J Med2004 Jan 22;350(4):406-10.

6. Thrall JH. The emerging role of pay-for-performance contracting for health careservices. Radiology 2004 Dec;233(3):637-40.

7. Galvin RS, Delbanco S, Milstein A, Belden G.Has the Leapfrog Group had an impact on thehealth care market? Health Aff (Millwood) 2005Jan-Feb;24(1):228-33.

8. Zaslavsky AM, Hochheimer JN, Schneider EC,et al. Impact of sociodemographic case mix onthe HEDIS measures of health plan quality. MedCare 2000 Oct;38(10):981-92.

The Formula for SuccessI cannot give you the formula for success,but I can give you the formula for failure,

which is: Try to please everybody.

—Herbert Bayard Swope, 1882-1958, American editor and journalist;first recipient of Pulitzer Prize for reporting, 1917


soul of the healer

“Zan”

acrylic on canvas

By Sevada Younesian, RN

Mr Younesian works in the Emergency Department at the Baldwin Park MedicalCenter. Mr Younesian draws upon his Middle Eastern background to create paintings

that celebrate women. He says he hopes to bring color and life to these womenwhose voices have been unheard for a long time.


announcements

15th AnnualKaiser PermanenteInternal & Family

MedicineSymposium

July 16-21, 2006Kauai Marriott, Hawaii

For registrationand program information

call 510-527-9500or 800-700-2636.

Save the Date …

Soul of the HealerArt & Stories ofThe Permanente Journal$18.95 each

A full-color collection of theart: paintings, photographs,sculptures, etc, and writings:

poetry, short stories, and essays, ofThe Soul of the Healer section of The Permanente

Journal. This soft-bound 150+ page book brings together inone volume the creative contributions of Permanenteclinicians from the first seven years of publication.

This Limited First Edition is now available.Place your order now—only $18.95 each.

To order, send an e-mail including your name, phonenumber, address and credit card information to Amy Eakinat [email protected] or call 503-813-2623. Multiple copiesmay be ordered at a discount.

If you prefer, you may send a check or money order,payable to The Permanente Journal, to the attention ofAmy Eakin, The Permanente Journal/Soul Book, 500 NEMultnomah Street, Suite 100, Portland, OR 97232.

Now Available

For a brochure or registration information, please visit:www.kpprimarycareconference.org

or call 1-510-625-6374.

Share your Artwork …

The Permanente Journal is always interestedin considering artwork by Kaiser Permanente

clinicians and employees.Submit a sample of your artwork today.

To submit art for consideration for the cover orinterior pages of The Permanente Journal, please

use the following guidelines: Send us a high-quality color photograph of your artwork nosmaller than 4"x5" and no larger than 8"x10".

Slides and digital images may also besubmitted. Include a cover letter explaining your

KP association, art background, medium, anda brief statement about the artwork

(description, inspiration, etc).

Send artwork samples to:Managing Editor, The Permanente Journal,

500 NE Multnomah St, Suite 100Portland, Oregon 97232

E-mail: [email protected]

Kaiser Per manenteNorther n Califor nia Ethics Department’s

15th Annual Ethics Symposium

Contemporary Ethical Dilemmas in Health CareSaturday, March 4, 2006

San Ramon Valley Conference Center, San Ramon, CA

For information and registration please go to:www.SignUp4.net/Public/as.aspx?EID=NORC11E


KP Aging Network Physician Namedto National Alzheimer’s AssociationBoard

Richar d D Della Penna, MD, CMI’s National ElderCare Clinical Lead and Director of the Kaiser Permanente(KP) Aging Network, has been appointed to the Na-tional Board of the Alzheimer’s Association. Dr DellaPenna states that his selection to be on the Board wasin recognition of KP’s long-term efforts to improve thequality and outcomes of care for members withAlzheimer’s disease and related dementias and theirfamilies. KP’s efforts with regard to and approaches todementia care have been heralded by the Associationas a “Model for the Nation’s Health Care System.” Fel-low directors include: Princess Aga Khan, NancyReagan, David Hyde Pierce, clinicians working to im-prove the quality of care of people with dementia, andscientists dedicated to unraveling the causes and even-tual prevention and treatment of Alzheimer’s diseaseand family members of people who have had the dis-ease. The Association’s mission is to eliminateAlzheimer’s disease through the advancement of re-search to provide care and support for those affected;and to reduce the risk of dementia through brain health.

KP Clinicians Named as Delegates toWhite House Conference on Aging

A number of KP clinicians were named and partici-pated as At-Large delegates to the 2005 White HouseConference on Aging (WHCoA). The conference makesrecommendations to the President and Congress to helpguide national aging policies for the next ten years andbeyond.

KP Executives on 100 MostPowerful List

Modern Healthcare magazine recently released itsfourth annual ranking of the 100 Most Powerful Peoplein Healthcare, naming Geor ge Halvorson, Chairmanand CEO, Kaiser Foundation Health Plan and Hospitals(KFHP/H), number 68, and Benjamin Chu , MD, Presi-dent, KFHP/H Southern California Region, number 73.

KP News Roundup

Barbara Caruso is a Senior Communications Consultant forThe Permanente Federation. E-mail: [email protected].

A compilation of news, significant awards, and accomplishments aboutPermanente clinicians and employees and the Permanente Medical Groups.

Perm

anen

te in

the

New

s

By Barbara Caruso

permanente in the news

Southern California PermanenteMedical Group (SCPMG)

Goldsmith Scholarship A war ded to Futur ePhysicians for Advancing Equal Car e

SCPMG awarded seven Southern California medicalstudents the second annual KP Oliver Goldsmith, MD,Scholarship for the Promotion and Advancement ofCulturally Responsive Care. The Goldsmith Scholarshipcelebrates students’ efforts to improve the health careof underserved communities while raising awarenessto the unique medical issues that affect ethnic minori-ties. Awardees receive a $5000 scholarship, mentoringfrom a KP clinician, and a clinical rotation at a KP facility.The seven recipients are: Jose A valos, ShabnamBesimanto, Candace Jones, Kristen Ochoa, KameelahPhilips, Eric Sandoval, and Candace T aylor .

Physician Receives A war dfor Educating Divers

Matthew Berry, MD, was awarded the Charlie BrownMemorial Award by the National Association of Under-water Instructors (NAUI). Dr Berry is a KP ResourcePhysician for Underwater and Hyperbaric Medicine andpractices Emergency Medicine at the West Los AngelesMedical Center. Last awarded in 1997, the Charlie BrownMemorial award is given for volunteer service to thediving community. Dr Berry received the award in rec-ognition of his community service in educating diversand physicians on diving safety and field treatment ofdiving injuries. Founded in 1959, NAUI is the oldestdive training and certifying organization in the world,and has trained millions of divers worldwide.

KP Souther n Califor nia Ear ns Top Rankingin Califor nia Health Plan Report Car d

KP’s Southern California Region (KPSC) earned thetop rating in the 2005 HMO Quality Report from theCalifornia Office of the Patient Advocate (OPA). KPSCwas the only health plan to earn two excellent or three-star ratings. KPSC also led the way in clinical quality,with 11 top scores in the 29 clinical measures cited in


permanente in the news

the report. KPSC was the only health plan in Californiato rate good or excellent in all four categories mea-sured by the OPA report card and was the only healthplan to rate two stars or good in the category, Care forStaying Healthy.

The Permanente Medical Group(TPMG)

Califor nia HealthCar e Foundation AnnouncesFellows for Health Car e Leadership Pr ogram

Three KP clinicians were selected by the CaliforniaHealthCare Foundation (CHCF) to participate as HealthCare Leadership Program fellows. The three KP clini-cians are Rajan Bhandari, MD, Santa Teresa MedicalCenter, Moses D Elam, MD, Central Valley, and DianeHildebrandt, BSN, Napa Medical Offices. The pro-gram helps talented professionals acquire the skillsneeded to positively influence health care policy anddelivery in California.

Physicians Receive TPMG Resear ch andTeaching A war ds

Four TPMG physicians received research and teach-ing awards for their exemplary efforts in these areas:Nazir Habib, MD, Vallejo, was recognized for his in-strumental role in bringing Fundamentals of CriticalCare Support (FCCS) Certification to HBS physicians.John Husokowski, MD, Oakland, was recognized forhis contributions to the Oakland KP Ob/Gyn ResidencyProgram. Randy Ber gen, MD, Walnut Creek, was rec-ognized for the research he conducted that establishedthe safety of cold-adapted trivalent intranasal influenzavirus vaccine (CAIV) in children over three years ofage and adolescents. Donald Dyson, MD, Santa Clara,was recognized for his prolific and highly regardedresearch contributions over the past 20 years, particu-larly in the field of maternal-fetal medicine.

The Southeast Permanente MedicalGroup (TSPMG)

Red Cr oss Philos A war d Pr esentedto KP of Geor gia

KP of Georgia received the prestigious Philos Awardfrom the Volunteer Council Committee of the Ameri-can Red Cross’ Metropolitan Atlanta Chapter. KP washonored for its significant financial contributions andfor its sponsorship of CPR Saturday.

Colorado Permanente Medical Group(CPMG)

5280 Magazine Names 18 KP “T op Doctors”Congratulations to the 18 KP physicians who were

named to the annual list of Denver’s top doctors in5280 Magazine. The top 250 honorees were selectedby their peers, via a random survey of 4000 metro areadoctors. The 18 CPMG physicians were: Jandel Allen-Davis, MD; William Bentley, MD; T im Collins, MD;Royal Ger ow, MD; Richar d Hathaway, MD; JamesJacobs, MD; Elizabeth Kincannon, MD; Richar dKoken, MD; Janet Kuhns, MD; Chris Lang, MD; JeanMilofsky, MD; Nora Mor genster n, MD; DavidMulica, MD; Mark Rhine, MD; Elizabeth Sofian, MD;Sophia Symko, MD; Edwar d Vaughn; and John W il-liams, MD.

Mid-Atlantic Permanente MedicalGroup (MAPMG)

MAS KFHP President Honor ed as InfluentialWomen Executive

Marilyn Kawamura, President of KFHP, Inc Mid-Atlantic States Region, was chosen as one ofWashington’s Women Who Mean Business 2005. Thislist honors the Region’s most influential and powerfulwomen executives as selected by the Washington Busi-ness Journal.

MAS Named Top Quality Health Planin Maryland

For the third year in a row, KP Mid-Atlantic Statesreceived more Star Performer and Above Average scoresthan any other participating HMO and POS plan in theState of Maryland, according to Measuring the Qualityof HMO and POS Plans: Consumer Guide, released bythe Maryland Health Care commission. KP was nameda Star Performer in 10 categories, 6 more Star Performermeasures than the next best health plan, and AboveAverage in 15 categories, 7 more than the next highestscoring health plan. ❖

KP News Roundup

Barbara Caruso compiled this material from KFHand PMG newsletters and regional KP Web sites.To submit news of physician or PMG awards and

recognitions, contact Ms Caruso [email protected].


crossword

57 Mennonites of Pennsylvania or Ohio59 Actress Dunaway of “Chinatown”60 Fish often seen in Japanese pools62 Very small amounts, or 9th Greek

letters66 Person with a drug habit67 Bits of rock-like precipitation68 What the foreskin covers69 Answer rudely70 Gradually go away, as a pain might71 Some brightly colored salamanders

Down1 Small, mischievous creature2 Kung ___, spicy chicken dish3 Short-acting paralytic drug, familiarly4 Top-selling cookie, introduced in 19125 WIDESPREAD CONFUSION (2 wds)6 MEDICINAL HERBS OF THE GENUS

HYPERICUM (hyph)7 Recover from surgery8 Stately tree9 Lacking almost all color, as a plant or

animal10 Braves’ Hall of Fame pitcher Warren11 GIZMOS THAT STABILIZE NECK

FRACTURES (2 wds)12 Done13 Golf accessories21 ___ Tai23 A PHYSICAL FINDING OF PRIME

IMPORTANCE (2 wds)24 Prevents, in legalese25 In music, having no key26 INTERNAL STRABISMUS (2 wds)28 WHERE A PERSON MIGHT FEEL A

HEADACHE (3 wds)30 They may be pale or amber33 ___ del Fuego34 The first-born of siblings37 Common site to pierce39 Gabor and Peron48 One’s mental structure, to an analyst50 Giants’ quarterback Manning52 Water pitchers55 “He’s one ___” (2 wds)56 Agcy for Apollo and Gemini (abbr)57 Fleischer and Onassis58 Gopher’s legacy61 Excellent bond rating63 Fancy marble used as a shooter64 Hard working insect65 US draft board (abbr)

35 Forceps and scalpels, for example36 Prevent the opponents from fulfilling a

bridge contract38 Satan40 When a symptom began41 When repeated, a rock music guitar

sound42 Covered with vines, as Dartmouth’s

buildings might be43 Out of fashion; stale44 Raw rock containing a valuable

mineral45 Mother-of-pearl46 Serious connective tissue disease,

often affecting multiple organs (abbr)47 Blood test for syphilis (abbr)49 Those who irritate or make fun of51 One who believes in a divinity that

created the world53 Building extension54 Rested one’s legs55 Type of street often found in a large

city (hyph)

Kenneth J Berniker, MD, is a Board-certified Emergency Physician at the KP Vallejo Medical Center. DrBerniker has long enjoyed solving crossword and cryptic puzzles and now creates his own. The challenges increating the puzzles include: completing the grid with usable answers and perhaps a theme, generatinginteresting clues of suitable difficulty, being error-free in framing questions and answers, and injecting humor.Have fun, and please send him your comments. E-mail: [email protected].

Across1 Therapeutic salt named after an

English town6 Home of the Mets10 Injured by a .44 Magnum14 Singer and songwriter Nyro15 Legendary Swiss archer William16 Surface a driveway, perhaps17 Cunning people18 Side of a doorway19 Away from the wind, as in sailing20 Standard unit of the pressure arising

in a liquid from its solutes22 Fluids said to flow in the veins of gods;

or, discharges from certain wounds24 Structure lying between the auricle

and the tympanic membrane (abbr)27 Exclamation of triumph or surprise28 ___-out (entering a basketball hoop

but not going through, hyph.)29 Mistakenly enter a restricted area by

wandering (2 wds)31 Epinephrine prefix32 French summer

Visit TPJ on the Web for answers to this puzzle: www.kp.org/permanentejournal

Created by Kenneth J Berniker, MD

Medicine Meets Religion


book reviews

S

REBUILT: How Becoming PartComputer Made Me More HumanBy Michael Chorost

Reviewed by Paul Bernstein, MD, FACS

New York: HoughtonMifflin; ISBN 0-618-37829-4.232 pages.

Paul Bernstein, MD, FACS,is the Regional Chief of Headand Neck Surgery forSCPMG. He is the MedicalDirector of Quality Assurancefor HEARx West, and Chairof the Head and NeckDivision of the AmericanCancer Society. He was alsothe 2005 San Diego AreaPartner of the Year. E-mail:[email protected].

The implantnot only giveshim the abilityto understand

the soundsaround him, itgives him thefreedom toshape how

peopleperceive him.

uddenly, instead of cars making their usual “vrump,”they sound like crumpling paper; words turn into

mumbled “mmmm mmbm bbmm verumf,” and thennothing. After a battery of MRIs and hearing tests, youfind you have irreversible hearing loss. You’re deaf.You’ve heard about cochlear implants, was it that oldTV show, The Six Million Dollar Man? Wasn’t that whatRush Limbaugh had done? Your hopes soar as you thinkof a bionic ear that will restore your hearing and bringyou back into the “normal” world.

Rebuilt, a memoir by Michael Chorost,takes us into his world of no sound. If“Going deaf is a kind of death …”1p187

Mr Chorost takes us through his stagesof rebirth. From the two-hour outpatientprocedure to the programming of theimplant, the reader is taken on a fasci-nating journey. In the author’s words,he becomes a cyborg. He is careful topoint out the difference between anandroid like the Terminator (a robot thatlooks like a human being) and a cyborg,a human with a bionic part. But unlikean artificial limb, a cochlear implant al-ters his perception of the world. The simple soundsof a bird, a car, or a horn are now different. Autumnleaves tinkle rather than crunch. Leaf blowers andtoilets sound like artillery fire. Sounds are so altered,he needs to relearn the sound and cadence of theworld around him.

How does this new computer stimulation trigger hiseighth cranial nerve? He describes it like a rock skip-ping over the surface of water. The 140,000 transistorsof his implant cannot completely replicate the 12,500outer hairs cells and 3500 inner hairs cells of his co-

chlea. The sixteen electrodes implanted through hisround window into his cochlea send a digital series ofones and zeroes that Chorost’s brain learns to interpret.

The metal disc attached magnetically behind his earto his implant is liberating for him, because peopledon’t know “… what the heck it is …”1p189 Unlike ahearing aid, people don’t assume the wearer is “…slow … [has] to be shouted at … old.”1p189 Imagine.The implant not only gives him the ability to under-

stand the sounds around him, it gives himthe freedom to shape how people per-ceive him.

In this moving account, the readerexperiences what it’s like to live in theauthor’s world, from the first cellphone he’s able to plug into his im-plant to the first time he fumbles toremove the wires in the throes of pas-sion. “[T]here’s nothing more isolatingthan deafness,” 1p188 Mr Chorost states,and his cochlear implant—his built-incomputer chip—makes him feel moreconnected to the world than before.With his internal “World Wide Web”

he learns to construct the environment around himand create a fulfilling new reality.

As we enter a new age of bionics and cyborgs, Re-built teaches us that although we can now make thedeaf hear, in the author’s words, “they cannot makeme listen.”1p183 To paraphrase Mr Chorost, it’s only whenwe listen that we become better human beings. ❖

Reference1. Chorost M. Rebuilt: How becoming part computer made

me more human. New York: Houghton Mifflin; 2005.


book reviews

L

Last Chance in Texas: The Redemption of Criminal Youthby John Hubner

Reviewed by David L Chadwick, MD

ast Chance in Texas is about a way some teenagerswho have committed serious crimes can be ha-

bilitated and re-enter society with a very low risk ofrecidivism. It holds interest for health providers forseveral reasons.

John Hubner’s factual account underscores the factthat virtually all delinquent youths were abused chil-dren. It can be assumed that all of them had contactwith health providers in their early months and years.It is likely that had their problems been recognized,opportunities for preventive interventions werepresent. Our ongoing failure to recognize risk andto provide the proven family supports that reduceabuse and later delinquency could be considered asa failure of the primary health care system becauseno other system has both access to almost all fami-lies with young children and the ability to engagethem. Home visiting programs have been shown toreduce child abuse and later delinquency.

Further, this population of youngpeople is at high risk to prematurelyre-enter the health system. Even if theymay have learned to avoid future crimi-nal acts, the long-term effects of ad-verse childhood experiences on healthwill probably catch up with them inthe forms of untreatable obesity, smok-ing, drug and alcohol use, heart dis-ease, and certain cancers.

Reading Mr Hubner’s book causesboth pain and joy as he mixes historyand facts from the juvenile justice sys-tem with the personal stories of theyoung people caught in that system.He shows how remarkable (and howhard) it is for them to take responsibil-ity and to learn empathy. An especiallymoving chapter describes how parentsof murdered children with extraordi-nary courage join with the professional

staff to confront youthful murderers or attempted mur-derers with the ongoing pain they have caused.

The methods employed by the staff at the GiddingsState School and supported by the Texas YouthCommission are also of great interest to mentalhealth professionals and are worthy of study bythe many correctional programs for youth in otherstates. The “Last Chance” in the title is apt; theyouths who fail to meet the tough criteria for pa-role from Giddings will be sent to adult prisons toserve out long sentences.

The specter of prison did not deter these youths andprison is not enough to turn them around in four orfive years. The Texas program, complex and multifac-eted, appears to offer some success. Some of the maincomponents appear to be firmly rooted in well-acceptedprinciples of cognitive-behavioral therapy; other tech-niques are considered unproven by mainstream psy-chologists. It has been difficult to isolate its many com-

ponents in a way that would allowrigorous therapeutic research. It’s alsopretty clear that putting on a programlike this in any state is a tough politi-cal task, and that superimposing anexpensive research program that mightshow why it works is unlikely.

The Texas program appears less ex-pensive than the ineffective programsprovided in California and many otherstates. These more typical programsreturn many youths to the street “an-grier and dumber” than when theywere confined. The Texas program isvery inexpensive in comparison withprolonged confinement.

Mr Hubner’s book is not a comfort-able read, but it is clearly and simplywritten with a clear message. It’s agood book for all professionals andespecially health professionals. ❖

New York: Random House,Inc; ISBN 0-375-50809-0

271 pages, $25.95

David L Chadwick, MD, isa pediatrician with a long

history of work in the fieldof child abuse. Dr Chadwick

is also Director, Emeritus,The Chadwick Center for

Children and Families,Children’s Hospital-San

Diego and AdjunctAssociate Professor,

Graduate School of PublicHealth, San Diego State

University. E-mail:[email protected].

Our ongoingfailure to

recognize risk andto provide theproven familysupports that

reduce abuse andlater delinquency

could beconsidered as afailure of the

primary healthcare system

because no othersystem has bothaccess to almostall families withyoung children

and the ability toengage them.


Book Reviews“ACP Medicine” David C Dale and

Daniel D Federman, editors.2005;9(3):89-90.

“Affect Regulation and The Repair of theSelf” by Allan N Schore.2005;9(2):109-10.

“Big Doctoring in America: Profiles inPrimary Care” by Fitzhugh Mullan,MD; Photographs by John Moses.2005;9(2):107-8.

“BrainWork: The NeuroscienceNewsletter” The Dana Foundation.2005;9(4):90.

“Consciousness and Healing: IntegralApproaches to Mind-Body Medicine”Marilyn Schlitz, Tina Amorok, andMarc S Micozzi, editors. 2005;9(3):88.

“Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide forthe Dying. 3rd edition” by DerekHumphry. 2005;9(2):112-3.

“Focus on Living: Portraits of Americanswith HIV and AIDS” Photographs andinterviews by Roslyn Banish;introduction by Paul M Volberding,MD. 2005;9(1):109.

“Frequently Overlooked Diagnoses” byMark A Marinella, MD. 2005;9(4):89.

“Prostitution, Trafficking, and TraumaticStress” by Melissa Farley, PhD, Editor.2005;9(1):113-4.

“The Sexy Years: Discover the HormoneConnection—The Secret to FabulousSex, Great Health, and Vitality, forWomen and Men” by SuzanneSomers. 2005;9(1):111-2.

“The Spirit Catches You and You FallDown: A Hmong Child, Her AmericanDoctors, and the Collision of TwoCultures” by Anne Fadiman.2005;9(2):111.

“A Woman’s Guide to Surgical Optionsin the New Millennium: A GentlerApproach” by Udo Wahn, MD.2005;9(1):110.

“Women’s Primary Health Care:Protocols for Practice 2nd edition” byWinifred L Star, Lisa L Lommel, andMaureen T Shannon, editors.2005;9(2):114.

Clinical ContributionsBariatric Surgery in the KP Northwest

Region: Optimizing Outcomes byUsing a Multidisciplinary Program.2005;9(3):52-7.

Can Patients and Physicians Thrive in the21st Century? 2005;9(1):87.

Chronic Pain is a Chronic Condition, NotJust a Symptom. 2005;9(3):43-51.

The Electronic Medical Record“Toolbox.” 2005;9(2):49-52.

The Emergency Contraception OnlineLearning Module. 2005;9(1):89.

Facilitating Physician Access to MedicalReference Information. 2005;9(4):27-32.

Family Violence Prevention Program:Another Way to Save a Life.2005;9(1):65-8.

Fighting Breast Cancer: A Call for a NewParadigm. 2005;9(1):73-6.

Four Decades of Research on HormonalContraception. 2005;9(1):29-34.

Fragile Fracture Care ManagementProgram. 2005;9(1):13-5.

A High-Quality Asthma Care: It’s NotJust About Drugs. 2005;9(3):32-6.

How Can We Reduce the Incidence ofContrast-Induced Acute Renal Failure?2005;9(3):58-60.

Intrauterine Contraception: Study toEvaluate Clinical Practice and toIncrease Utilization. 2005;9(1):16-9.

The Kaiser Permanente InterregionalBreast Care Leaders. 2005;9(1):56-60.

The Kaiser Permanente NorthwestCardiovascular Risk FactorManagement Program: A Model forAll. 2005;9(2):19-26.

Kaiser Permanente Women’s HealthCenter of Excellence in CulturallyCompetent Care. 2005;9(1):84-6.

KP Northwest Preoperative BriefingProject. 2005;9(2):35-9.

Laparoscopically Assisted VaginalExtraction of the Kidney afterLaparoscopic Radical Nephrectomy.2005;9(1):46-7.

Malnutrition in the Elderly: AMultifactorial Failure to Thrive.2005;9(3):38-41.

Mammography Screening: AddressingMyths and Other Reasons forNoncompliance. 2005;9(1):52-4.

Management of Menopause and MidlifeHealth Issues: What Do MidlifeWomen Want from Primary CareClinicians? 2005;9(1):20-4.

Managing High-Risk Obstetric Casesand Analyzing Neonatal Outcomes:The KP Northern California RegionalPerinatal Service Center.2005;9(1):37-40.

Minilaparotomy: A Minimally InvasiveAlternative for Major GynecologicAbdominal Surgery. 2005;9(1):41-5.

Pain Management Doesn’t Have to be aPain: Working and CommunicatingEffectively with Patients who haveChronic Pain. 2005;9(2):41-8.

Perinatal Patient Safety Project.2005;9(2):28-33.

The Perinatal Patient Safety Project: NewCan Be Great! 2005;9(1):25-7.

Preparing for Successful Surgery: AnImplementation Study. 2005;9(3):23-7.

Preventing Unintended Pregnancy: EightYears of Effort at KP San Diego.2005;9(1):69-71.

A Quarter Century of Hospice Care: TheSouthern California Kaiser PermanenteExperience. 2005;9(3):28-31.

Sentinel Lymph Node Biopsy for Patientswith Breast Cancer: Five-YearExperience. 2005;9(1):77-83.

Stereotactic Radiosurgery: Instrumenta-tion and Theoretical Aspects—Part 1.2005;9(4):23-6.

Teen Challenges. 2005;9(1):90-1.Tobacco Dependence Program: A

Multifaceted Systems Approach toReducing Tobacco Use Among KaiserPermanente Members in NorthernCalifornia. 2005;9(2):9-18.

Translating Research into InnovativePractices. 2005;9(1):36.

Treating Chronic Pain: New Knowledge,More Choices. 2005;9(4):9-18.

Vision, Research, Innovation andInfluence: Early Start’s 15-Year Journeyfrom Pilot Project to RegionalProgram. 2005;9(1):62-4.

What To Do with Hypertension and aMurmur Found During aPreparticipation Physical Evaluation?2005;9(4):20-2.

Why Research at KP? 2005;9(1):10.

Women at Risk for Coronary HeartDisease: How Research is TranslatedInto Innovation and QualityOutcomes at Kaiser Permanente.2005;9(1):48-51.

The Women’s Health Research Institute:Mission Overview with FeatureResearch Projects. 2005;9(1):11-2.

The Women’s Health Track of the KaiserPermanente National Primary CareConference. 2005;9(1):88.

CommentaryCare, Whether it’s Called Population—or

Disease-Management, SidneyGarfield, MD, Would Like the Idea.2005;9(2):90-2.

The Coordinated Clinical StudiesNetwork: A Multidisciplinary Allianceto Facilitate Research and ImproveCare. 2005;9(4):33-5.

Encountering Particulars: A Life inMedicine. 2005;9(3):19-22.

Healing Metabolism: A NaturopathicMedicine Perspective on AchievingWeight Loss and Long-Term Balance2005;9(3):16-8.

Normal Birth. 2005;9(1):96-8.

Crosswor dMaking Rounds. 2005;9(4):88.Military Medicine. 2005;9(3):87.Rh Positive. 2005;9(2):105.Spotlight on “KP”. 2005;9(1):108.

Editorial CommentsA Call to Action. 2005;9(3):5.Health & Healing Overview.2005;9(3):3-4.

The James A Vohs Award for Quality—The Seventh Annual PermanenteJournal Special Issue. 2005;9(2):8.

The Second David M Lawrence, MD,Chairman’s Patient Safety Award.2005;9(2):27.

Women’s Health Kaiser Permanente—Improving Women’s Lives throughHealth Care Research, Innovation, andEducation. 2005;9(1):2.

Volume 9

Index of Articles — by Section


index

Health SystemsAcquiring Evidence—Tips for EffectiveLiterature Searching. 2005;9(2):58-60.

Balance Sheets: Tools to Inform Changesin Practice. 2005;9(2):61-2.

The Care Management Institute:Harvesting Innovation, MaximizingTransfer. 2005;9(4):37-9.

The Care Management Institute: Makingthe Right Thing Easier to Do.2005;9(2):56-7.

Diffusing Innovation in Your Practice.2005;9(2):78-80.

Doctor, Should I Take Hormones?2005;9(1):92-3.

Evidence-Based Guidelines.2005;9(2):83-8.

Evidence-Based Medicine andPopulation-Based Care: Caring forPatients with Heart Failure.2005;9(2):65-9.

Fail Often To Succeed Sooner:Adventures in Innovation.2005;9(4):44-9.

From Evidence to Outcomes:Implementing Clinically Effective andCost-Efficient Population-BasedInterventions. 2005;9(2):63-4.

From Standardized Patient to Care Actor:Evolution of a Teaching Methodology.2005;9(3):79-82.

How to Find a Sponsor for Your PracticeInnovation. 2005;9(4):55.

The Ideal: Innovation and Transfer.2005;9(4):36.

Innovation in the Kaiser PermanenteColorado Region: Where We’ve Been,Where We are Going. 2005;9(4):40-3.

Integrating Evidence with KPHealthConnect: Making the RightThing Easier to Do. 2005;9(2):74-7.

KP Evidence-Based Medicine in theCommunity. 2005;9(2):81-2.

Managing High-Risk, High-Cost Patients:The Southern California KaiserPermanente Experience in theMedicare ESRD DemonstrationProject. 2005;9(2):93-7.

Meditation. 2005;9(3):67-8.Meditation, Prayer and Spiritual Healing:The Evidence. 2005;9(3):63-6.

Owning Our Own Health—ModelingHealthy Living. 2005;9(4):64-7.

Pastoral Spiritual Care. 2005;9(3):71-2.The Permanente Journal Cosponsorship

of the Evidence-Based MedicineSymposium, December 3 & 4, 2004.2005;9(2):53.

Permanente Medicine in a ChangingWorld: Challenges and Opportunities.2005;9(2):54-5.

Practical Steps for Practice Transfer: TheFour A’s of Adoption. 2005;9(4):50-1.

Roundtable Discussion: Transfer ofSuccessful Practices. 2005;9(4):56-9.

Sharing Clinical Decisions by DiscussingEvidence with Patients. 2005;9(2):70-3.

Shifting from Traditional toBiopsychosocial Pediatrics. Modifyingthe Pediatrician-Parent Relationship toPromote Normal ChildhoodDevelopment. 2005;9(4):60-3.

Spiritual Moments. 2005;9(3):69-70.Spirituality in the Medical Encounter: TheGrace of Presence. 2005;9(3):73-4.

Spirituality Symposium: PanelDiscussion. 2005;9(3):75-7.

Stealing Shamelessly: Practice TransferSuccess Factors. 2005;9(4):52-4.

A Symposium on Meditation, Prayer andSpiritual Healing. 2005;9(3):62.

KP in the CommunityA Casualty Come to Life (Permanente

and the Tsunami Relief Efforts).2005;9(4):80.

Compassion—An Ever-Present Mission(Permanente and the Tsunami ReliefEfforts). 2005;9(4):75.

A Cough and a Child (Permanente andthe Tsunami Relief Efforts).2005;9(4):76.

Disaster Relief—“What Can I Do toHelp?” 2005;9(1):99-102.

Dr V, Batticaloa Attending (Permanenteand the Tsunami Relief Efforts).2005;9(4):77.

Enclave Services: An Office with aPurpose. 2005;9(2):98-9.

First True Chance (Permanente and theTsunami Relief Efforts). 2005;9(4):73-4.

Flying Turtles (Permanente and theTsunami Relief Efforts). 2005;9(4):81.

I Got More Than I Gave (Permanente andthe Tsunami Relief Efforts).2005;9(4):82.

The Importance of Working Together(Permanente and the Tsunami ReliefEfforts). 2005;9(4):79.

Indonesia—What We Heard: EyewitnessAccounts From Survivors (Permanenteand the Tsunami Relief Efforts).2005;9(4):77.

KP Made a Difference (Permanente andthe Tsunami Relief Efforts).2005;9(4):80.

Mama Donut (Permanente and theTsunami Relief Efforts). 2005;9(4):80.

People Lost Everything Twice(Permanente and the Tsunami ReliefEfforts). 2005;9(4):78.

Permanente and the Tsunami ReliefEfforts—One Year Later—TheVolunteers’ Stories: A Journal.2005;9(4):71.

The Pictures Children Drew (Permanenteand the Tsunami Relief Efforts).2005;9(4):77.

Post-Tsunami Malaria in Indonesia—ThePivotal Contributions of PermanentePhysicians. 2005;9(4):69-71.

A Purely Humanitarian Effort(Permanente and the Tsunami ReliefEfforts). 2005;9(4):82.

School House Horror (Permanente andthe Tsunami Relief Efforts).2005;9(4):79.

The Small Things (Permanente and theTsunami Relief Efforts). 2005;9(4):78.

Strange Alliances (Permanente and theTsunami Relief Efforts). 2005;9(4):76.

Two Little Girls and My Daughter(Permanente and the Tsunami ReliefEfforts). 2005;9(4):78.

Untitled (Permanente and the TsunamiRelief Efforts). 2005;9(4):79.

A Wave and Two Children (Permanenteand the Tsunami Relief Efforts).2005;9(4):76.

Per manente in the NewsKP News Roundup. 2005;9(1):103-6.KP News Roundup. 2005;9(2):101-3.KP News Roundup. 2005;9(3):83-4.KP News Roundup. 2005;9(4):83-5.

Soul of the HealerAfter a Solstice Storm. 2005;9(3):42.Bolinas Ridge. 2005;9(1):28.Canine Cake Walk. 2005;9(1):72.causa mortis. 2005;9(3):61.Domestic Violence in the KP Workplace:

Letter from a Physician Survivor.2005;9(1):61.

Egg Whites. 2005;9(1):55.Faces of AIDS Photography Display.2005;9(1):94-5.

Forty-two. 2005;9(3):15.Happy Hour. 2005;9(4):68.Jessie. 2005;9(1):35.Mr Statue.com. 2005;9(3):78.nil admirari. 2005;9(3):85.The Old Farmhouse Looked Older.2005;9(4):8.

Pap. 2005;9(2):100.Pelican on the Pier. 2005;9(4):19.Pretty Penny. 2005;9(2):40.Roman Windows. 2005;9(2):34.Sedona Bronze Dancer. 2005;9(2):106.Solitude. 2005;9(2):89.sub quandum aeternitatus. 2005;9(3).Sunset Modified. 2005;9(3):37.Tea in the Garden. 2005;9(4).Things That Are Round. 2005;9(1).Tracks. 2005;9(2).Vernazza. 2005;9(4):86.

Index of Articles — by Section


A Call to Action. 2005;9(3):5.Bachman KH, Buck B, Hanna J, Mucha

TJ, Greenwood ML, Moiel D. BariatricSurgery in the KP Northwest Region:Optimizing Outcomes by Using aMultidisciplinary Program.2005;9(3):52-7.

Baker C. A Cough and a Child(Permanente and the Tsunami ReliefEfforts). 2005;9(4):76.

Bakshi N. Forty-two. 2005;9(3):15.Balian M. Canine Cake Walk.2005;9(1):72.

Balian M. Jessie. 2005;9(1):35.Balian M. Things That Are Round.2005;9(1).

Barrett PH, Okawa G, Bowman J.Evidence-Based Guidelines.2005;9(2):83-8.

Beekley S. First True Chance(Permanente and the Tsunami ReliefEfforts). 2005;9(4):73-4.

Beekley S. Permanente and the TsunamiRelief Efforts—One Year Later—TheVolunteers’ Stories: A Journal.2005;9(4):71.

Bellman P, Havens C, Bertolucci Y,Streeter B. Facilitating PhysicianAccess to Medical ReferenceInformation. 2005;9(4):27-32.

Bergen R. School House Horror(Permanente and the Tsunami ReliefEfforts). 2005;9(4):79.

Berniker KJ. Making Rounds.2005;9(4):88.

Berniker KJ. Military Medicine.2005;9(3):87.

Berniker KJ. Rh Positive. 2005;9(2):105.Berniker KJ. Spotlight on “KP”.2005;9(1):108.

Binstock M. Fighting Breast Cancer: ACall for a New Paradigm.2005;9(1):73-6.

Brott B. Mr Statue.com. 2005;9(3):78.Brott B. Tracks. 2005;9(2).Brunt I. Normal Birth. 2005;9(1):96-8.Caruso B, Mustille M, Rabrenovich V.

Owning Our Own Health—ModelingHealthy Living. 2005;9(4):64-7.

Caruso B. KP News Roundup.2005;9(1):103-6.




Chan SP. I Got More Than I Gave(Permanente and the Tsunami ReliefEfforts). 2005;9(4):82.

Charlu M. People Lost Everything Twice(Permanente and the Tsunami ReliefEfforts). 2005;9(4):78.

Che M, Ettinger B, Johnston J, PressmanA, Liang J. Fragile Fracture CareManagement Program. 2005;9(1):13-5.

Chen JCT, Girvigian MR. StereotacticRadiosurgery: Instrumentation andTheoretical Aspects—Part 1.2005;9(4):23-6.

Chicoine G. Diffusing Innovation in YourPractice. 2005;9(2):78-80.

Crites Y, Ching J, Lessner C, Ray D.Managing High-Risk Obstetric Cases andAnalyzing Neonatal Outcomes: The KPNorthern California Regional PerinatalService Center. 2005;9(1):37-40.

Crooks P. Managing High-Risk, High-Cost Patients: The Southern CaliforniaKaiser Permanente Experience in theMedicare ESRD DemonstrationProject. 2005;9(2):93-7.

Cullen J. Teen Challenges. 2005;9(1):90-1.Davenport J. Sunset Modified.2005;9(3):37.

DellaPenna RD. “Final Exit: ThePracticalities of Self-Deliverance andAssisted Suicide for the Dying. 3rdedition” by Derek Humphry.2005;9(2):112-3.

Diaz M, Larsen B. Preparing forSuccessful Surgery: An Implementa-tion Study. 2005;9(3):23-7.

Dudl RJ, Wong M. From Evidence toOutcomes: Implementing ClinicallyEffective and Cost-Efficient Population-Based Interventions. 2005;9(2):63-4.

Elder C. Meditation. 2005;9(3):67-8.Evans C. Malnutrition in the Elderly: A

Multifactorial Failure to Thrive.2005;9(3):38-41.

Faison D. causa mortis. 2005;9(3):61.Faison D. nil admirari. 2005;9(3):85.Faison D. sub quandum aeternitatus.2005;9(3).

Farber HJ. A High-Quality Asthma Care:It’s Not Just About Drugs.2005;9(3):32-6.

Felitti VJ. “ACP Medicine” David C Daleand Daniel D Federman, editors.2005;9(3):89-90.

Felitti VJ. “BrainWork: The NeuroscienceNewsletter” The Dana Foundation.2005;9(4):90.

Felitti VJ. “Frequently OverlookedDiagnoses” by Mark A Marinella, MD.2005;9(4):89.

Fernando C. A Wave and Two Children(Permanente and the Tsunami ReliefEfforts). 2005;9(4):76.

Fitzpatrick L. Sedona Bronze Dancer.2005;9(2):106.

Flanagan T, Serrato CA, Altschuler A,Tallman K, Thomas E. Management ofMenopause and Midlife Health Issues:What Do Midlife Women Want fromPrimary Care Clinicians?2005;9(1):20-4.

Garzon H. Compassion—An Ever-Present Mission (Permanente and theTsunami Relief Efforts). 2005;9(4):75.

Gaskill JR. Vernazza. 2005;9(4):86.Gee SM, Mirkin R. Can Patients andPhysicians Thrive in the 21st Century?2005;9(1):87.

Getz L. “Big Doctoring in America:Profiles in Primary Care” by FitzhughMullan, MD; Photographs by JohnMoses. 2005;9(2):107-8.

Glasser MH. Minilaparotomy: AMinimally Invasive Alternative forMajor Gynecologic AbdominalSurgery. 2005;9(1):41-5.

Godfrey RS, Holmes DR, Kumar AS,Kutner SE. Sentinel Lymph NodeBiopsy for Patients with Breast Cancer:Five-Year Experience. 2005;9(1):77-83.

Goldstein A, Gee S, Mirkin R. TobaccoDependence Program: A MultifacetedSystems Approach to ReducingTobacco Use Among KaiserPermanente Members in NorthernCalifornia. 2005;9(2):9-18.

Greene SM, Larson EB, Boudreau DM,et al. The Coordinated Clinical StudiesNetwork: A Multidisciplinary Allianceto Facilitate Research and ImproveCare. 2005;9(4):33-5.

Handley M. Balance Sheets: Tools toInform Changes in Practice.2005;9(2):61-2.

Hardee JT, Kasper IK. From StandardizedPatient to Care Actor: Evolution of aTeaching Methodology. 2005;9(3):79-82.

Hayward J. Enclave Services: An Officewith a Purpose. 2005;9(2):98-9.

Herrada B, Agarwal J, Abcar AC. HowCan We Reduce the Incidence ofContrast-Induced Acute Renal Failure?2005;9(3):58-60.

Hertz B. Untitled (Permanente and theTsunami Relief Efforts). 2005;9(4):79.

Huberman AK, King H, Steinbruegge J.Roundtable Discussion: Transfer ofSuccessful Practices. 2005;9(4):56-9.

Huberman AK. The Ideal: Innovation andTransfer. 2005;9(4):36.

Jacobs L. Disaster Relief—“What Can IDo to Help?” 2005;9(1):99-102.

Jacobs L. Indonesia—What We Heard:Eyewitness Accounts From Survivors(Permanente and the Tsunami ReliefEfforts). 2005;9(4):77.

Janisse T. Health & Healing Overview.2005;9(3):3-4.

Janisse T. The Permanente JournalCosponsorship of the Evidence-BasedMedicine Symposium, December 3 &4, 2004. 2005;9(2):53.

Janisse T. Roman Windows.2005;9(2):34.

Janisse T. Spirituality Symposium: PanelDiscussion. 2005;9(3):75-7.

Janisse T. A Symposium on Meditation,Prayer and Spiritual Healing.2005;9(3):62.

Jones CI, Chen W, Mulligan KS.Preventing Unintended Pregnancy:Eight Years of Effort at KP San Diego.2005;9(1):69-71.

Joyce JS, Fetter MM, Klopfenstein DH,Nash MK. The Kaiser PermanenteNorthwest Cardiovascular Risk FactorManagement Program: A Model forAll. 2005;9(2):19-26.

Kale L. Doctor, Should I Take Hormones?2005;9(1):92-3.

King H, Tallman K, Huberman AK.Practical Steps for Practice Transfer:The Four A’s of Adoption.2005;9(4):50-1.

King HS. Shifting from Traditional toBiopsychosocial Pediatrics. Modifyingthe Pediatrician-Parent Relationship toPromote Normal ChildhoodDevelopment. 2005;9(4):60-3.

Kirkengen AL. Encountering Particulars:A Life in Medicine. 2005;9(3):19-22.

Klatsky AL. The James A Vohs Award forQuality—The Seventh AnnualPermanente Journal Special Issue.2005;9(2):8.

Volume 9

Index of Articles — by Author


index

Klatsky AL. The Second David MLawrence, MD, Chairman’s PatientSafety Award. 2005;9(2):27.

Krall MA. The Electronic Medical Record“Toolbox”. 2005;9(2):49-52.

Kruger KJ. The Small Things (Permanenteand the Tsunami Relief Efforts).2005;9(4):78.

Levin E, Arango J. Women at Risk forCoronary Heart Disease: HowResearch is Translated Into Innovationand Quality Outcomes at KaiserPermanente. 2005;9(1):48-51.

Levy IJ. Solitude. 2005;9(2):89.Lieberman L, Taillac C, Goler N. Vision,Research, Innovation and Influence:Early Start’s 15-Year Journey from PilotProject to Regional Program.2005;9(1):62-4.

Lora D. “Consciousness and Healing:Integral Approaches to Mind-BodyMedicine” Marilyn Schlitz, TinaAmorok, and Marc S Micozzi, editors.2005;9(3):88.

Majmudar H. The Pictures ChildrenDrew (Permanente and the TsunamiRelief Efforts). 2005;9(4):77.

Malone KA. Pap. 2005;9(2):100.Marsh B, Price D. Innovation in the

Kaiser Permanente Colorado Region:Where We’ve Been, Where We areGoing. 2005;9(4):40-3.

McCarthy S. A Casualty Come to Life(Permanente and the Tsunami ReliefEfforts). 2005;9(4):80.

McCaw B, Kotz K. Family ViolencePrevention Program: Another Way toSave a Life. 2005;9(1):65-8.

Meghani M. A Purely HumanitarianEffort (Permanente and the TsunamiRelief Efforts). 2005;9(4):82.

Meyer M. The Importance of WorkingTogether (Permanente and theTsunami Relief Efforts). 2005;9(4):79.

Milch M, Brumley RD. A QuarterCentury of Hospice Care: TheSouthern California Kaiser PermanenteExperience. 2005;9(3):28-31.

Mims AD, Zetzsche J, Leatherwood KA.Mammography Screening: AddressingMyths and Other Reasons forNoncompliance. 2005;9(1):52-4.

Moreno M. Domestic Violence in the KPWorkplace: Letter from a PhysicianSurvivor. 2005;9(1):61.

Mulligan M. After a Solstice Storm.2005;9(3):42.

Murray KD. Pretty Penny. 2005;9(2):40.Newhouse D, Servin M, Seshagiri M.

Kaiser Permanente Women’s HealthCenter of Excellence in CulturallyCompetent Care. 2005;9(1):84-6.

Newhouse N. Spiritual Moments.2005;9(3):69-70.

Nunes J, McFerran S. Perinatal PatientSafety Project. 2005;9(2):28-33.

Nunes J, McFerran S. The PerinatalPatient Safety Project: New Can BeGreat! 2005;9(1):25-7.

Nunes J. Bolinas Ridge. 2005;9(1):28.Nunes J. Egg Whites. 2005;9(1):55.Okawa G. Integrating Evidence with KP

HealthConnect: Making the RightThing Easier to Do. 2005;9(2):74-7.

Ong AL, Vigil DV. What To Do withHypertension and a Murmur FoundDuring a Preparticipation PhysicalEvaluation? 2005;9(4):20-2.

Ozsu V. “The Sexy Years: Discover theHormone Connection—The Secret toFabulous Sex, Great Health, andVitality, for Women and Men” bySuzanne Somers. 2005;9(1):111-2.

Packia Raj LV. Two Little Girls and MyDaughter (Permanente and theTsunami Relief Efforts). 2005;9(4):78.

Petitti DB, Sidney S. Four Decades ofResearch on Hormonal Contraception.2005;9(1):29-34.

Pettay HS, Branthaver B, Cristobal K,Wong M. The Care ManagementInstitute: Harvesting Innovation,Maximizing Transfer. 2005;9(4):37-9.

Pietersen R. KP Made a Difference(Permanente and the Tsunami ReliefEfforts). 2005;9(4):80.

Pimental S. Acquiring Evidence—Tips forEffective Literature Searching.2005;9(2):58-60.

Pivik C. Pelican on the Pier. 2005;9(4):19.Poole B. Happy Hour. 2005;9(4):68.Poole B. The Old Farmhouse LookedOlder. 2005;9(4):8.

Poole B. Tea in the Garden. 2005;9(4).Postlethwaite D. The EmergencyContraception Online LearningModule. 2005;9(1):89.

Postlethwaite D. Faces of AIDSPhotography Display. 2005;9(1):94-5.

Postlethwaite D. Intrauterine Contracep-tion: Study to Evaluate ClinicalPractice and to Increase Utilization.2005;9(1):16-9.

Postlethwaite D. Translating Researchinto Innovative Practices.2005;9(1):36.

Price D. Sharing Clinical Decisions byDiscussing Evidence with Patients.2005;9(2):70-3.

Redding CA. “The Spirit Catches You andYou Fall Down: A Hmong Child, HerAmerican Doctors, and the Collisionof Two Cultures” by Anne Fadiman.2005;9(2):111.

Richlin M. “Affect Regulation and TheRepair of the Self” by Allan N Schore.2005;9(2):109-10.

Sachs RH. How to Find a Sponsor forYour Practice Innovation. 2005;9(4):55.

Schlitz M. Meditation, Prayer andSpiritual Healing: The Evidence.2005;9(3):63-6.

Selby J. Why Research at KP?2005;9(1):10.

Shaber R. Women’s Health KaiserPermanente—Improving Women’sLives through Health Care Research,Innovation, and Education.2005;9(1):2.

Shaber R. The Women’s Health ResearchInstitute: Mission Overview withFeature Research Projects.2005;9(1):11-2.

Shaber R. The Women’s Health Track ofthe Kaiser Permanente NationalPrimary Care Conference.2005;9(1):88.

Shearer D, Littlewood M. The KaiserPermanente Interregional Breast CareLeaders. 2005;9(1):56-60.

Smidt-Jernstrom K. Pastoral SpiritualCare. 2005;9(3):71-2.

Smith DS. Strange Alliances (Permanenteand the Tsunami Relief Efforts).2005;9(4):76.

Starr-Seaman L. “A Woman’s Guide toSurgical Options in the NewMillennium: A Gentler Approach” byUdo Wahn, MD. 2005;9(1):110.

Steimle A. Evidence-Based Medicine andPopulation-Based Care: Caring forPatients with Heart Failure.2005;9(2):65-9.

Stolzberg S. “Prostitution, Trafficking,and Traumatic Stress” by MelissaFarley, PhD, Editor. 2005;9(1):113-4.

Sunoo CS, Aaberg RA, Nakamura JK.Laparoscopically Assisted VaginalExtraction of the Kidney afterLaparoscopic Radical Nephrectomy.2005;9(1):46-7.

Sutherland E. Healing Metabolism: ANaturopathic Medicine Perspective onAchieving Weight Loss and Long-TermBalance 2005;9(3):16-8.

Sutherland E. Spirituality in the MedicalEncounter: The Grace of Presence.2005;9(3):73-4.

Tallman K, King H, Huberman AK.Stealing Shamelessly: Practice TransferSuccess Factors. 2005;9(4):52-4.

Tamoria S. Flying Turtles (Permanenteand the Tsunami Relief Efforts).2005;9(4):81.

Torres N. Mama Donut (Permanente andthe Tsunami Relief Efforts).2005;9(4):80.

Waczek A. “Women’s Primary HealthCare: Protocols for Practice 2ndedition” by Winifred L Star, Lisa LLommel, and Maureen T Shannon,editors. 2005;9(2):114.

Wallace P. The Care ManagementInstitute: Making the Right Thing Easierto Do. 2005;9(2):56-7.

Wallace P. Care, Whether it’s CalledPopulation—or Disease-Management,Sidney Garfield, MD, Would Like theIdea. 2005;9(2):90-2.

Weil J. Dr V, Batticaloa Attending(Permanente and the Tsunami ReliefEfforts). 2005;9(4):77.

Weissberg J. Permanente Medicine in aChanging World: Challenges andOpportunities. 2005;9(2):54-5.

Whitten CE, Cristobal K. Chronic Pain isa Chronic Condition, Not Just aSymptom. 2005;9(3):43-51.

Whitten CE, Donovan M, Cristobal K.Treating Chronic Pain: NewKnowledge, More Choices.2005;9(4):9-18.

Whitten CE, Evans CM, Cristobal K. PainManagement Doesn’t Have to be aPain: Working and CommunicatingEffectively with Patients who haveChronic Pain. 2005;9(2):41-8.

Witt D. Post-Tsunami Malaria inIndonesia—The Pivotal Contributionsof Permanente Physicians.2005;9(4):69-71.

Wolitz R. “Focus on Living: Portraits ofAmericans with HIV and AIDS”Photographs and interviews by RoslynBanish; introduction by Paul MVolberding, MD. 2005;9(1):109.

Wong WF. KP Evidence-Based Medicinein the Community. 2005;9(2):81-2.

Wright MA. KP Northwest PreoperativeBriefing Project. 2005;9(2):35-9.

Zuber CD, Alterescu V, Chow M. FailOften To Succeed Sooner: Adventuresin Innovation. 2005;9(4):44-9.

Index of Articles — by Author


CME Evaluation Form

Section A.page 16Article 1. Predictive Value of the Rapid WholeBlood Agglutination D-Dimer Assay (AGENSimpliRED) in Community Outpatients withSuspected Deep Venous Thrombosis

Which of the following statements is not correct?a. the AGEN SimpliRED d-dimer assay has a

negative predictive value of 20.2% in this studyb. the lower the prevalence of the deep venous

thrombosis, the higher the negative predictivevalue of the assay

c. all patients with high pretest probability of deepvenous thrombosis should have compressionultrasonography (CUS)

d. the sensitivity and specificity varies upon thetype of d-dimer assay

Which of the following statements is correct?a. this study has negative predictive value of

99.3% by AGEN SimpliRED methodb. the sensitivity and specificity of d-dimer assay

can be applied interchangeablyc. the CUS is as sensitive as venography for

detecting thrombus in the distal veins of thecalf

d. if d-dimer is positive, there is no need for CUS

page 29Article 2. Genetic Services in the KP SouthernCalifornia Region: Delivering the Promises ofTomorrow Today

Minimum requirements for taking a genetic familyhistory include:

a. obtain information on at least three generations ofthe family

b. ask about both sides of the familyc. record ethnicity and raced. record consanguinitye. all of the above

Which of the following is incorrect?Fabry disease is an inherited metabolic disorder firstdescribed in 1898. Characteristics of the disorderinclude:

a. caused by mutations in the GAL (alpha galactosi-dase A gene)

b. X-linked recessive inheritancec. causes disabling pain crises in boys as young as

ten years of aged. enzyme replacement treatment is not currently

available to treat affected individualse. DNA testing is available to determine if a

woman with a family history of Fabry is a carrierof the disease

Earn your CME credits onlineFill out this form on our Web site:www.kp.org/permanentejournal

(Continued on next page)

Returncompleted

form byMay 31, 2006.

All PMG physicians and those clinicians eligible to do so may earn up to two hours of Category 1 credit for readingand analyzing the four designated CME articles, by selecting the most appropriate answer to the questions below, and bysuccessfully completing the evaluation form. Please return (fax or mail to the address listed on the back of this form) toThe Permanente Journal by May 31, 2006 . You must complete all sections to r eceive cr edit. (Completed forms willbe accepted until May 2007. Acknowledgment will be mailed within two months after receipt of form.)

The Kaiser Permanente National Continuing Medical Education Program (KPNCMEP) is accredited by the Accreditation Council for ContinuingMedical Education to provide continuing medical education for physicians. The KPNCMEP takes responsibility for the content, quality, and scientific

integrity of this CME activity. The KPNCMEP designates this educational activity for up to two hours of Category 1 CME credit for each TPJ issueapplicable to the AMA Physician Recognition Award and/or Physicians Award. Each physician should claim credit for only those hours that were

actually spent in this educational activity. All authors in this issue report no conflicts of interest.


(Continued from previous page)

page 77Article 4. Pay for Performance: At Last or Alas?

Pay-for-performance initiatives were first advocated in health care by:a. US House of Representativesb. RAND Corporationc. Leapfrog Groupd. US Food and Drug Administratione. United States Chamber of Commerce

Clinical conditions or outcomes that have been frequentlytargeted in pay-for-performance strategies include all thefollowing, except:

a. management of congestive heart failureb. results of hip replacement surgeryc. bariatric surgeryd. breast cancer screening ratese. postoperative antibiotic usage

Section B.Referring to the CME articles and to the stated objectives, please check the box next to each statement as appropriate.

Article 1 Article 2 Article 3 Article 4

The article covered the stated objectives.

I learned something new that was important.

I plan to use this information as appropriate.

I plan to seek more information on this topic.

I understood what the author was trying to say.

StronglyAgree

StronglyDisagree

5 4 3 2 1

StronglyAgree

StronglyDisagree

5 4 3 2 1

StronglyAgree

StronglyDisagree

5 4 3 2 1

StronglyAgree

StronglyDisagree

5 4 3 2 1

Mail or fax completed form to: The Permanente Journal500 NE Multnomah Street, Suite 100, Portland, OR 97232

Phone: 503-813-2623 • Fax: 503-813-2348

Objectives1) to inculcate the use of evidence-based medicine as part of the science of medicine. 2) to stress the art of medicine via enhanced patientphysician communication, improved care experience for patients, and more satisfying care giving experience for physicians and staff throughbetter teamwork. 3) to review appropriate updates on the diagnosis and treatment of clinical conditions. 4) to describe infrastructure andsystems improvements that lead to improvements in outcomes and patient care experiences.

Section D. (Please print)

Name: ______________________________________________

E-mail: ______________________________________________

Address: ______________________________________________

______________________________________________

Signature: ______________________________________________

Date: ______________________________________________

Section C.What change(s), if any, do you plan to make in

your practice as a result of reading these articles?

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

page 42Article 3. Update on Interventional Neuroradiology

Which statement is incorrect?Carotid stenting is contraindicated in patients with:

a. contralateral carotid occlusionb. clinically significant medical comorbidityc. low cervical stenosisd. recurrent postendarectomy stenosis

Which statement would you most disagree with?Interventional radiology progression has been enhanced by:

a. the availability of digital subtraction angiographyb. the replacement of invasive neurosurgeons by

interventional radiologists in all treatmentsc. the development of roadmap fluroscopic imagingd. rapid improvements in successive generations of

medical devices and materials

CME Evaluation Form


Advisory BoardRichard Abrohams, MD; Internist and Geriatrician .................................................... TSPMG

Terry Bream, RN, MN; Manager, Nursing Administration ......................................... SCPMG

Brian Budenholzer, MD; Director, Clinical Enhancement and Development ................. GHC

Dan Cherkin, PhD; Senior Scientific Investigator ...................................................... GHCHS

Linda Fahey, NP; Regional Coordinator of Advanced Practice .................................. SCPMG

Tom Godfrey, MD; Director of Communications ............................................................. TPF

Carol Havens, MD; Director, Department of Continuing Medical Education ............... TPMG

Arthur Hayward, MD; Internist and Geriatrician, Chief, Continuing Care Services ....... NWP

Tom Janisse, MD, MBA; Chairperson ............................................................................ NWP

Michael Mustille, MD; Associate Executive Director, External Relations .......................... TPF

Arlene Sargent, EdD, RN; Director of Education and Research .................................... TPMG

Joanne Schottinger, MD; Asst to Assoc Medical Director, Technology Assessment ....... SCPMG

Eric Schuman, PA; Family Practice Clinician ................................................................ KFHP

Mark Snyder, MD; Executive Director, Research and Information Management ....... MAPMG

Paul Wallace, MD; Executive Director, Care Management Institute ................................. TPF

David Waters, MD; Department of Ophthalmology; Member, Board of Directors ........ HPMG

Eddie Wills, Jr, MD; Assistant Medical Director, Prof Development & Support Svcs ..... OPMG

Levin, MD; For-Shing Lui, MD; Tamara MacLean, FNP; Mibhali Maheta, MD; Harold Mancusi-Unearo, Jr, MD, FACS; Laure Mazzara, MD; Bonnie McDonnell, RNP; Laurie Miller, MD; JohnMitchell, MD; Mary Mockus, MD, PhD; Ronald Morgan, MD, PhD; Stanley NG, MD; ValerieOzsu, NP; Karen Pantazis, MD; Steve Petty, MD; Dennis Pocekay, MD; Judi Price, PA-C;Roshan Raja, MD; Rafiq Sheikh, MD, MRCP (UK); Larry Sheridan, MD; Andris Skuja, PhD;Jeffrey Smith, MD; Elizabeth Smith, RNP; Prasit Vassantachart, MD; Gail Wagner, MD; LaurieWalsh, NP; Kaho Wong, MD, PhDThe Southeast Permanente Medical Group, Inc (TSPMG): Richard Abrohams, MD; GayleArberg, CANP; Joshua Barzilay, MD; Luke Beno, MD; Angel Cobiella, MD, MBA; Rick Derby,MS, LPC; Kenneth Ellner, MD; Marshall Fogel, MD; James Hipkens, MD, PhD; JeffreyHoffman, MD; Stanley Jagielski, MD; Sharon Lehman, MD; Adrienne Mims, MD; Sam Moss,MD; Sean Murphy, MD; Milton Sarlin, MD; Sandy Schafer, MSN; Helen Selser, MD, MMM;Gregory Valentine, MD; Gail Vest, MSN, MBA; S Luke Webster, MD; Alonzo White, MD,MBA; Marcia Williams, MD; Eric Zurbrugg, MDSouthern California Permanente Medical Group (SCPMG): Antoine Abcar, MD; Sherif Aboseif,MD; Anna Maria Andia, MD; Maria Ansari, MD; David Apel, MD; Fariba Ariz, MD; Zarin Azar,MD; Paul Bernstein, MD, FACS; Matthew Berry, MD; Trish Beuoy, CNM; Raj Bhagat, MD;Solomon Bitew, MD; Robert Blum, MD; Harsimran Brara, MD; Gayne Brenneman, MD; IoneBrunt, CNM; Kenneth Burns, MD; Timothy Carpenter, DO; Connie Casillas, MD; KreightonChan, MD; Kevin Chang, MD; Winjing Chang, MD; Joseph Chen, MD, PhD; Hae-Kyung Cho,NP; Ashok Chopra, MD; Reema Chugh, MD; Naomi Cohen, NP; William Crawford, MD;Roberto Cueva, MD; Dale Daniel, MD; Dereck De Leon, MD; James Delaney, PAC; RichardDell, MD; Mark Dreskin, MD; Karen Durinzi, MD; Alan Evans, MD; Michael Farooq, MD;Shireen Fatemi, MD; F Ronald Feinstein, MD; Vincent Felitti, MD; Linda Fitts, MD; ValoraFlukers, RNP; Peter Fung, MD; Brendan Gaylis, MD; Yoav Gershon, MD; Cary Glass, MD;Andrew Golden, MD; Glenn Goldis, MD; Adam Guo, MD, PhD; Paul Gweon, MD; Joel Handler,MD; Paul Hartman, MD; Lubna Hasanain, MD, MPH; Yassamin Hazrati, MD; Lisa Heikoff, MD;Chris Helmstedter, MD; Lucretia Hemminger, RNP; Diane Hom, MD; Aram Hovanessian, MD;Adam Howard, MD; Steve Huang, MD; Robert Hye, MD; Gladys Inga-Surainder, MD; HoracioJinich, MD; Samir Johna, MD, FACS; Sara Jones-Gomberg, MD; Sharon Kalina, MD; CraigKalthoff, MSN, FNP; Michael Kanter, MD; Siamak Karimian, MD; MaryAnn Kazem, NP; AfshinKhatibi, MD; Gary Kodel, MD; Charles Koo, MD; John D Kovac, MD; Tracy Kritz, MD; JudyKuhlman, NP; Nam Lam, MD; Daniel Lang, MD; Michael Lee, MD; Hollis Lee, MD; DavidLerman, MD, JD; Margaret Lin, MD; James Lindeen, MD; K David Liu, MD, MSc; CarlaLizarraga, RNP, CDE; Felicio Lorenzo, MD; Marcus Magallanes, MD; Daniel Marcus, MD; JuanyMazaira, NP; Michael McBeth, MD; Kerry McCabe, CNM; Patrick Merrill, MD; Steven Minaglia,MD; Alexander Miric, MD; Natasha Mironov, CNM; Richard Moldawsky, MD; Mark Mueller,MD; Manuel Myers, MD; Michael Neri, MD; Lisa Nyberg, MD, MPH; Theresa O’Donnell,MD; Ronda Ochoa, CPNP; Naheed Olsen, MD; Christine Phan, MD; Willye Powell, MD;Holly Pressburg, NP; Diana Ramos, MD; Albert Ray, MD; William Reilly, MD; Eugene Rhee,MD; Bradley Richie, MD; Ronald Rosengart, MD; Marlene Rosenwald-Becker, NP; MarkRutkowski, MD; Michael Ryan, MD; Firoozeh Sahebi, MD; Charles Salemi, MD; LisaSanders, MD; Asma Saraj, MD; Ramin Sarshad, MD; Gail Sateri, RNP; Thomas Schares, MD,MBA; Robert Schechter, MD; Matthew Schneiderman, MD; Michael Schwartz, MD; TheodoreScott, NP; Pranav Shah, MD; Alexander Shar, MD; Sung Shin, MD; Ellen Song, NP; Steven Soto deMayor, PA; Ricardo Spielberger, MD; Vishwas Tadwalkar, MD, FACS; Christopher Tarnay, MD,FACOG; Mitsuo Tomita, MD; Timothy Tran, MD; Melanie Turner, NP; Jessie Uppal, MD; KaroleVelzy, RNP; Jim Wang, MD; Edward C Wang, MD; John Weaver, MD; Calvin Weisberger, MD;Penelope Westney, MD; Nicolas Wieder, DO; Pauline Woo, MD; Edward Yang, MD; HuiquanZhao, MD, PhD; Fred Ziel, MD

Review BoardColorado Permanente Medical Group, PC (CPMG): Tim Adair, PA; Paulanne Balch, MD; PaulBarrett, MD, MSPH; John Brozna, MD, PhD; Heather Burton, MD, MA; Theresa Capaci, PA;Michael Chen, MD; Kathleen Cramm, PsyD; Richard Erickson, MD; Kenneth Faber, MD;Deborah Fisher, MD; Timothy Garling, PA; William Georgitis, MD, RDC; James Hardee, MD;Gregory Kirk, MD; Jill Levy, MD; Evelyn Lifsey, LPC; Karen Lucas, MD; Randall McVean, MD;Clara Elizabeth Miller, PhD; Judy Mouchawar, MD, MSPH; Ted Palen, MD, PhD; AlfonsoPantoja, MD; Robert Podolak, MD; Nancy Rogers, MD; Andrew Schreffler, MD; Peter Schultze,MD; Healther Shull, MD; Marie Spollen, PsyD; Richard Spurlock, MD; Michael Tobin, PhD;Patrick Williams, MD; Charles Wilson, MD; William Wright, MDHawaii Permanente Medical Group, Inc (HPMG): Scott Beattie, PA; Rossini Botev, MD; LisaCamara, MD; Monique Canonico, DO; John Chen, MD; Anita Dekker-Jansen, MD; HobieFeagai, MSN; James Ford, MD, MBA; Robert Frankel, PA-C; Paul Glen, MD; Lisa Hui, PCP;Esther Ines, FNP; Randy Jensen, MSN; Paula King, NP; Brian Lee, MD; Michelle Marineau,MSN, RN; Chenoa Morris, PA; Kevin Murray, PA; Bill Pfeiffer, MD; Stein Rafto, MD; CarlosRios, MD; J Marc Rosen, MD; Christian Sunoo, MDMid-Atlantic Permanente Medical Group, PC (MAPMG): Akin Abisogun, MD, PhD; DelroyAnglin, MD; Jean Arlotti, NP; Michael Caplan, MD; Maurice Cates, MD; Gail Cavallo, NP;Soma Chakraborty, MD; Susan Chhabra, MD; Harish Dave, MD; Christopher Della Santina,MD; Tarun Dharia, MD; Andrew Dutka, MD; Brian Egan, MD; Carol Forster, MD; HaroldFruchter, PA-C; Daniel Glor, MD; Virgil Graham, MD; Alan Halle, MD; Ann Hellerstein, MD;Mahrukh Hussain, MD; Leon Hwang, MD; Mutombo Kankonde, MD; Saul Kaplan, MD;Stuart Katz, MD; Ronald Klayton, MD; Thomas Krisztinicz, MD; Robert Kritzler, MD; LonnieLee, MD, L AC; Hing-Chung Lee, MD; Jeff Lowenkron, MD; Paula McNinch, MS; AnthonyMorton, MD; Cathriya Penny, NP; Peter Pham, MD; Martin Portillo, MD, FACP; AshokPrahlad, MD; Daniel Schwartz, MD; Christopher Spevak, MD, MPH; Duane Taylor, MD; MarkTerris, MD; Devika Wijesekera, MD; Sue Wingate, RN, DNSC; Bradley Winston, MD; ECWynne, MD; Jing Zhang, MD, PhDNorthwest Permanente, PC, Physicians and Surgeons (NWP): Michael Alberts, MD, PhD;Keith Bachman, MD; Kendall Barker, MD; Marcia Bertalot, NP; David Black, MD, MPH;Candace Bonner, MD, MPH; Radhika Breaden, MD, MPH; Suzanne Brown, CRNA; HomerChin, MD; Les Christianson, DO; Vicki Cohen, CNM; Susan Cooksey, PhD; Paul DeBaldo Jr,NP; Lawrence Dworkin, MD; Charles Elder, MD, MPH; Kitty Evers, MD; Adrianne Feldstein,MD, MS; Norman Freeman, MD; Patricia Hanson, PsyD; Bettylou Koffel, MD; Richard Konkol,MD; Mike Kositch, MD; Louis Kosta, MD, FACS; John Lasater, MD, MPH; Theresa Laskiewicz,MD; Steve Lester, MD; Amy Lindholm, MS; Joseph MacKenzie, PA; Sherwin Moscow, MA;Jeanne Mowry, MD; Chuong Nguyen, MD; Luanne Nilsen, MD; Christopher Pearce, OD; JimPowell, MD; Jock Pribnow, MD, MPH; James Prihoda, MD; Anita Rao, MD; Jacob Reiss, MD;Ed Ruden, MD; Joan Sage, MD; Michael Salinsky, MD; Ronald Sandoval, PhD; AlistairScriven, MD; Susan Sharp, PhD; David Shenson, MD; Kelly Sievers, CRNA; PhD; JohnSobeck, MD; Kathy Stewart, MD; Stephen Stolzberg, MD; Ron Swan, MS LPC; Micah Thorp,DO; Kathyleen Tomlin, LPD-CADC; Kelly Tuttle, NP; Victoria VanDyke, CNM; David Watt,MD; Don Wissusik, MA, MS; David Zeps, MDOhio Permanente Medical Group, Inc (OPMG): Andrew Altman, MD; Joseph Armao, MD;Kurt Birusingh, MD; Stephen Cheng, MD; Lydia Cook, MD; Eliot Gutow, LISW; Mark Hardy,DPM; Mark Roth, MD; Sardul Singh, MD; J Michael Wertman, MDThe Permanente Medical Group, Inc (TPMG): Pamela Anderson, MD; Wayne Arioto, DO;Jonathan Blum, MD; Lucienne Bouvier, MD; Jeffrey Brown, MD; Sherry Butler, MD; ThomasDailey, MD; Lianna Edwards, FNP-C; Rita Enright, NP; Pascal Fuchshuber, MD, PhD;Gordon Garcia, MD; Jay Gehrig, MD; Jan Herr, MD; Raymond Hilsinger, Jr, MD; GavinJacobson, MD; Myles Lampenfeld, MD; Juan Larach, MD; Theodore Levin, MD; David

EditorsTom Janisse, MD, MBA Editor-In-Chief& Publisher

Vincent J Felitti, MD Book ReviewsLee Jacobs, MD Health Systems

Arthur Klatsky, MD Clinical Contributions& Abstracts

Helen Pettay Care Management Institute

Scott Rasgon, MD KP In The Community& Corridor ConsultJon Stewart Public Policy

KM Tan, MD Continuing Medical Education

ProductionMerry Parker Managing Editor & Publisher

Lynette Leisure Print & Web Designer

Amy Eakin Director of Publishing Operations

Max McMillen Assistant Editor & Writer

Sharon Sandgren Production Assistant

Editing provided by the MedicalEditing Service of TPMGPhysician Education andDevelopment DepartmentLila Schwartz Senior Editor

David W Brown Copyright LibrarianJuan Domingo Assistant Editor - Graphics

Jan Startt Assistant Editor - Copyright

Administrative Team

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Mission: The Permanente Journal iswritten and published by the cliniciansof the Permanente Medical Groups andKFHP to promote the delivery of superiorhealth care through the principles andbenefits of Permanente Medicine.


2 LETTERS TO THE EDITOR

3 PERMANENTE ABSTRACTS

7 HMO ABSTRACTS

81 ANNOUNCEMENTS

84 CROSSWORD

85 BOOK REVIEWS

87 INDEX

91 CME EVALUATION FORM

Spring 2006/ Volume 10 No. 1

On the cover:

“Totem” by Joseph MacKenzie,PA, is a photograph recognizingthe peoples of the Northwestcoast who still carve great cedarlogs into the figures that fill theirstories about the beginnings ofthe world. Mr MacKenzie printshis photographs in his homestudio using archival inks andwatercolor paper to add depthand richness to the colors. He isa member of The BroadwayGallery in Longview, WA, andparticipates in other localexhibition events.

Mr MacKenzie is in the Department of Gastroenter-ology on the Interstate campus in Portland, OR.More of his art can be seen on page 24.

CLINICAL CONTRIBUTIONS 9 Stereotactic Radiosurgery:

Indications and Results — Part 2.Joseph C T Chen, MD, PhD;Michael R Girvigian, MD

This second of two parts pre-sents indications for this in-creasingly important option inthe treatment of central nervoussystem disease and discussesresults reported in the medicalliterature.

16 Predictive Value of the RapidWhole Blood AgglutinationD-Dimer Assay (AGENSimpliRED) in CommunityOutpatients with SuspectedDeep Venous Thrombosis.Julieta E Hayag, MD; Prem PManchanda, MD

The efficacy of using d-dimerassay to diagnose suspecteddeep venous thrombosis is re-viewed in this retrospectivestudy that considered electronicmedical record results of d-dimer assay and compressionultrasonography.

The Permanente Journal500 NE Multnomah St, Suite 100Portland, Oregon 97232www.kp.org/permanentejournal

ISSN 1552-5767


SOUL OF THE HEALER24 “Green Sea Turtle”

Joseph MacKenzie, PA

56 “The Monks”Ming Jing (Mike) Wang, MD

80 “Zan”Sevada Younesian, RN

21 Corridor Consult

Snoring Versus ObstructiveSleep Apnea: A Case Report.Paul Bernstein, MD, FACS;JoAnne Higa Ebba, MD

This case report examinesthe diagnosis and treatmentof obstructive sleep apnea.

CME

CCC UPDATE51 Institute for Culturally Competent

Care: Clinicians’ Needs Assessment2005. Gayle Hunt; Saleena Gupte,DrPH, MPH

This article describes the 2005survey and the learnings gleanedfrom it.

53 A Successful Partnership to HelpReduce Health Disparities at KaiserPermanente: The Institute forCulturally Competent Care and theKaiser Permanente School ofAnesthesia. Nilda Chong, MD, MPH,DrPH; Sassoon M Elisha, CRNA, MS,EdD; Maria Maglalang, RN, MN, NP;Karen Koh, MPH, DrPHi

This article describes the genesisevolution, and potential impact ofan ongoing partnership betweenthe KP school of Anesthesia andthe California State University sys-tem in incorporating a formal cul-tural competence program.

a focus on new technology - thepermanentejournal.org · a focus on new technology -...

Documents