1

TABLE OF CONTENTS

Welcome Message................................................................................................................ 1

Program Agenda ................................................................................................................... 3

Co-Chair Biographies ............................................................................................................ 9

Speaker Biographies ........................................................................................................... 11

Speaker Abstracts…………………………………………………………………………………………………………..25

List of Delegates................................................................................................................. .37

Supporter Organizations..................................................................................................... 42

Appendices ......................................................................................................................... 43

USBJI Overview of Programs

USBJI Network of Participating Groups

Notes Pages ....................................................................................................................... 48

Welcome Message

Dear Delegates,

On behalf of the United States Bone and Joint Initiative (USBJI), we would like to welcome you to Washington and thank you for joining us in what should be an exciting and challenging discussion on best practices in patient-centered musculoskeletal health care. In the midst of the great changes in the financing of health care in the United States, we strongly believe that the musculoskeletal community must find ways to identify best practices in the care of patients and put patients first in determining the new funding and organizational structures that will no doubt develop as health care reform progresses. To meet that goal, we have invited to the Summit a broad range of stakeholders representing patients, providers, payors, government, industry and professional organizations. Together, we will collaborate to develop a consensus statement on best practices in patient-centered care that can be an action framework for future activities, including advocacy at the local, state and national levels. As we embark on this program, we would like to thank our speakers, sponsors and the staff of the USBJI who devoted extraordinary effort to making this Summit a success. We extend a special appreciation to Toby King, the Executive Director of the USBJI. Toby has with great skill and commitment, worked hard to keep a sharp focus on patient-centered care and provide a meeting structure that will be interactive, informative and enjoyable. We look forward to working together in the coming days as we try to understand the meaning of best practices in musculoskeletal health care and assure the central focus on patients in the future.

Sincerely,

David S. Pisetsky, MD, PhD Summit Co-Chair

Gregory M. Worsowicz, MD, MBA Summit Co-Chair

Program Agenda

Monday, November 18, 2013 – Grand Ballroom

0800-0815 Opening and Welcome from USBJI President and Summit Co-chairs:

Steve Gnatz, MD, MHA, USBJI President Medical Director

Physical Medicine & Rehabilitation Loyola University Medical Center Maywood, IL David S. Pisetsky, MD, PhD, Summit Co-Chair Professor of Medicine and Immunology Duke University Medical Center Chief of Rheumatology Durham VA Medical Center Durham, NC Gregory M. Worsowicz, MD, MBA, Summit Co-Chair Professor of Clinical PM&R Chairman Department of Physical Medicine & Rehabilitation University of Missouri Columbia, MO

0815-0900 Key note address John R. Tongue, MD Immediate Past President

American Academy of Orthopaedic Surgeons Tualatin, OR

0900-1030 Session One: What are best practices?

The goal of this session is to consider the operational definition of best practice; the evidence used in determining recommendations and guidelines on best practice; and the process by which recommendations and guidelines are established, disseminated and implemented.

• The challenge of identifying best practices Jason Busse, BSc, MSc, DC, PhD Assistant Professor Department of Clinical Epidemiology & Biostatistics McMaster University Hamilton, ON

• The process for establishing recommendations Kenneth D. Saag, MD, MSc Jane Knight Lowe Professor of Medicine Director Center for Outcomes Effectiveness Research and Education (COERE) and Center for Education and Research on Therapeutics (CERTs) of Musculoskeletal Disorders University of Alabama at Birmingham Birmingham, AL

• Decision-making in best practices

James O. Sanders, MD Member AAOS Evidence Based Quality and Value Committee School of Medicine and Dentistry University of Rochester Rochester, NY

1030-1045 Refreshment break

1045-1230 Session Two: What is patient-centered care?

The goal of this session is to consider the concept of patient-centered care and the role of the patient in determining best practice and outcome using patient reported outcome measures.

• The patient perspective: How does the patient view illness and goals and outcomes of treatment? Beverley H. Johnson President/CEO Institute for Patient- and Family-Centered Care Bethesda, MD

• Patient reported outcomes: How can patient-reported outcomes improve clinical trials as well as practice? Vibeke Strand, MD, FACP, FACR Biopharmaceutical Consultant and Clinical Professor Adjunct Division of Rheumatology/Immunology Stanford University Portola Valley, CA

• The impact of diversity: How do patient demographics influence the delivery of best practices and determine care outcome? Kelli D. Allen, PhD Associate Research Professor Health Services Research & Development, Durham VA Medical Center Department of Medicine, Duke University Medical Center

• The measurement of functional outcomes: How to assess patient outcomes during rehabilitation Allen W. Heinemann, PhD, ABPP (RP), FACRM Professor Physical Medicine and Rehabilitation

Feinberg School of Medicine, Northwestern University Director Center for Rehabilitation Outcomes Research

Rehabilitation Institute of Chicago Chicago, IL

1230-1400 Lunch – Atrium Ballroom Opportunity for table discussions

1400-1515 Session Three: Implementing best practices

The goal of this session is to discuss implementation of best practices, focusing on the role of different stakeholders and the impact of care settings. This session will also consider models of musculoskeletal care and the interactions among providers who participate in interdisciplinary care. Discussants will review both challenges and successful strategies to implementation within their systems.

• The role of the health care system: How to organize care to deliver best practices Ronald Swinfard, MD President & CEO Lehigh Valley Health Network Allentown, PA

• The role of the payer: How do payers promote best practices? Kurt Hoppe, MD Assistant Professor Department of Physical Medicine and Rehabilitation College of Medicine Mayo Clinic Rochester, MN

• The role of specialty hospitals: How to organize comprehensive musculoskeletal care Mary K. (Peggy) Crow, MD Physician-in-Chief and Chair, Rheumatology Hospital for Special Surgery New York, NY

1515-1530 Refreshment break

1530-1700 Break-out groups – Hermitage, Madison, Montpelier, Grand Ballroom

How to implement best practices in your community

The goal of this group is to discuss implementation of best practices in different care settings, emphasizing interaction among providers and the creation of better models of interdisciplinary care in a community. Since communities differ markedly in the range and organization of services that are available, who implements best practice and assures its utilization? Participants will be encouraged to discuss examples from their own experiences, highlighting challenges as well as strategies for success.

Session Leader: Sunitha Baskaran, PhD Vice President & Team Lead for Musculoskeletal Solutions Gary & Mary West Health Institute La Jolla, CA

How to advocate for best practices The goal of this group is to discuss the role of advocacy in achieving best practices within the health care system. Advocacy occurs at various levels including state and national government as well as health care payers. Effective advocacy requires knowledge of best practices, including any guidelines and recommendations, as well as political strategies and resources for advocacy programs. Since musculoskeletal diseases are very diverse, stakeholders can differ. An important question thus concerns coordination of efforts to increase success and avoid competition.

Session Leader: Kathleen A. Arntsen President & CEO Lupus Foundation of Mid & Northern New York LRI Advocacy Ambassador Utica, NY How can the patient obtain best practices? Obtaining best practices for individual patients can involve complex decision-making for both the patient and provider. This decision-making is based on an understanding of what constitutes best practices and their potential for delivery within the health care system. In many instances, a best practice has not been established in an evidence-based way and providers may differ in their assessment of alternatives. The patient needs good information to participate in this discussion which may differ markedly, concerning the setting, whether acute or chronic or medical or surgical. How is the patient to know what the best practice is and whether he/she will obtain it?

Session Leader: Maura Daly Iversen, PT, DPT, SD, MPH, BSc Professor and Chair Department of Physical Therapy Northeastern University Boston, MA

Patient Registries: How can the data help determine best practice? The goal of this break-out group is to consider the use of patient registries as an analytic

approach to determine best practices. At present, there are large registries that contain longitudinal data on the care of patients with a variety of musculoskeletal diseases. Although such registries usually record information from the routine care of patients, they nevertheless can provide valuable insight into the course of disease and the impact of various therapies. This group will consider the strengths and limitations of data in such registries and how best to use “real world” data to assess and evaluate best practices and develop models for improvement.

Session Leader: Salahuddin Kazi, MD Vice Chair of Education & Director of Residency Training Department of Internal Medicine Associate Professor of Medicine Division of Rheumatic Diseases UT Southwestern Medical Center Dallas, TX

1700-1800 Breakout group reports

1900-2130 Dinner – Atrium Ballroom

Our guest speaker will present an overview of cutting-edge technologies that allow personalized treatment as an element in patient-centered care delivery models.

• Human genomics a decade after the human genome project: Opportunities and challenges Eric D. Green, MD, PhD Director National Human Genome Research Institute National Institutes of Health Bethesda, MD

Tuesday, November 19, 2013 – Grand Ballroom

0800-0815 Welcome and Summary of Previous Day – Chairs

0815-0900 Key note address Steven Wartman, MD, PhD President

Association of Academic Health Centers Washington, DC

0900-1200 Session Four: What are today’s best practices for musculoskeletal conditions?

The goal of this session is to consider issues of best practice for specific musculoskeletal conditions, considering available evidence to develop guidelines and recommendations and the challenges in implementation. This session will also consider gaps in knowledge and the types of research needed to create best practices.

Theme One: Falls and Fracture Prevention

• What are best practices for managing osteoporosis? Debra Sietsema, PhD, RN Michigan State University Grand Rapids, MI

• How does a fracture liaison service improve outcomes? Nora Strick, MD Internal Medicine Physician Co-Lead Healthy Bones Program Southern California Kaiser Permanente Assistant Clinical Professor UCLA School of Medicine Los Angeles, CA

• Establishment of a Fracture Liaison Service: Challenges of the Open vs. Closed System Laura L. Tosi, MD Director, Bone Health Program Division of Orthopaedics & Sports Medicine Children’s National Medical Center Washington, DC Member, Own the Bone Program

• What are best practices for sport injury prevention?

Thomas Best MD, PhD, FACSM Professor and Pomerene Endowed Chair Professor of Biomedical Engineering and Bioinformatics Chief Division of Sports Medicine Co-Director The OSU Sports Medicine Center Team Physician OSU Department of Athletics, Ohio State University College of Medicine Columbus, OH

Theme Two: Back Pain

• What are best practices in spine surgery for fusions and scoliosis? Baron Lonner, MD Clinical Professor of Orthopaedic Surgery NYU Hospital for Joint Diseases New York, NY

• What are best practices for spinal stenosis? William Charles Watters, III, MD, MMS, MS Houston, TX

• How do rheumatologists and orthopedists collaborate to determine and implement best practices for back pain? David Borenstein, MD Clinical Professor of Medicine Division of Rheumatology George Washington University Medical Center Washington, DC

1200-1400 Lunch – Atrium Ballroom

Open discussion and development of recommendations

Breakout group leaders will present their recommendations, there will be an open microphone for all delegates to ask questions and begin development of specific recommendations for the position paper, considering such issues as the role of different providers and the challenges in developing cooperation and implementing recommendations.

1400 Closing Remarks—Steve Gnatz, MD, MHA, USBJI President

Co-Chair Biographies

David S. Pisetsky, MD, PhD Professor of Medicine and Immunology Duke University Medical Center Chief of Rheumatology Durham VA Medical Center Durham, NC

David S. Pisetsky, MD, PhD, received his BA from Harvard College magna cum laude in 1967 and his PhD and MD degrees from the Albert Einstein College of Medicine in 1972 and 1973. He was then an intern and resident in Internal Medicine at the Yale-New Haven Hospital from 1973-1975. From 1975-1978, he was a clinical associate at the National Cancer Institute, studying the immune response to protein antigens. He joined the faculty of the Duke University Medical Center in 1978 as Chief of Rheumatology at the Durham VA Hospital where he has remained since. He served as Chief of Rheumatology at Duke from 1996-2007. Dr. Pisetsky has conducted basic and translational research on the pathogenesis of systemic lupus erythematosus (SLE), focusing on the generation of antinuclear antibodies and the immunological properties of nuclear macromolecules. His studies were among the first to establish the antigenic and mitogenic activity of bacterial DNA, the antigenicity of oligonucleotides and the ability of synthetic oligonucleotides to modulate immune responses. More recently, he has investigated the release of DNA and related nuclear molecules during cell death. He is also studying the activity of nucleic acid binding polymers (NABPs) as a way to block immune responses induced by DNA and RNA. Dr. Pisetsky has had grant funding from the NIH, Veterans Administration and various foundations. He has published over 350 articles and chapters and has edited several textbooks and volumes. From 2000-2005, he served as Editor of Arthritis and Rheumatism and was the first Physician Editor of The Rheumatologist from 2006-2011. He is currently on the editorial board of Annals of Rheumatic Disease and Arthritis Research and Therapy. He continues to see patients at the Durham VA Hospital.

Gregory M. Worsowicz, MD, MBA, received his medical degree from the University of Florida School of Medicine in 1986 and completed a residency in 1990 in Physical Medicine and Rehabilitation at Baylor College of Medicine in Houston, Texas. Since residency, he has practiced in both academic and private settings. He served as the Director of Satellite Services in the Department of Physical Medicine and Rehabilitation at the University of Medicine and Dentistry of New Jersey (UMDNJ) until 2002. Since that time, he has served as the Chairman of the Department of Physical Medicine and Rehabilitation at the University of Missouri School of Medicine and holds the HealthSouth Endowed Chair in Physical Medicine and Rehabilitation. He also serves as the Chair of University Physicians at the University of Missouri that has over 400 practicing physicians. His clinical and research interests include the cost effective systems of care/program development, health care policy, and geriatric rehabilitation. He has presented regionally and nationally as well as authored articles on practice management and systems of post-acute care. He served as a Co-Principal Investigator for the Missouri Arthritis Rehabilitation Research and Training Center (MARRTC) that was funded by the National Institute on Disability and Rehabilitation Research (NIDRR). He has served as a Board of Directors member for the Association of Academic Physiatrists, American Congress of Rehabilitation Medicine, and the American Academy of Physical Medicine and Rehabilitation and is currently the Vice President of the American Academy of Physical Medicine and Rehabilitation.

Gregory M. Worsowicz, MD, MBA Professor of Clinical PM&R Chairman, Department of Physical Medicine & Rehabilitation University of Missouri Columbia, MO

Speaker Biographies

Dr. Kelli Allen is a health services researcher and exercise physiologist whose research focuses on improving care and outcomes for patients with osteoarthritis and other chronic pain conditions. Her current research focuses on: 1) Development and testing of patient and provider-based interventions to improve osteoarthritis treatment and self-care behaviors (e.g., exercise, weight management, coping skills) in the primary care setting, 2) Identifying causes of disparities in osteoarthritis outcomes and developing interventions to reduce disparities, 3) Promoting informed decision-making among patients with osteoarthritis, particularly women and racial/ethnic minorities.

Dr. Allen is currently the PI of a VA-funded study to compare individual vs. group-based models of delivering physical therapy services to veterans with knee osteoarthritis. She is also PI of two studies (one NIH-funded, one VA-funded) examining combinations of patient-based and provider-based interventions for improving outcomes among primary care patients with lower extremity osteoarthritis. Another ongoing study is evaluating internet and DVD versions of patient decision aids for hip and knee osteoarthritis.

Kathleen Arntsen currently serves as President & CEO of the Lupus Foundation of Mid and Northern NY and as the Lupus Patient Representative for OHCA with the FDA and the IUIS/WHO/AF/CDC Autoantibody Standardization Committee and is Advocacy Ambassador for the Lupus Research Institute.

She is a persuasive voice as a national advocate for lupus, rheumatologic, and autoimmune diseases and has provided testimony before numerous governmental agencies. Kathleen is committed to ensuring all Americans have access to appropriate, affordable medical care and encourages patient-centered healthcare and empowerment programs aimed at enhancing quality of life. She has developed educational programs on clinical research for diseases of unmet need and supports the advancement of biomedical innovation. Kathleen has received numerous professional awards, and is a graduate of Colgate University.

Dr. Sunitha Baskaran is Vice President and Team Lead for Musculoskeletal Disease Solutions at the Gary & Mary West Health Institute, an independent, non-profit 501(c)(3) medical research organization whose mission is to develop high-value, innovative patient-centered solutions. Previously, Dr. Baskaran was a Junior Partner at McKinsey & Company, where she advised senior management of leading health care companies around the world. She has consulted for the Bill & Melinda Gates Foundation in their Global Health Division, and served as a Senior Vice President at DJO Global, a Blackstone Portfolio Company. She also served in a variety of leadership roles at Life Technologies. She has been an invited guest lecturer at the University of California, San Diego where she taught at the Rady School of Management and the Jacobs School of Engineering. She is co-author of “A License to Cure” which appeared in the McKinsey Quarterly and has been required reading at leading business schools. She earned her PhD in Biotechnology and Biochemical Engineering at Dartmouth College where she was the recipient of the Henry J. McCarthy 1931 Fellowship.

Kelli Allen, PhD Associate Research Professor Department of Medicine Duke University Medical Center Research Health Scientist Durham VA Medical Center Durham, NC

Kathleen A. Arntsen President & CEO Lupus Foundation of Mid & Northern New York LRI Advocacy Ambassador Utica, NY

Sunitha Baskaran, PhD Vice President & Team Lead for Musculoskeletal Solutions Gary & Mary West Health Institute La Jolla, CA

Dr. Tom Best is the Pomerene Endowed Chair of Primary Care and Director of the Division of Sports Medicine in the Department of Family Medicine at Ohio State University. He holds joint appointments in the College of Engineering and the School of Allied Health Medical Professions. Dr. Best serves as the Team Physician for the OSU men’s ice hockey team as well as a consultant to American and Canadian national hockey teams.

Prior to joining the OSU Sports Medicine staff in 2005, Dr. Best spent 10 years on the faculty of the University of Wisconsin College of Medicine as well as team physician for the Wisconsin athletic department. A graduate of The University of Windsor (Canada), Dr. Best attended medical school at The University of Western Ontario. In addition to his medical training, Dr. Best holds a master’s degree in kinesiology and a doctorate in biomedical engineering (Duke University).

Dr. Best’s clinical interests include muscle/tendon injuries, osteoarthritis, concussion, endurance athletes and evidence-based medicine. His research on muscle inflammation and repair has been NIH-funded for 15 consecutive years and has resulted in over 100 peer-reviewed publications. His work on muscle injury and repair has also been funded by the National Science Foundation. He is co-editor of the book Evidence-Based Sports Medicine, now in its 2nd edition. Other research areas include: effects of the quadriceps on knee osteoarthritis, benefits of core training on injury prevention, and cytokines and low back pain.

Dr. Best has presented over 200 lectures, including invited presentations to nine international countries. Dr. Best is past recipient of several honors for his research including the Kappa Delta and the Arnold Siegal Stapp research awards. He has been involved with the training of 15 Sports Medicine Fellows and seven PhD students, along with over 20 Master’s students.

An active member in the American College of Sports Medicine (ACSM) for 21 years, Dr. Best is a fellow and the 2010-2011 President of ACSM. He is the Associate Editor-in-Chief of the journal Medicine and Science in Sports and Exercise, the official journal of the American College of Sports Medicine. He serves on the editorial boards of several other sports medicine and orthopedic journals.

Dr. Best is certified by the American Board of Family Practice and holds a Certificate of Additional Qualification in Sports Medicine. He is a member of The Canadian Academy of Sports Medicine, the American Medical Society for Sports Medicine, and The American Academy of Family Physicians. Recently he was re-elected to a three-year term on the Board of Directors for the United States Bone and Joint Initiative. He also serves on the Board of Directors for the National Youth Sport and Safety Institute as well as the Advisory Board for the National Space Biomedical Research Institute.

Dr. David Borenstein was the 74th President of the American College of Rheumatology. He graduated with a BA degree from Columbia University in 1969. He received his Doctor of Medicine, completed his internship and residency in internal medicine on The Osler Medicine Service and his fellowship in rheumatology at the Connective Tissue Division at The Johns Hopkins University School of Medicine and The Johns Hopkins Hospital from 1969 to 1978. Dr. Borenstein is board certified in internal medicine with sub-specialty certification in rheumatology. He is a Master of the American College of Rheumatology and the American College of Physicians. He is a member of Arthritis and Rheumatism Associates in Washington, DC. He became an Assistant Professor of Medicine at The George Washington University Medicine Center in 1978. In 1989, he was promoted to Professor of Medicine. During this period he was Associate

David Borenstein, MD Clinical Professor of Medicine, Division of Rheumatology George Washington University Medical Center Washington, DC

Tom Best, MD, PhD, FACSM Professor and Pomerene Endowed Chair Professor of Biomedical Engineering and Bioinformatics Chief—Division of Sports Medicine, Co-Director— The OSU Sports Medicine Center Team Physician—OSU Department of Athletics, Ohio State University College of Medicine Columbus, OH

Director for education and research for the Division of Rheumatology. He became a Clinical Professor of Medicine on the voluntary faculty in 1997. Dr. Borenstein has been active in a number of medical professional organizations. He is a member of the 250-physician International Society for the Study of the Lumbar Spine where he was chairman of the membership committee in 2003. He has also participated with activities of the American College of Physicians. He was chairman of the Credentials Committee for the District of Columbia Chapter in 2001 through 2004. He was designated a Laureate of the ACP Chapter in 2005. He was President of the Rheumatism Society of the District of Columbia in 1993. Dr. Borenstein was the Vice President of the Metropolitan Washington Chapter of the Arthritis Foundation from 2006-2007. He received the Henry Taylor Award in 2005 and The President’s Award for Lifetime Service in 2008. In 2011, he was awarded the Marriott Lifetime Achievement Award. Dr. Borenstein has been actively involved with activities of the American College of Rheumatology and the Rheumatology Research Foundation including the Government Affairs Committee and the Board of Directors from 2005 to 2011. Dr. Borenstein is an author of Low Back and Neck Pain: Comprehensive Diagnosis and Management, 3rd Edition, a textbook on spinal disorders for physicians. He is also author of Heal Your Back: Your Complete Prescription for Preventing, Treating, and Eliminating Back Pain, a book written for the lay population. He is the host of Speaking of Health with Dr. B, an internet radio program. Dr. Borenstein has earned the recognition and praise of the medical community by being named an outstanding specialist in rheumatology in Washingtonian magazine, Washington Consumer’s Checkbook, Best Doctors in America, Who’s Who in Medicine and Health, Who’s Who in America, and Who’s Who in the World.

Dr. Jason Busse is an Assistant Professor in the Department of Anesthesia and Department of Clinical Epidemiology & Biostatistics at McMaster University. He has been active clinically in the management of disability secondary to chronic pain and other medically unexplained syndromes since 1999.

Dr. Busse has authored over 100 peer-reviewed publications with a focus on medically unexplained syndromes, disability management, predictors of recovery, and methodological research. His academic efforts are supported by a New Investigator Award from the Canadian Institutes of Health Research.

Dr. Mary Crow is Physician-in-Chief and Chair of the Department of Medicine at Hospital for Special Surgery, Professor of Medicine and Chief of the Rheumatology Division at Weill Cornell Medical College, and Professor of Immunology in its Graduate School of Medical Sciences. She holds the Joseph P. Routh Endowed Chair in Medicine and is Senior Scientist, Co-Director of the Mary Kirkland Center for Lupus Research, and Director of the Autoimmunity and Inflammation Program in the Research Division of the Hospital for Special Surgery. Dr. Crow received her MD at Cornell, Internal Medicine and Rheumatology subspecialty training at New York Hospital, and post-doctoral research training at Rockefeller University in the laboratory of Dr. Henry Kunkel. Dr. Crow’s research has focused on the induction and regulation of human autoimmune diseases. She was among the first to characterize the functional

Mary K. Crow, MD Physician-in-Chief Chair, Rheumatology Hospital for Special Surgery New York, NY

Jason Busse, BSc, MSc, DC, PhD Assistant Professor Department of Clinical Epidemiology & Biostatistics McMaster University Hamilton, ON

properties of human dendritic cells and has studied self-reactive T cells in the prototype systemic autoimmune diseases, systemic lupus erythematosus and rheumatoid arthritis. She continues to investigate the underlying triggers of autoimmune disease and the cellular and cytokine mediators of immune system activation and inflammation in those disorders. She has been a leader in the identification of the central role of type I interferon in the pathogenesis of systemic autoimmune diseases. Dr. Crow has served on the Medical and Scientific Committee of the Arthritis Foundation, on the S.L.E. Foundation’s Medical Advisory Committee, and is currently Chair of the Scientific Advisory Board of the Alliance for Lupus Research. She is a past president of the American College of Rheumatology and the Henry Kunkel Society and was named an “Arthritis Hero” by the Arthritis Foundation in 2001.

Dr. Eric D. Green is the Director of the National Human Genome Research Institute (NHGRI) at the National Institutes of Health (NIH), a position he has held since late 2009. NHGRI is the largest organization in the world dedicated solely to genomics research, and aims to advance human health through genomics research. Previously, he served as the NHGRI Scientific Director (2002-2009), Chief of the NHGRI Genome Technology Branch (1996-2009), and Director of the NIH Intramural Sequencing Center (1997-2009).

While directing an independent research program for almost two decades, Dr. Green was at the forefront of efforts to map, sequence, and understand eukaryotic genomes, including significant, start-to-finish involvement in the Human Genome Project.

Now, as Director of NHGRI, Dr. Green is responsible for providing overall leadership of the Institute’s research portfolio and other initiatives; this requires

significant coordination with other NIH components, funding agencies, and research organizations. In 2011, Dr. Green led NHGRI to the completion of a strategic planning process that yielded a new vision for the future of genomics research, entitled Charting a course for genomic medicine from base pairs to bedside (Nature 470:204-213, 2011).

Dr. Kurt Hoppe is a consultant at the Mayo Clinic, Rochester, MN, Assistant Professor in the Department of Physical Medicine & Rehabilitation, Mayo Clinic College of Medicine, Vice Chair for Inpatient Clinical Practice, and Medical Director of the Rehabilitation Unit. He is also Associate Medical Director for Mayo Clinic Health Solutions, Mayo’s health insurance and health benefits administration company.

Dr. Hoppe is the current President of the American Academy of Physical Medicine & Rehabilitation. He has served as Chair of the American Hospital Association Governing Council for Long-Term Care and Rehabilitation, and as Chair of the Minnesota Medical Association Quality Committee. He has been involved with health care policy issues, both nationally and regionally, for over two decades, and has served most recently on numerous committees and workgroups advising on health care quality, performance measurement, public reporting, and for the last two years on the workgroup that assisted in the development of the consumer website for MNsure, Minnesota’s insurance exchange.

Eric D. Green, MD, PhD Director, National Human Genome Research Institute National Institutes of Health Bethesda, MD

Kurt Hoppe, MD Assistant Professor Department of Physical Medicine and Rehabilitation College of Medicine Mayo Clinic Rochester, MN

Maura Daly Iversen, PT, DPT, SD, MPH, BSc Professor and Chair Department of Physical Therapy School of Health Professions Bouve College of Health Sciences Northeastern University Boston, MA

Beverley H. Johnson President/CEO Institute for Patient- and Family-Centered Care Bethesda, MD

Dr. Maura Daly Iversen is a Professor and Chair of the Department of Physical Therapy at Northeastern University. She also holds a faculty appointments as a Senior Lecturer, Department of Medicine, Harvard Medical School, Foreign Adjunct Professor In Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden, Honorary Professor of Health Sciences, University of Southern Denmark, Odense, Denmark and an Adjunct faculty in the HERACLEIA Human Centered Laboratory, University of Texas, Arlington. She holds a clinical research appointment in the Section of Clinical Sciences, Division of Rheumatology, Immunology & Allergy, Brigham & Women’s Hospital, Boston, Massachusetts. Dr. Iversen received a BSc degree and a Certificate in Physical Therapy from Simmons College, a Master of Public Health from Boston University, a Doctor of Physical Therapy from MGH Institute of Health Professions and a Doctor of Science degree in Behavioral Science and Clinical Epidemiology from Harvard University. She completed her postdoctoral training in clinical epidemiology in the Department of Medicine, Harvard Medical School. During her doctoral and postdoctoral training, she conducted clinical trials of exercise in patients with rheumatic conditions, specifically lumbar spinal stenosis, rheumatoid arthritis and systemic lupus erythematosus. Her doctoral dissertation focused on rheumatologist-patient communication about exercise as an intervention to manage arthritis symptoms. Prior to her arrival at Northeastern University in the fall of 2009, Dr. Iversen served as an Assistant Professor of Medicine, Harvard Medical School. Her recent research focuses on behaviors interventions to improve adherence to pharmacologic and non-pharmacologic therapies in rheumatic conditions. She is also interested in technologies to promote physical activity and independence in persons with arthritis.

Dr. Iversen is currently funded by NIAMS and NCAM. Her projects include: Physical activity in Rheumatoid Arthritis: Towards Personalized Counseling; a Randomized Controlled Trial of Tai Chi versus Physical Therapy for Knee Osteoarthritis, Motivational Interviewing to Improve Adherence to Osteoporosis Medications in Older Adults, and primary care physician’s attitudes toward prescription of disease modifying agents in rheumatoid arthritis. She has also received funding from the National Arthritis Foundation, the Foundation for Physical Therapy, the Research and Education Foundation, and the Farnsworth Foundation. She serves as collaborator on a number of National Science Foundation grants together with colleagues in computer science and engineering to facilitate transfer of technology into health care. Additionally she has received certification in medical simulation from the Center for Medical Simulation, a Harvard Medical School/MIT collaborative. Dr. Iversen has mentored over 30 master level and doctoral students in the U.S. and abroad. She is the recipient of the 2011 Distinguished Scholar Award and is the 2013 Distinguished Lecturer, Association of Rheumatology Health Professionals/American College of Rheumatology. She has also received awards for advocacy, research and/or professional service from the Arthritis Foundation and the American Physical Therapy Association.

Beverley H. Johnson is the President/CEO of the Institute for Patient- and Family-Centered Care in Bethesda, Maryland. She has provided technical assistance to over 250 hospitals, health systems, primary care practices, and federal, state, and provincial agencies. Bev has authored and co-authored many publications on patient- and family-centered practice. She recently served as Project Director for a multi-year initiative to develop resource materials for senior leaders in hospital, ambulatory, and long-term care settings on

Salahuddin Kazi, MD Vice Chair of Education & Director of Residency Training Department of Internal Medicine Associate Professor of Medicine Division of Rheumatic Diseases UT Southwestern Medical Center Dallas, TX

how to partner with patients, residents, and families to enhance the quality, safety, and the experience of care. Bev serves on the Selection Committee for the American Hospital Association-McKesson Quest for Quality Prize and is a member of the Board of Directors for the Patient-Centered Primary Care Collaborative (PCPCC). She is also a member of Premier’s QUEST/PACT Advisory Panel, the American College of Physicians’ Advisory Board for Patient Partnership in Healthcare, and the Advisory Group for the World Innovation Summit for Health. Bev was presented with the Humanitarian Award by Pediatric Nursing in 1990, and the Lloyd Bentsen Award in 1992. In 2007, she was honored with The Changemaker Award by the Board for the Center for Health Care Design and The Gravens Award for leadership in promoting optimal environments and developmental care for high-risk infants and their families. Most recently, she was a recipient of a Dorland Health 2011 People Award.

Dr. Salahuddin Kazi received his training in Internal Medicine and Rheumatology at UT Medical School at Houston. He is the Vice Chair of Education & Director of Residency Training in the Department of Internal Medicine. He is an Associate Professor of Medicine in the Division of Rheumatic Diseases. Additionally, Dr. Kazi works with patient registries and clinical information systems, such as the electronic health record, to improve clinical decision making, promote efficiency and support patient safety and quality of care. He also serves on the American College of Rheumatology Registries and Health Information Technology Committee.

Dr. Baron Lonner is the Chief of the Division of Spine Surgery and Professor of Orthopedic Surgery at Beth Israel Mount Sinai Medical Center in New York City. He has over 70 publications in the orthopedic literature. His research interests include outcomes in spinal deformity surgery and non-operative care. He and his team have developed two new outcomes instruments for adolescent idiopathic scoliosis. Dr. Lonner has a keen interest in the interplay of cost and quality and the value equation in spine care. He is a reviewer for four spine journals. He is also an associate editor on the editorial board for the Journal of Spinal Deformity. Dr. Lonner is a member of the Scoliosis Research Society and is Chair Elect of the Advocacy Committee.

Dr. Kenneth G. Saag is Jane Knight Lowe Professor of Medicine, Division of Clinical Immunology/Rheumatology at the University of Alabama at Birmingham (UAB), and Professor of Epidemiology, at UAB School of Public Health. He is the founding Director of the Deep South Musculoskeletal (DSM) Center for Education and Research on Therapeutics (CERTs) and Director of the AHRQ-supported UAB T32 in Health Services Research. Dr. Saag is also Director of the UAB Center for Outcomes and Effectiveness Research (COERE), Director of the UAB Center of Research Translation (NIAMS P50) in Gout and Hyperuricemia, and Associate Director of the Multidisciplinary Clinical Research Center (NIAMS P60).

Baron Lonner, MD Clinical Professor of Orthopaedic Surgery NYU Hospital for Joint Diseases New York, NY

Kenneth D. Saag, MD, MSc Jane Knight Lowe Professor of Medicine Director, Center for Outcomes Effectiveness Research and Education (COERE) and Center for Education and Research on Therapeutics (CERTs) of Musculoskeletal Disorders University of Alabama at Birmingham Birmingham, AL

Dr. Saag’s current research focuses on epidemiology and outcomes of osteoporosis and gout. He studies methods to translate evidence into practice and to design large practical trials for both arthritis and osteoporosis. Dr. Saag currently serves on the Board of Trustees of the National Osteoporosis Foundation, on the Board of Directors of the American Gout Society, and on the Board of Directors of the American College of Rheumatology (ACR) and is also a member of the Advocacy Task Committee of the American Society of Bone and Mineral Research (ASBMR). Dr. Saag is the recipient of the 2013 Rheumatology Research Foundation Excellence in Investigative Mentoring Award.

Dr. James O. Sanders is Professor of Orthopaedics and Rehabilitation and Professor of Pediatrics at the University of Rochester and Golisano Children’s Hospital where he is Chief of the Division of Pediatric Orthopaedics and Associate Director of Pediatric Surgical Services. He served as Chief of Staff of Shriners Hospitals for Children in Erie, Pennsylvania from 1997-2007, and in private practice with Pediatric Orthopedic Associates of San Antonio from 1992 –1997. He graduated from Southern Methodist University in 1982 with degrees in Civil Engineering and Chemistry, from Johns Hopkins School of Medicine in 1986, completed his residency in Orthopaedic Surgery at the University of Texas Health Science Center at San Antonio in 1991 and his Fellowship at Texas Scottish Rite Hospital for Children in pediatric orthopaedics and scoliosis in 1992. In his current role, besides having an active clinical and surgical practice, Dr. Sanders is involved in program development and quality improvement for the pediatric surgical programs at the University of Rochester. He is particularly involved with the hospital’s analysis and improvement of pediatric

surgery care using information sources such as NSQIP-Peds. He maintains an active research program and has received several awards including the Huene Memorial Award for Excellence and Promise in Pediatric Orthopaedics from the Pediatric Orthopaedic Society of North American in 2009, the Outstanding Clinical Scientific Paper from POSNA in 2008, and the Hibbs Award for Best Clinical Paper from the Scoliosis Research Society in 1996. His particular research interests include spinal deformity in young children, skeletal maturation and how it relates to orthopedic disorders, and systems improvement in pediatric surgical care. Dr. Sanders serves on several local and national committees. He is Section Leader for Appropriate Use Criteria for the AAOS, and a member of the AAOS Evidence Based Quality and Value Committee and previously the Associate Chair of the Guidelines Oversight Committee. He is Program Chair for the SRS and a member of the SRS Evidence Based Medicine and Surgical Safety Committees and also serves on the POSNA Evidence Based Medicine and Quality Safety Value Initiative Committees. Locally, he serves on the University of Rochester Medical Faculty Group (URMFG) Executive Committee, the Medical School Advisory Council Steering Committee, the Golisano Children’s Hospital Quality & Patient Safety Council, the Golisano Children’s Hospital Executive Committee and the U of R Dept. of Orthopaedics Research Committee. Outside of work, his interests are in developing quality pediatric care in developing countries. He enjoys spending time with his wife Tricia, seeing their four grown sons, fly fishing, hiking, and bike riding and is always open to fly fishing invitations.

James O. Sanders, MD Member, AAOS Evidence Based Quality and Value Committee University of Rochester Medical Center School of Medicine and Dentistry University of Rochester Rochester, NY

Dr. Debra Sietsema is the Clinical Research Director at Orthopaedic Associates of Michigan where she specializes in evidence-based research regarding bone health and other orthopaedic issues. She established a Bone Health / Fracture Liaison Service Program at her place of employment. Dr. Sietsema is an Associate Professor at Michigan State University. She serves in various organizations including the American Orthopaedic Association’s Own the Bone program, NAON, NOF’s Nursing Advisory Council, and the Orthopaedic Trauma Association. Dr. Sietsema has presented osteoporosis and orthopaedic trauma research topics at AOA, AAOS, and NAON conferences. She has published numerous articles about fractures and other orthopaedic subjects and has developed a fragility fracture nursing continuing education course for NAON.

Dr. Vibeke Strand, MD, is an adjunct clinical professor in the Division of Immunology and Rheumatology at Stanford University School of Medicine. She has been a clinical rheumatologist for 32 years, previously in subspecialty practice in San Francisco and as a clinical research investigator, and senior director of clinical research at three pharmaceutical and biotech companies. Since 1991, Dr. Strand has led a consulting practice offering clinical research and regulatory strategy expertise to pharmaceutical and biotech companies focusing to translate basic research into rational design of randomized controlled trials, evaluate

their results, and defend approval of novel products to the FDA and EMA for autoimmune diseases, including rheumatoid arthritis [RA], osteoarthritis [OA], systemic lupus erythematosus [SLE], gout and fibromyalgia [FMS]. Over the past 20 years she has participated in the development of all the approved biologic agents and synthetic DMARDs in RA and SLE.

Dr. Strand’s commitment to promoting forums for the discussion of rational product development among industry, FDA, and academia led to her establishing and co-chairing the biyearly “Innovative Therapies in Autoimmune Disease” meetings [1988 – 2007]. She has been an invited speaker at FDA Arthritis Advisory Committee meetings discussing Guidance Documents for RA, OA, SLE, FMS, and pain.

Since 1992, she has served as a member of the Executive Organizing Committee of the international Outcomes in Rheumatology Clinical Trials [OMERACT] consensus conferences [1992 – 2014]; co-chairing OMERACT 7 (2004) and 11 (2012); with a strong interest in patient-reported outcomes. She helped found and co-chaired the Clinical Immunology Society Spring Fellows School. She is on the Board of the Northern California chapter of the Arthritis Foundation and their Medical and Scientific Committee, and the Scientific Advisory Board of CORRONA.

She has authored over 265 original publications, is a Fellow of the American College of Physicians (1982), the American College of Rheumatology (1986) and is a member of the Cosmos Club (1994) and Substitute Board of Managers (2013 –). She graduated from Swarthmore College with honors in a double major: Zoology and Sociology/Anthropology and from the University of California San Francisco School of Medicine.

Debra Sietsema, PhD, RN Michigan State University Grand Rapids, MI

Vibeke Strand, MD, FACP, FACR Biopharmaceutical Consultant And Clinical Professor Adjunct Division of Rheumatology/Immunology Stanford University Portola Valley, CA

Nora Strick, MD Internal Medicine Physician Co-Lead Healthy Bones Program, Southern California Kaiser Permanente Assistant Clinical Professor, UCLA School of Medicine Los Angeles, CA

Ronald Swinfard, MD President & CEO Lehigh Valley Health Network Allentown, PA

Dr. Nora Strick is a board certified General Internist at Kaiser Permanente in Los Angeles. She is an assistant clinical professor at UCLA School of Medicine and has been the physician co-lead for the internationally recognized Southern California Kaiser Permanente Healthy Bones program since its inception in 2004. Dr. Strick is a Los Angeles native, who did her undergraduate training at the University of California Santa Barbara with a degree in Psychology. She received her Doctorate of Medicine degree from the Medical College of Wisconsin in Milwaukee and completed her residency training in Internal Medicine at Cedars-Sinai Medical Center in Los Angeles. Since finishing residency, she has been working as a Primary care physician at Kaiser Permanente. She was the President of the Medical Staff in 2011, and is a member of the Kaiser Permanente National and Southern California Osteoporosis guideline committee. Dr. Strick has always had a special interest in Women’s Health. She has been a member of the Southern California Kaiser Permanente Women’s Health Leadership Committee for 13 years. She is the director and creator of a Women’s Health rotation for Internal Medicine Residents, which partners with the Hollywood Sunset Free Clinic. She is also a member of a new and innovative multi-disciplinary high risk breast care clinic that serves BRCA positive patients.

Dr. Ronald Swinfard was named President and Chief Executive Officer of Lehigh Valley Health Network (LVHN) in November 2010. LVHN is a comprehensive integrated health network that includes three hospitals, an over 600-member employed physician group and ten community health centers. The network is the region’s largest employer with more than 12,000 employees. LVHN is recognized for numerous national honors, including Magnet status for nursing. In October 2013, the American Nurses Credentialing Center awarded the Magnet Prize®, one of its highest honors, to LVHN for its role in “Transforming Patient Care Through Telehealth.” It has been ranked as one of “America’s Best Hospitals” by U.S. News & World Report for 18 consecutive years, most recently in 2013 in seven care areas, and ranked as “high performing” in five care areas. In 2012, LVHN received accreditation from The Joint Commission as the first hospital in the state of Pennsylvania and one of the first three in the U.S. to be officially certified as a Comprehensive Stroke Center. The network also ranks as one of the nation’s top hospitals for quality and patient safety (The Leapfrog Group), and one of the 100 Most Wired health networks (Hospitals & Health Networks) for embracing health care technology. Most recently, LVHN entered into an alliance with six other comparably sized health systems to form AllSpire Health Partners. The new consortium will carry out joint activities in the areas of patient care services, research and education to enhance the value of health care that communities receive. Previous to this, Dr. Swinfard had been the Chief Medical Officer of LVHN since October 2003. As CMO, Dr. Swinfard oversaw education and research, and in this role was the interface for LVHN’s academic affiliation with the University of South Florida. Dr. Swinfard came to LVHN from the

University of Missouri - Columbia where he was Chair of the Department of Dermatology as well as Section Chief, Dermatology for the Harry S. Truman VA Medical Center. Prior to assuming these roles, Dr. Swinfard also held the positions of Chair of the Department of Internal Medicine, Chief Medical Director, Ambulatory Services, University of Missouri Health System, Medical Director, Missouri Telemedicine Network and Medical Director, Network Development at the University of Missouri. Prior to these positions, Dr. Swinfard was in private practice for 4 ½ years. He served as an officer in the U.S. Army in Vietnam and taught high school prior to entering medical school. Dr. Swinfard holds a Doctor of Medicine degree from the University of Missouri-Columbia and is board-certified in dermatology. He trained in internal medicine at the University of Virginia and subsequently completed a dermatology residency at the University of Missouri-Columbia. Dr. Swinfard received his undergraduate degree in zoology from the University of Missouri-Columbia. Dr. Swinfard is a Fellow in the American College of Physicians and the American Academy of Dermatology, and a member of the American College of Physician Executives, and Clinical Professor of Dermatology at University of South Florida, Tampa, Florida. He serves on United Healthcare Consortium’s Performance Improvement and Comparative Data Committee, and is a member of the Health Management Academy CEO Forum. In March of 2013, Dr. Swinfard was named by NJBiz as one of the “Power 50 Healthcare,” an award recognizing the top players in hospitals, insurance, regulatory affairs and more.

John R. Tongue, MD, is the Immediate Past-President of the American Academy of Orthopaedic Surgeons. Dr. Tongue is in private practice in Tualatin, Oregon. He is also an Adjunct Associate Professor at Oregon Health Sciences University in Portland. Dr. Tongue is the recipient of numerous awards and honors, including the AAOS Humanitarian Award, the National Highway Traffic Safety Association Public Service Award for his work in passing the Oregon Safety Belt Law, and the Oregon Medical Association’s Doctor-Citizen of the Year Award.

Dr. Laura L. Tosi is the Director of the Bone Health Program at Children’s National Medical Center (CNMC) and Associate Professor of Orthopaedics and Pediatrics at George Washington University in Washington, DC. Her clinical practice focuses on the orthopedic care of children and young adults with physical disabilities and/or issues related to bone health. Dr. Tosi is a graduate of Harvard Medical School and she received her orthopaedic training at the Columbia Presbyterian Hospital in New York and the Hospital for Sick Children in Toronto. Dr. Tosi has previously served on the Board of Directors of the American Academy of Orthopaedic Surgeons, the Pediatric Orthopaedic Society of North America, the Orthopaedic Research and Education Foundation, and the Academic Orthopaedic Society. She currently serves on

John R. Tongue, MD Immediate Past President American Academy of Orthopaedic Surgeons

Laura L. Tosi, MD Director, Bone Health Program Division of Orthopaedics & Sports Medicine Children’s National Medical Center Washington, DC Member, Own the Bone Program

the Board of the Society for Women’s Health Research and the United States Bone and Joint Initiative. She was the founding chair of the AAOS Women’s Health Issues Committee and was Co-chair of the AAOS-NIH Workshop “Influence of Sex and Gender on Musculoskeletal Health.” She currently chairs the Scientific Committee of the Society for Women’s Health Research and serves on the Interspecialty Medical Council of the National Osteoporosis Foundation, the “Own the Bone” Steering Committee of the American Orthopaedic Association, and the Medical Advisory Committee of the Osteogenesis Imperfecta Foundation. Dr Tosi was Co-Chair of the meeting “Adults with Cerebral Palsy: A workshop to define the challenges of treating and preventing the secondary musculoskeletal and neuromuscular complications in this rapidly growing population” in 2008 and chaired the 10th Scientific Meeting of the Osteogenesis Imperfecta Foundation, “Improving Musculoskeletal Outcomes for Individuals with OI” in 2010, as well as their 12th Scientific Meeting “Assessing the Impact of Osteogenesis Imperfecta on Nonskeletal Systems.” Dr. Tosi is a past President of the Ruth Jackson Orthopaedic Society, the professional association for women in orthopaedics. She received their Presidential Special Merit Award in Year 2000 for her outreach on topics on women’s health. Other awards include the AAOS Diversity Award in 2005, National Human Genome Research Institute “Great Award” (Genome Recognition Of Employee Accomplishments and Talents) awarded as part of the team that discovered the gene defect in Proteus syndrome in 2012, and the American Medical Student Association, Women Leaders in Medicine Award in 2013.

In July 2005, Dr. Steven Wartman became the 3rd President of the Association of Academic Health Centers (AAHC), a non-profit association based in Washington, DC that seeks to advance health and well-being through the vigorous leadership of the multifaceted institutions that educate the next generation of health professionals, conduct cutting edge biomedical and clinical research, and offer comprehensive patient care from the basic to the most advanced levels. Prior to assuming this position, he was Executive Vice President for Academic and Health Affairs and Dean of the School of Medicine at the University of Texas Health Science Center in San Antonio. Dr. Wartman’s more than 25 year career in academic medicine includes chairing a department of medicine at two institutions and being the founding director of a division of general internal medicine. Dr. Wartman is a board certified internist, sociologist and Master of the American College of Physicians. He received his AB from Cornell University and his MD and PhD degrees from Johns Hopkins University. He was also a Robert Wood Johnson Clinical Scholar at Johns Hopkins and a Henry Luce Scholar in Indonesia. Dr. Wartman is currently recognized internationally for his work in the organization and management of academic health centers, where he has taken the lead on critical issues such as the need for alignment among an institution’s clinical, research, and education programs. In 2008, he founded AAHC International™ (AAHCI), a global organization dedicated to improving health and well-being worldwide. In 2012, he edited a new book, Confluence of Policy and Leadership in Academic Health Science Centers, published by Racliffe Press, New York and London, that for the first time provides a comprehensive overview of the academic health center enterprise.

Steven Wartman, MD, PhD President, Association of Academic Health Centers Washington, DC

He has received numerous awards and honorary degrees, and is currently a Distinguished Professor in the Department of Medicine at Georgetown University and an Adjunct Professor of Medicine at George Washington and Johns Hopkins Universities.

Dr. William Watters is a graduate of Harvard Medical School in Boston and has done residencies in both Internal Medicine and Orthopedic Surgery as well as advanced training in spinal surgery at the University of Pennsylvania in Philadelphia.

On coming to Houston, Texas, from Philadelphia, he served for 5 years as Chairman of the Department of Orthopedic Surgery at a large multispecialty clinic. Since that time he has practiced Orthopedic Spinal Surgery at the Bone and Joint Clinic of Houston. Dr. Watters has authored numerous articles and book chapters on diseases of the spine and spoken frequently, both nationally and internationally, on spinal disease. He is an expert on Evidence-based Medicine and has served in this capacity as the chair of major committees at the American Academy of Orthopedic Surgery (AAOS) and The North American Spine Society (NASS). In addition Dr. Watters is the past Research Council Chair of NASS, serves on the Board of Directors of NASS and the American Board of Spine Surgery. He is the current President of NASS and is a past-president of The Texas Spine Society. He sits on the Board of Advisers for World Spine Care and for Palladian Health Care. Dr. Watters sits on the Editorial Advisory Board for The

Spine Journal and reviews for Spine and the Journal of the Spinal Arthroplasty Society. Dr. Watters has represented the AAOS at the NQF, the NCQA (The Back Pain Recognition Program and Physician Recognition Programs) and Co-chaired the AMA/Rand project on Gaps in Orthopedic Care as well as served as Co-Chairman of the AMA PCPI Low Back Pain Measure Development work group. Dr. Watters has represented NASS on the Robert Wood Johnson/ABIM Episodes of Care for Low Back Pain project, sits on BC/BS expert panel on Blue Distinction Centers for Spine Surgery, the MEDCAC Advisory Board for CMS and was the Co-Chair for the AMA Consortium Work Group to develop Performance Measures for Degenerative Spinal Stenosis.

William Charles Watters, III, MD Houston, TX

Speaker Abstracts

Kelli D. Allen, PhD

The impact of diversity: How do patient demographics influence the delivery of best practices and determine care outcome? Many studies have identified disparities in health care for musculoskeletal (MSK) conditions, including low back pain, osteoporosis, osteoarthritis, and rheumatoid arthritis. These disparities occur across multiple demographic characteristics, such as gender, race / ethnicity, education, income, and insurance status. Some examples include the following:

• African American and Hispanic women are less likely than non-Hispanic White women to receive bone mineral density testing, and fewer minority women receive medications after a diagnosis of osteoporosis.

• African Americans and women with osteoarthritis are less likely to undergo total joint replacement surgery, or they delay surgery until later disease states.

• In emergency departments, non-white patients with back pain (and other pain conditions) are less likely to receive analgesia than non-white patients.

• Among patients with rheumatoid arthritis, males, non-Whites, and those with low socioeconomic status zip codes are less likely to receive disease-modifying antirheumatic drugs.

These data represent a rapidly growing body of “first generation” health care disparities studies (e.g. studies that document the existence of disparities) addressing MSK conditions. There are far fewer “second generation” studies (explaining the reasons for disparities) and a dearth of “third generation” studies (providing solutions for eliminating disparities). Overall, second generation studies have identified both patient factors (e.g.

beliefs about risk for disease and efficacy of treatment, preference for aggressive vs. non-aggressive treatment) and provider factors (e.g. variability in treatment recommendations according to patient demographic characteristics) that contribute to various disparities in MSK care. One recent example of a third generation study showed that an educational intervention significantly increased the willingness of African American patients with osteoarthritis to consider joint replacement surgery (Ibrahim et al, 2013). More work is needed to develop and test implementable interventions that address the many disparities in MSK care.

There are several general principles and strategies that hold promise for reducing healthcare disparities, including MSK care. First, consistent practice of evidence-based medicine, supported by system design tools, not only improves overall quality indicators but can lead to greater healthcare equity (e.g. Navarro et, al, 2011). A second important approach is fostering shared decision making regarding treatment choices. This is a key element of patient-centered care that can be supported by decision aid tools, which solicit patient preferences and encourage productive patient-provider communication. A third important area involves recognizing and addressing areas where implicit/unconscious biases (racial and other) may be contributing to disparate treatment. Greater application of these approaches in health systems can lead to more equitable care for vulnerable patient groups with MSK conditions.

David Borenstein, MD

How do rheumatologists and spine surgeons collaborate to determine and implement best practices for back pain?

Back pain accounts for 30% to 50% of rheumatic complaints in a general medical practice. Although relatively few patients with back pain require surgical intervention, these individuals are usually evaluated and treated by orthopedic and neurosurgeons. Internists and rheumatologists are capable to diagnose local and systemic musculoskeletal disorders. They are familiar with the cornerstones of conservative management for low back and neck pain including patient education, physical modalities, and drug therapy.

The systematic approach to low back pain is based upon the epidemiological data that most individuals (90%) have back pain on the basis of a mechanical disorder and over 50% will be improved at 2 weeks and 90% at 2 months. Most patients improve without diagnostic laboratory and radiographic tests. These diagnostic tests and invasive surgical procedures should be limited to the patients with specific historical and physical findings suggesting a more serious cause for the symptom of back pain.

The American College of Physicians and the American Pain Society have published diagnostic and therapeutic guidelines for low back pain based upon systematic reviews of clinical trials in the medical literature. Applying these recommendations to clinical patients must be made with care since many of the more complicated patients were excluded from the clinical trials used for the review. The guidelines have the greatest applicability to those individuals with mechanical sources of low back pain. These guidelines can be used as a model for best practices in the diagnosis and care of low back pain patients.

One medical model that may conform to the general principles listed in the ACP guidelines is The Spine Center. The Spine Center at the George Washington University Medical Center was conceived as an entity that would bring together the expertise of a variety of specialties to evaluate and treat individuals with chronic low back pain who had not improved. The staff of the center included rheumatologists, neurosurgeons, orthopedic surgeons, neurologists, neuroradiologists, anesthesiologists, psychiatrists, physical therapists, and work hardening experts. Patients were referred to the center and would be evaluated by those individuals who had expertise to evaluate and treat their condition. This organization of care was cost-effective in that individuals who required surgical care were identified early in the process while the majority of individuals benefited from multidisciplinary therapy.

This multidisciplinary model can be organized either in a medical center or in a community network of physicians with interest in the care of spinal patients. These centers promote best practices thereby setting the medical community standards of back care.

Jason Busse, BSc, MSc, DC, PhD

The challenge of identifying best practices

Clinicians are often faced with the task of reviewing the published literature to help inform best practices for managing patient's complaints. Randomized controlled trials (RCTs) are generally considered the gold-standard for evaluating therapeutic approaches. The quality of evidence provided by an RCT is affected by the strength of methodological safeguards implemented to reduce risk of bias and the validity of reported outcome measures.

This talk will review recent strategies for assessing the risk of bias introduced by loss to follow-up, as well as current standards for evaluating the validity of composite endpoints and subgroup analyses. Attendees are advised to consider how they currently evaluate these issues when reviewing the literature to identify best practices.

Eric D. Green, MD, PhD

Human Genomics a decade after the Human Genome Project: Opportunities and Challenges

The Human Genome Project’s generation of a reference human genome sequence was a landmark scientific achievement of historic significance. It also signified a critical transition for the field of genomics, as the new foundation of genomic knowledge started to be used in powerful ways by researchers and clinicians to tackle increasingly complex problems in biomedicine. To exploit the opportunities provided by the human genome sequence and to ensure the productive growth of genomics as one of the most vital biomedical disciplines of the 21st century, the National Human Genome Research Institute (NHGRI) is pursuing a broad vision for genomics research beyond the Human Genome Project. This vision includes using genomic data, technologies, and insights to acquire

a deeper understanding of genome function and biology as well as to uncover the genetic basis of human disease. Some of the most profound advances are being catalyzed by revolutionary new DNA sequencing technologies; these methods are producing prodigious amounts of DNA sequence data as part of studies aiming to elucidate the complexities of genome function and to unravel the genetic basis of rare and complex diseases. Together, these developments are ushering in the era of genomic medicine.

Kurt Hoppe, MD

The role of the payer: How do payers promote best practices?

The pace of medical discovery, and the capabilities of medicine to provide care for patients, is truly stunning. However, as recent national debates about increasing healthcare expenditures have demonstrated, attempts at slowing the rate of healthcare inflation have proved to be both contentious and elusive.

It is in this context that government and businesses, and by proxy commercial payers, have sought to use instruments and methods to better understand the price, quality, and value of healthcare interventions. Many have been at least partially successful, though not all and likely not long-term. One of the most popular focuses of discussion, though, has been the rapid adoption of best practices and measurement of adherence to their recommendations for care.

Today’s presentation will explore a range of options available to payers to ensure appropriate utilization of services and optimal outcomes by promoting best practices in musculoskeletal care.

Beverley H. Johnson

The patient perspective: How does the patient view illness and goals and outcomes of treatment?

What is Patient- and Family-Centered Care? The core concepts were developed with patients and families defining what was important to them. These concepts provide a framework for enhancing quality, safety, and the experience of care.

Managing a chronic condition in social isolation is a risk factor and often does not result in the best outcomes for the patient. Professional organizations should provide leadership in developing approaches that foster authentic partnerships with the patient and family in direct clinical encounters, as well as in quality improvement and health care redesign. It is imperative to design high quality, safe, cost efficient systems of care and we cannot do that without patient and family advisors selected and prepared to be improvement partners with clinicians, staff, administrative leaders, educators, and researchers.

What can USBJI, other muscular skeletal organizations, and individual health care professionals do to ensure that patients living with musculoskeletal disorders and their families are full partners in their care and in building patient- and family-centered systems of care? With this commitment to partnerships, there is hope for achieving the Triple Aim—improving the experience of care, the health of populations, and reducing costs.

Baron Lonner, MD

What are best practices for fusions for scoliosis?

Value-based care for scoliosis is a multi-faceted discussion that includes considerations of pathology, age of disease onset, natural history, outcomes, cost, and cost/outcome unit (QALY), and incremental cost effectiveness of operative versus non-operative interventions, as well as the dimension of time.

A growing body of evidence and ongoing research points to the benefit of spinal arthrodesis (fusion) in appropriately-indicated patients. The intersection of outcomes, complications, cost, cost effectiveness, and timing of intervention as well as gaps in evidence will be explored in this presentation.

James O. Sanders, MD

Decision-making in best practices

The biggest decision in best practices is to actually get started.

The problems in starting are inertia, lack of leadership, and our own internal biases against failure.

The physician’s thought process is along the lines of:

“I provide best practice and I know it because …”

1. I am well trained 2. I read and keep up with the literature 3. My patients love me 4. I do complex procedures with skill 5. I am a great diagnostician 6. My patients get better because of what I do

Unfortunately, we seek confirmation that what we do is best and that we are good. But, the reality is:

a. Patients and their disorders are complex b. Systems are complex c. Regression to the mean clouds our perception d. Failures happen

The next decision is what to tackle

1. The obvious choices are high cost, high impact 2. But, sometimes developing the team with a few smaller projects can develop and provide credibility to

the process 3. Small wins to start

Once you decide to provide best practice, you have to figure out what it is, through one of several methods:

1. Keep your head down and move ahead – our usual default a. We are already great b. Just work harder and keep up with the latest procedures and literature c. Unfortunately, no one can keep up with the literature d. The pressures of hospitals, payers, and government are all toward higher and higher goals e. By running fast, you will only get further behind

2. EBM Approach – What does the best literature say?

a. Bias and confounding effect our decisions i. The Charlie Turkelson cycle of regression to the mean

ii. Selection bias of observational studies iii. Publication bias

b. A good source of published evidence based is EBM syntheses i. Pubmed Clinical Queries

ii. Systematic reviews iii. Clinical practice guidelines iv. Appropriate Use Criteria

What about when there isn’t good evidence but you need to do something?

1. The PSDA Approach a. The PSDA approach is a powerful method of improving care but is very labor intensive b. The Deming Cycle

i. Plan ii. Do

iii. Study iv. Act

c. The PDSA method requires planned collection of reasonably quality data: i. Timely

ii. Risk stratified iii. Objective

d. This approach requires teams with differing expertise: i. Physician/surgeon

ii. Statistical help iii. Nurses and others who understand the systems

e. PSDA Quality teams need a commitment from leadership f. They also require credible medical personnel to champion the efforts g. Eliminate unnecessary process variation

i. You cannot improve the processes that are different every time ii. There are many tools available

1. Lean process 2. 6-Sigma

h. Goals of PDSA can be anything from: i. Achieving an EBM best practice

ii. Improving patient satisfaction iii. Decreasing medication errors iv. Lowering surgical site infections

2. Consensus Approach

a. To move work ahead in the absence of evidence, consensus can be a great starting place. b. On a small scale, it can be done with informal methods among a few practitioners to standardize

their practices and then institute the PSDA cycle. c. On larger scales, it can use formal methods such as the Delphi or nominal group technique. d. Consensus will not provide evidence, but it can provide the consistency and ability to institute

an effect PSDA cycle

3. Both a Borrower and Lender Be: a. Particularly for areas where you are resource poor, copy what others have done successfully. b. Don’t feel guilty if you borrow c. Don't’ be proprietary in sharing d. Both borrowing and lending improve patient care

Do I have the energy to do this?

1. These projects can become big 2. You need to be committed because resistance is very common 3. The more you can create an environment where this is desired and rewarded, the easier it becomes. 4. Engagement and support of leadership is essential

So, what do you need for best practices?

1. Availability of EBM resources to identify the best published evidence a. CPG b. Systematic Reviews c. Cochran d. AUC

2. Gathering and analyzing important data with continued surveillance 3. Expertise in healthcare PDSA 4. Physician and administrative leadership support 5. Respected cheerleaders who can convince leaders and staff of the importance of QI and can move the

initiative ahead

I provide Best Practice >> We create the environment and develop and empower good teams to identify, promote and create systems for best practices.

Debra L. Sietsema, PhD, RN

What are best practices for managing osteoporosis?

Osteoporosis is a devastating disease that leads to significant morbidity and mortality as a result of fragility fractures. Fragility fractures predispose to subsequent fractures. Yet, most people with a fragility fracture are not screened, treated, or managed for osteoporosis to reduce their risk of subsequent fractures.

Different models of care are described in the literature. The effective “best practice” model for managing osteoporosis following a fragility fracture is a coordinated fracture liaison service managed by a nurse practitioner (NP). Following a fragility fracture, patients are identified, assessed, counseled, treated, and evaluated for osteoporosis as part of a comprehensive service. Electronic lists and electronic health records are essential to identify early, for billing, to integrate PQRS, and to track quality measures. Assessment includes history and physical exam, risk factor analysis, DXA scan, and laboratory tests. This assessment is followed by an individualized plan of care with teaching, counseling regarding behavioral lifestyle modifications, supplements, and pharmacologic interventions as appropriate. Evaluation occurs with each visit regarding persistence of the treatment, presence of subsequent fracture, and integration of data for quality improvement reports. The NP coordinated model of care is more intense and can be executed from inpatient to the outpatient clinic. The NP has increased assessment skill, the authority to prescribe, and can bill for services. This allows the NP to serve as a liaison among the multidisciplinary team and manage the care in an effective manner.

This presentation will present the steps to success in the development and maintenance of a NP coordinated fracture liaison service. Potential issues and solutions will be discussed. A case study will be of an effective program will be applied.

Vibeke Strand MD, FACP FACR

PATIENT REPORTED OUTCOMES [PROs]: How can PROs improve clinical trials as well as practice?

We have long known in rheumatic diseases that discrepancies exist between patient reported and physician assessments of global disease activity. These discrepancies are particularly evident in conditions such as systemic lupus erythematosus and vasculitis, where treatments may also adversely impact general well-being and health related quality of life [HRQOL]. Perhaps one of the best examples of the value of PROs in randomized clinical trials

[RCTs] is exemplified by the American College of Rheumatology Response criteria in rheumatoid arthritis [RA], where 3 of the 7 components are patient reported: pain, physical function [Health Assessment Questionnaire – HAQ] and global disease activity. These outcomes have now been incorporated into the RAPID 3 as a simple sum of their scores as an outcome for use in daily practice. It has been repeatedly shown that serial assessments over time well illustrate patients’ responses to initiation of or addition of new therapies, as well as identifying when responses wane over time. Having patients track their progress over time contributes to better clinical management and improved compliance.

Investigators complain that patients develop questionnaire fatigue in RCTs, but typically the time required to complete them is reduced with repetition, and use of personal digital assistants [PDAs] to track PROs has also eased this perceived burden. Tracking PROs in daily practice doesn’t have to be a burden to the practitioner or staff, as websites are now available where patients can score the forms and download or email copies for incorporation in their office records or electronic medical record [EMR].

Several challenges remain, including assessing outcomes in young healthy individuals and/or weekend warriors after orthopedic procedures,

when no impairment in physical function existed pre injury and none or little will be expected post operatively. How then to ascertain improvement in function: range of motion? muscle strength? and/or level of activity? Another is to understand how treatment may further improve a patient who is now high functioning thanks to our new therapies despite a significant burden of pain and/or fatigue from arthritis or an autoimmune disease. One readily trackable solution may be incorporation of pedometers with mobile phone apps such as Jawbone and Fitbit, wireless trackers of physical activity as well as sleep. These could be used as a means to measure responses in RCTs where the impact of treatment may significantly improve pain and function [and fatigue], thereby regular physical activity and sleep. We now have an opportunity to more creatively include patient centric outcomes in our RCTs and daily practice.

Nora Strick, MD

Southern California Kaiser Permanente Healthy Bones Program

The Healthy Bones program is an integrated care delivery system at 14 medical centers throughout Southern California. This program has decreased the hip fracture rate 48% lower than expected, saved Kaiser Permanente $52 million in hip fracture costs and generated $10 million per year with osteoporosis coding. In addition SCPMG is 1st in the United States in osteoporosis management in women (with a HEDIS measure of 88%).

This program was created in 2004, with the mission statement: “Kaiser Permanente Southern California promotes good bone health for members of all ages through osteoporosis prevention strategies and treatment to lower the risk of osteoporotic fractures.” The original goals were to reduce the hip fracture rate by 25%-50%, increase the number of DXA scans in patient at risk for fragility fractures,

increase the number of patients on treatment who are at risk for fractures, standardize treatment of osteoporosis, improve cost effectiveness and reduce mortality and morbidity associated with fractures.

The Healthy Bones Model of Care was built on the following guiding principles: Using current successful best practices, taking into account current and new HEDIS measures, minimizing handoffs, minimizing patient return visits, maximizing use of non-MD providers, limiting impact on Primary Care Providers (but keep them “in the loop”), and ensuring appropriate diagnosis capture and reporting.

The key components of the Healthy Bones program are: Passionate Champions with clear Mission and Goals, strong regional/local infrastructure, centralized workflow with dedicated Healthy Bones Care Managers and support staff, regional “at risk” database, “just in time” member education and treatment, robust performance reporting, in-reach/outreach supported by electronic health record and provider education/job aids/member education.

In summary, there are several key components to a successful Healthy Bones program, and they all work together. There needs to be consistent and reliable in-reach and outreach programs for post fracture DXAs and screening DXAs. There needs to be timely treatment and education, and monitoring of medication adherence. Some “game changers” for a successful program include: Clear vision and scope, measurable goals, leaders with a passion, local ownership and accountability, minimal patient handoffs, and targeted investments.

Ronald Swinfard, MD

The role of the health care system: How to organize care to deliver best practices

With the rapidly changing paradigm of health care delivery in the United States, all service lines of care in health systems will be challenged to re-engineer care delivery. With the addition of nearly 10,000 Medicare beneficiaries per day and the increased activity and mobility of the Medicare population, no service line will be more challenged than musculoskeletal care. The management of arthritis and demand for joint replacement will make this a potentially profitable but challenging service line to coordinate.

Setting aside ones individual philosophical perspective and political views, reform of healthcare is best encapsulated in the Institute for Healthcare Improvement’s triple aim. The engineering and redesign of all service lines must follow these three aspects of cost control, enhanced quality of care, and education and management of the individual’s health, or population health.

Controlling costs will require greater efficiencies in the delivery of care which will challenge health systems to “make or buy” the competencies necessary to manage musculoskeletal conditions across the continuum. This is most evident in addressing “bundled payments” which will necessitate new forms of partnerships, collaborations, and potentially acquisitions/mergers. Tighter “connections” (hand overs/hand offs) will be necessary to control costs, insure quality outcomes, and give patients confidence that there is true coordination of care from beginning to end of a care episode. The demonstration of quality outcomes (not just processes) should be required by payors for full reimbursement.

In this session, “The role of the healthcare system: How to organize care to deliver best practices?” there will be a discussion of how one health care system (Lehigh Valley Health Network, Allentown PA) is addressing these challenges in the delivery of musculoskeletal care for the future.

Laura L. Tosi, MD

Establishment of a Fracture Liaison Service: Challenges of the Open vs. Closed System

It has long been established that the occurrence of a fragility fracture signals the potential for subsequent fracture, and often represents the first opportunity for care of underlying osteoporosis. It is also well accepted that a fracture liaison service can improve the probability that a fracture patient receives appropriate care. While several well-known closed U.S. health systems have established robust fracture liaison services, the majority of at-risk patients receive care outside their reach.

This presentation will explore the known barriers to providing optimal post-fracture evaluation and treatment and then review evidence-based strategies for designing a successful post fracture care program in an open system. In addition, recent lessons from the Own the Bone Program, a post fracture care program specifically designed for use in the open system environment, will be reviewed.

Steven A. Wartman, MD, PhD, MACP

The new physics of patient care

The term “disruptive innovation” is increasingly being used with regard to projected changes in the delivery of patient care. These changes, fostered by science, technology, and economics are poised to profoundly impact care from both the patient's and clinician's points of view.

Examples include: care increasingly moving from fixed settings to wherever the patient happens to be; the challenge of choosing diagnostic and therapeutic options in very large data sets; increasingly personalized entrepreneurial technologies; growing patient empowerment; and evolving payment mechanisms.

These challenges call for, in my view, a "new physics of patient care" that is based on the principles of care anywhere, care in teams, and care by large data sets. Successfully adapting to the new environment requires an integrative, interprofessional vision, assumption of financial risk for patient and population health, and the development of new expertise.

William C. Watters, III, MD, MMS, MS

What are best practices for spinal stenosis?

While certain skeletal dysplasias such as achondroplasia and pseudoachondroplasia can result in spinal stenosis at a young age, most spinal stenosis patients are in an older age category and have acquired the condition as a result of degenerative changes in the aging spine. Cervical spinal stenosis is a significant condition which can have serious sequelae but has not been studied nearly as extensively as lumbar spinal stenosis which will be the focus of this presentation. The North American Spine Society published an extensive systematic review and Clinical Practice Guideline on the diagnosis and treatment of lumbar spinal stenosis in 2008 (Watters WC, et al. The Spine Journal, 8, 305-310, 2008). This review and guideline were updated and published in 2013 (Kreiner, DS, et al. The Spine Journal, 13, 734-743, 2013) and will be the focus of this discussion on best practices for lumbar spinal stenosis.

List of Delegates

Julie Agel, MA, ATC Harborview Medical Center Vandana Ahluwalia, MD, FRCPC Ontario Rheumatology Association Kelli D. Allen, PhD Duke University Medical Center Musculoskeletal Summit Speaker Linda L. Altizer, RN, MSN, ONC Western Maryland Health System Barbara Anderson, RN, MS, COHN-S American Association of Occupational Health Nurses Kim Apollony, PharmD, MS, CGP Amgen Kathleen Arntsen Lupus Foundation of Mid & Northern New York Musculoskeletal Summit Breakout Session Leader Nancy A. Baker, ScD, MPH, OTR/L University of Pittsburgh Sunitha Baskaran, PhD Gary & Mary West Health Institute Musculoskeletal Summit Breakout Session Leader Marla Beatty, MBA, FACHE Southern Illinois School of Medicine Anita Bemis-Dougherty, PT, DPT, MAS American Physical Therapy Association United States Bone and Joint Initiative – Board Member Thomas Best, MD, PhD, FACSM Ohio State University College of Medicine United States Bone and Joint Initiative – Board Member Musculoskeletal Summit Speaker David Borenstein, MD George Washington University Medical Center Musculoskeletal Summit Speaker Jennifer Boyer, RN, MBA Springfield Clinic

Verona Brewton Zimmer, Inc.

Mari T. Brick, MA National Association of Chronic Disease Directors Sean T. Bryan, MD American Medical Society for Sports Medicine Judi Buckalew American Academy of Orthopaedic Surgeons Lenore M. Buckley, MD, MPH Yale School of Medicine Hulya Bukulmez,MD MetroHealth Medical Center, Case Western Reserve University Jason Busse, BSc, MSc, DC, PhD McMaster University Musculoskeletal Summit Speaker Scott Cassidy, MBA West Health Institute David Chapman-Smith, LLB (Hons), FICC World Federation of Chiropractic Sonia Chaudhry, MD Connecticut Children’s Medical Center Mary K. (Peggy) Crow, MD Hospital for Special Surgery Musculoskeletal Summit Speaker Paul Dougherty, DC American Chiropractic Association Lisa DuShane United States Bone and Joint Initiative

Beatrice J. Edwards, MD, MPH American Society for Bone and Mineral Research United States Bone and Joint Initiative – Board Member

Paul W. Esposito, MD, FAAOS, FAAP Children’s Hospital and Medical Center United States Bone and Joint Initiative – Board Member

James Eubanks, Jr., DC, MS West Hartford Group, Inc. Corey Fidler, DPM Children’s National Medical Center Sandra M. Frear Lupus Foundation of Mid and Northern New York Julie Fritz, PT, PhD University of Utah Brian J. Galinat, MD Christiana Care Kristy Glass American Academy of Orthopaedic Surgeons Steve M. Gnatz, MD, MHA American Academy of Physical Medicine and Rehabilitation United States Bone and Joint Initiative – President Marc Goldstein, EdD American Physical Therapy Association Eric D. Green, MD, PhD National Institutes of Health Musculoskeletal Summit Speaker Suzanne Groah, MD, MSPH American Spinal Injury Association Karen L. Hackett, FACHE, CAE American Academy of Orthopaedic Surgeons Ann M. Hayes, PT, DPT, MHS, OCS Saint Louis University Allen W. Heinemann, PhD, ABPP (RP), FACRM Northwestern University Musculoskeletal Summit Speaker Haniel Hernandez, MD Washington, DC, VA Medical Center Kurt Hoppe, MD Mayo Clinic Musculoskeletal Summit Speaker

Marybeth Horodyski, EdD, ATC, LAT, FNATA National Athletic Trainers’ Association Chinghui (Jean) Hsieh, PhD MedStar National Rehabilitation Network Laura Hughes, MD, MSPH University of Alabama at Birmingham Catherine Irwin, PT, MHS, OCS Illinois Bone & Joint Institute Maura Daly Iversen, PT, DPT, SD, MPH, BSc Northeastern University Musculoskeletal Summit Breakout Session Leader Joshua J. Jacobs, MD American Academy of Orthopaedic Surgeons Beverley H. Johnson Institute for Patient- and Family-Centered Care Musculoskeletal Summit Speaker Brian Johnstone, PhD Orthopaedic Research Society United States Bone and Joint Initiative– Board Member Joanne M. Jordan, MD, MPH Osteoarthritis Research Society International Petra Kaufman, MD, MSc National Institute of Neurological Disorders and Stroke Salahuddin Kazi, MD UT Southwestern Medical Center Musculoskeletal Summit Breakout Session Leader Randy Kilburn DePuy Synthes Joint Reconstruction Grayce Kim, PharmD Amgen Carmen S. Kirkness, PhD University of Illinois College of Medicine at Peoria Jeffrey P. Knezovich, CAE American Joint Replacement Registry

Jeffrey A. Kramer, FACHE, CAE United States Bone and Joint Initiative Marjorie Kulesa, RN, BS, ONC, CNOR National Association of Orthopaedic Nurses United States Bone and Joint Initiative– Board Member

Michael LeCroy, MD Orthopaedic Trauma Association

Amye L. Leong, MBA Bone and Joint Decade, the Global Alliance for Musculoskeletal Health Nicole Lezin Cole Communications Barron Lonner, MD NYU Hospital for Joint Diseases Musculoskeletal Summit Speaker Peter J. Mandell, MD American Academy of Orthopaedic Surgeons Joan A. McGowan, PhD National Institute of Arthritis and Musculoskeletal and Skin Disease Rich D. McQuarrie, PT McQuarrie’s Physical Therapy Melinda S. Mock, RN, ONC, CLCP Healthcare Cost Consultants Justin Moore, PT, DPT American Physical Therapy Association Jennifer Morse, RN, BSN Southern Illinois University School of Medicine Sarah Murphy American Orthopaedic Association/Own the Bone Joseph P. O’Brien, MBA National Scoliosis Foundation Amy Phelan, MD UT Southwestern Medical Centers and Hospitals

S. Pisetsky, MD, PhD Duke University Medical Center Musculoskeletal Summit Co-Chair Peter Polverini, DDS, DMSc American Association for Dental Research Jeremy Raimo, MBA, PT West Health Institute Ellen M. Raney, MD Pediatric Orthopaedic Society of North America United States Bone and Joint Initiative– Board Member E. Anthony Rankin, MD Orthopaedic Research & Education Foundation Tonya Reddy, BS, NP Springfield Clinic Elizabeth A. Regan, MD, PhD National Jewish Health Kenneth Rogers, PhD, ATC Nemours/Alfred I. DuPont Hospital for Children Kenneth D. Saag, MD, MSc University of Alabama at Birmingham Musculoskeletal Summit Speaker Barbara Sack, MHSA, CMPE American Association of Orthopaedic Executives United States Bone and Joint Initiative– Board Member James O. Sanders, MD University of Rochester Musculoskeletal Summit Speaker Robert Schaal, PT Missouri Orthopaedic Institute John T. Schousboe, MD, PhD International Society for Clinical Densitometry Debra Sietsema, PhD, RN Michigan State University Musculoskeletal Summit Speaker

Heather Smith, PT, MPH American Physical Therapy Association Louis Sportelli, DC American Chiropractic Association Courtney Sprouse, BS Children’s National Medical Center Robert A. Stanton, MD American Orthopaedic Society for Sports Medicine Thomas E. Stautzenbach, CAE American Academy of Physical Medicine and Rehabilitation Jerome Stewart, MSA, MBA West Health Institute Vibeke Strand, MD, FACP, FACR Stanford University Musculoskeletal Summit Speaker Nora L. Strick, MD Kaiser Permanente Musculoskeletal Summit Speaker Ronald Swinfard, MD Lehigh Valley Health Network Musculoskeletal Summit Speaker Kimberly Templeton, MD University of Kansas Medical Center United States Bone and Joint Initiative– Board Member and Past President David Teuscher, MD American Academy of Orthopaedic Surgeons Cate Thorin, JD Zimmer, Inc. John R. Tongue, MD American Academy of Orthopaedic Surgeons Musculoskeletal Summit Speaker Laura L. Tosi, MD Children’s National Medical Center United States Bone and Joint Initiative– Board Member Musculoskeletal Summit Speaker

Gale Tucker, PharmD Amgen Lee VanderLugt, DO American Osteopathic Academy of Orthopaedics John M. Ventura, DC American Chiropractic Association United States Bone and Joint Initiative– Board Member Steven Wartman, MD, PhD Association of Academic Health Centers Musculoskeletal Summit Speaker William Charles Watters, III, MD, MMS, MS Musculoskeletal Summit Speaker John Wood, PhD West Health Institute Gregory M. Worsowicz, MD, MBA University of Missouri Musculoskeletal Summit Co-Chair Janet S. Wyatt, PhD, RN, FAANP Arthritis Foundation United States Bone and Joint Initiative– Board Member Scott Zellner DePuy Synthes

Supporters We gratefully acknowledge the following for making

this conference possible with their support.

Major

American Academy of Orthopaedic Surgeons

Supporter

Amgen

DePuy Synthes

Zimmer

Contributor

American Academy of Physical Medicine & Rehabilitation

American Board of Orthopaedic Surgery

American College of Sports Medicine

American Physical Therapy Association

American Society for Bone and Mineral Research

Biomet

National Athletic Trainers' Association

Pediatric Orthopaedic Society of North America

Appendices

Overview of Programs

The United States Bone and Joint Initiative (USBJI) is a unique organization of organizations that brings together the broad musculoskeletal community of healthcare professional and patient organizations, to address issues of common concern, including increasing advancing research and innovation, advocating for access to care, and educating the public and policymakers.

• Advocates for the importance of musculoskeletal care, innovation, new treatments, research, and raising awareness

• Advocates for improved technology for diagnosis and treatment • Advocates for access to specialist care, as well as for system-wide models of care that cover the lifespan • Provides prevalence, economic and societal cost data on major musculoskeletal conditions for use by

members in their advocacy efforts, and by researchers • Provides public education programs on prevention and treatment options offered nationwide to thousands

annually • Is developing a pipeline of successfully funded clinician-scientists • Organizes symposiums that assemble musculoskeletal healthcare professionals, patient advocates, and

governmental leaders

Many of the programs aim to establish a solid foundation for long term growth of the musculoskeletal field, including professional education, and increasing the pipeline of successfully funded musculoskeletal researchers. Others address more immediate needs such as healthcare reform, and raising the profile of bone and joint disorders. The USBJI also reaches out to primary care providers, and specialists concerned with co-morbidities, as well as to organizations representing diverse ethnic populations. The USBJI is the National Action Network of the worldwide Bone and Joint Decade in the United States.

The Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal and Economic Cost (BMUS) This publication includes credible and independently-produced data to support raising the profile of musculoskeletal health, and to make the case for the value of scientific research, innovation and access to specialist care. This publication is used by decision-makers, legislators and other policy-makers, granting organizations, Federal and State agencies, provider/payer formularies, employers (wellness in the workplace), the press, researchers, educators, healthcare professionals, patients and industry/suppliers. It covers all major musculoskeletal conditions and is available online (www.boneandjointburden.org).

Musculoskeletal Summits The cost of musculoskeletal disease in the United States is approaching $1 trillion each year and is likely to increase as the population ages and life styles become more active. These increases have led to unprecedented debate on health care and possible redirection of major programs. Current models for care delivery are unsustainable and new strategies to optimize health and improve quality of life are demanded. To proactively meet the challenges of a changing world and establish priorities for resource allocation in the future, the musculoskeletal health care community must define and measure the value of the care it provides, and consider ways to provide care more efficiently as well as with improved outcomes. The USBJI views this issue as critical and convened a first summit to address The Value of Musculoskeletal Care from the perspective of patients, providers, industry and payers among others. The Summit provided a framework for healthcare professional societies, and resulted in twelve Recommendations. The USBJI is now working on the next Summit to be held November 18-19, 2013, in Washington, DC, on Best Practices in Patient-Centered Musculoskeletal Care.

Chronic Osteoarthritis Management Initiative (COAMI) This inter-disciplinary initiative aims to address change in the management of osteoarthritis on the basis of scientific advances that have been made in recent years, like other chronic diseases. The COAMI Work Group, including representatives from more than 20 leading professional societies, including specialties, primary care, ethnic populations and those treating co-morbidities, met May 2012 and issued a Call to Action which is being published and disseminated widely among professional societies. The Call to Action is geared to health professionals, policy makers and the public and emphasizes the variety of providers that have a role to play. The Call includes convening a conference (in 2013) to lead to further recommendations to build agreement across professional groups for developing models of care; reaching out to other partners; developing standardized screening tools and indicators of OA; developing tools that promote patient engagement; supporting existing advocacy and awareness efforts; and supporting an OA specific research agenda.

Young Investigators Initiative A grant mentoring and career development program that aims to increase musculoskeletal research by increasing the pipeline of clinician and basic scientists, has to date engaged more than 275 participants of which 132 participants have obtained musculoskeletal research funding for more than 471 grants totaling over $117 million;

Clinical research in the musculoskeletal diseases performed by young investigators is not keeping pace with the increasing burden of these diseases in the U.S. The USBJI offers this program consisting of workshops and mentoring to provide early-career clinical investigators an opportunity to work with experienced researchers to assist them in securing funding. This program of workshops and mentoring is open to promising junior faculty or senior fellows or post-doctoral researchers that have been nominated by their department or division chairs. It is open to senior fellows or residents that are doing research and have a faculty appointment in place or confirmed. Workshops take place in the Spring and in the Fall. The unique aspect of this program is the opportunity for attendees to maintain a relationship with a mentor until their application is funded.

Project 100 Too many graduating medical students do not have the knowledge and skills required to properly diagnose and treat patients with musculoskeletal diseases. In collaboration with the Association of American Medical Colleges and the National Board of Medical Examiners, among other organizations, Project 100 works to increase formalized instruction in musculoskeletal medicine in medical schools. In 2002, less than 50% of medical schools offered this formalized instruction; by the end of 2009, the instruction was offered in 80% of medical schools. This likely will result also in greater interest in a career in the musculoskeletal specialties.

Public Education Programs USBJI Public Education programs focus on prevention, treatment and rehabilitation of musculoskeletal conditions, in partnership with national and local healthcare professional, patient and public organizations committed to improving musculoskeletal health. As of Oct. 2013, more than 100 sessions of Fit to a T (bone health & osteoporosis), Experts in Arthritis, and PB&J (for adolescents) have been held this year, including the 500th session of Fit to a T, for a total of 700 sessions nationwide, reaching an audience of more than 24,000 people.

National Awareness Week Bone and Joint Health Awareness Week is celebrated worldwide every year October 12-20 with condition-specific themes and activities. During the week, days are dedicated to specific musculoskeletal conditions: World Arthritis Day (Oct. 12), World Spine Day (Oct. 16), World Trauma Day (Oct. 17), World Pediatric Bone and Joint Day (Oct. 19), World Osteoporosis Day (Oct. 20). The USBJI and its committees collaborate with member organizations to develop and promote activities.

Pediatric Specialty Group Obesity is the primary focus of this grouping of pediatric specialty organizations that form part of the USBJI. The group has developed a case statement which is to be published in Arthritis and Rheumatism on the effects of obesity on musculoskeletal health and a Symposium on this topic will be published in Clinical Orthopaedics and Related Research in late 2013 or early 2014 with electronic publication earlier. The group develops stories for Awareness Week and World PB&J Day (Kids and Vitamin D Deficiency in 2012), as well as participating in the development of the Pediatric Chapter of BMUS, and the Summit programs.

Spine Specialty Group The group, as well as participating in BMUS and the Summit programs, is working on Critical Outcome Tools for Multi-Disciplinary Spine Care, and a patient education program. (10/2013)

Founding Members American Academy of Orthopaedic Surgeons American Academy of Pediatrics American Academy of Physical Medicine & Rehabilitation American Chiropractic Association American College of Rheumatology American Physical Therapy Association American Society for Bone and Mineral Research Arthritis Foundation National Athletic Trainers’ Association National Osteoporosis Foundation Orthopaedic Research & Education Foundation Orthopaedic Research Society Pediatric Orthopaedic Society of North America Rheumatology Research Foundation Shriners Hospitals for Children Participating Members American Association of Hip & Knee Surgeons American Association of Occupational Health Nurses American Association of Orthopaedic Executives American Board of Orthopaedic Surgery American College of Foot & Ankle Surgeons American College of Sports Medicine American College of Surgeons American Medical Society for Sports Medicine American Orthopaedic Association American Orthopaedic Foot & Ankle Society American Orthopaedic Society for Sports Medicine American Osteopathic Academy of Orthopedics American Shoulder & Elbow Surgeons American Society for Surgery of the Hand American Society of Orthopaedic Physician’s Assistants American Spinal Injury Association Arthroscopy Association of North America Hip Society International Society for Clinical Densitometry Knee Society Limb Lengthening & Reconstruction Society Mid-America Orthopaedic Association Musculoskeletal Transplant Foundation National Association of Orthopaedic Nurses National University of Health Sciences New York State Chiropractic Association Orthopaedic Trauma Association Osteogenesis Imperfecta Foundation Paget Fdn. for Paget’s Disease of Bone & Related Disorders Palmer College of Chiropractic Ruth Jackson Orthopaedic Society Scoliosis Research Society TMJ Association University of Connecticut School of Medicine Univ. of Iowa Roy J. & Lucille A. Carver Coll. Of Med. - Ortho. University of Kansas School of Medicine - Orthopaedics University of Rochester Sch. of Med. & Dentistry - Orthopaedics

Associate Members Biomet Ruby DePuy, Inc. Ruby Eli Lilly Diamond Sanofi Biosurgery Diamond Medtronic, Inc. Sapphire Pfizer, Inc. Emerald Zimmer Emerald Legend: Diamond, Emerald, Ruby, Sapphire, Topaz

U.S. BONE AND JOINT INITIATIVE NETWORK PARTICIPATING GROUPS

Participating Organizations Advocates for the American Osteopathic Association Advocates for the Texas Osteopathic Medical Association American Academy for Cerebral Palsy & Developmental Med. American Academy of Osteopathy American Association for Dental Research American Association for Hand Surgery American Association of Anatomists American Association of Colleges of Osteopathic Medicine American Association of Neurological Surgeons American Automobile Association American Board of Physical Medicine & Rehabilitation American Congress of Rehabilitation Medicine American Juvenile Arthritis Organization American Occupational Therapy Association American Osteopathic Association American Osteopathic College of Radiology American Society for Reconstructive Microsurgery American Society for Testing & Materials–Med. & Surgical Cte. Association of Academic Physiatrists Association of Bone and Joint Surgeons Association of Children’s Prosthetic-Orthotic Clinics Association of Rheumatology Health Professionals Board of Specialty Societies Business and Professional Women/USA Cervical Spine Research Society Children’s Hospital of Philadelphia – Orthopaedic Surgery Clinical Orthopaedic Society Congress of Chiropractic State Associations Connecticut Orthopedic Society Crippled Children’s Rehabilitation Effort Department of Veterans Affairs Fibrous Dysplasia Foundation, Inc. Foundation for Chiropractic Education & Research Foundation for Osteoporosis Research and Education Foundation for Sarcoidosis Research Health Volunteers Overseas – Orthopaedics Overseas Indiana Hand Center International F.O.P. Association, Inc. International Osteopetrosis Association Intl. Soc. of Arthroscopy, Knee Surgery, & Ortho. Sports Med. J. Robert Gladden Society LGD Alliance (Lymphangiomatosis & Gorham’s Disease) Melorheostosis Association MHE Research Foundation Michigan Osteopathic Association Musculoskeletal Tumor Society National Association of Chain Drug Stores Foundation National Association of Commissions for Women National Association of Orthopaedic Technologists North American Spine Society Orthopaedic Rehabilitation Association Osteoarthritis Research Society International Ponseti International Association for Clubfoot Treatment SICOT (US Section) Society for Biomaterials Society of Military Orthopaedic Surgeons Southern Orthopaedic Association Spina Bifida Association of America and Foundation The Spine Health Foundation, Inc. Spondylitis Association of America Cerebral Palsy International Research Foundation Western Orthopaedic Association XLH Network, Inc.

Medical Schools Albany Medical College Albert Einstein College of Medicine of Yeshiva University Baylor College of Medicine Boston University School of Medicine The Brody School of Medicine at East Carolina University Case Western Reserve University School of Medicine Chicago Med. School at Rosalind Franklin Univ. of Med. & Sci. Columbia University College of Physicians & Surgeons Creighton University School of Medicine Dartmouth Medical School University of California, Los Angeles David Geffen School of Medicine Drexel University College of Medicine Duke University School of Medicine East Tennessee State University James H. Quillen Coll. of Medicine Eastern Virginia Medical School Emory University School of Medicine Florida State University College of Medicine Georgia Health Sciences University George Washington Univ. School of Med. & Health Sciences Georgetown University School of Medicine Harvard Medical School Howard University College of Medicine Indiana University School of Medicine Jefferson Medical College of Thomas Jefferson University Johns Hopkins University School of Medicine Keck School of Medicine of the University of Southern California Loma Linda University School of Medicine Louisiana State University School of Medicine in Shreveport Louisiana State University School of Medicine in New Orleans Loyola University Chicago Stritch School of Medicine Marshall University Joan C. Edwards School of Medicine Mayo Medical School Medical College of Wisconsin The University of Toledo College of Medicine Medical University of South Carolina College of Medicine Meharry Medical College Mercer University School of Medicine Michigan State University College of Human Medicine Morehouse School of Medicine Mount Sinai School of Medicine New York Medical College New York University School of Medicine Northeastern Ohio Universities College of Medicine and Pharmacy Northwestern University, The Feinberg School of Medicine Ohio State University College of Medicine Oregon Health & Science University School of Medicine Pennsylvania State University College of Medicine Ponce School of Medicine Rush Medical College of Rush University Medical Center Saint Louis University School of Medicine Sanford School of Medicine The University of South Dakota Southern Illinois University School of Medicine Stanford University School of Medicine State University of NY Downstate Medical Ctr. Coll. Of Medicine State University of New York Upstate Medical University The School of Medicine at Stony Brook University Med. Center Temple University School of Medicine Texas A & M Health Science Center College of Medicine Texas Tech Univ. Health Sciences Ctr. Paul L. Foster Sch. of Med. Tufts University School of Medicine Tulane University School of Medicine UMDNJ – New Jersey Medical School UMDNJ – Robert Wood Johnson Medical School Uniformed Srvcs Univ. of the Health Sciences-F. Edward Hebert Universidad Central del Caribe School of Medicine Univ. at Buffalo St. Univ. of NY Sch. of Med & Biomed. Sci. University of Alabama School of Medicine University of Arizona College of Medicine University of Arkansas for Medical Sciences College of Medicine University of California, Davis, School of Medicine University of California, Irvine School of Medicine University of California, LA, David Geffen School of Medicine

University of California, San Diego, School of Medicine University of California, San Francisco, School of Medicine Univ. of Chgo. Div. of the Biological Sci. The Pritzker Sch of Med. University of Cincinnati College of Medicine University of Colorado School of Medicine University of Florida College of Medicine University of Hawaii John A. Burns School of Medicine University of Illinois College of Medicine University of Iowa Roy J. & Lucille A. Carver Coll. Of Medicine University of Kansas School of Medicine University of Kentucky College of Medicine University of Louisville School of Medicine University of Maryland School of Medicine University of Massachusetts Medical School University of Miami, Leonard M. Miller School of Medicine University of Michigan Medical School University of Minnesota Medical School University of Mississippi School of Medicine University of Missouri-Columbia School of Medicine University of Missouri-Kansas City School of Medicine University of Missouri School of Medicine University of Nebraska College of Medicine University of Nevada School of Medicine University of North Carolina at Chapel Hill School of Medicine University of North Dakota School of Med. and Health Sciences University of Oklahoma College of Medicine University of Pennsylvania School of Medicine University of Pittsburgh School of Medicine University of Puerto Rico School of Medicine University of Rochester School of Medicine & Dentistry University of South Alabama College of Medicine University of South Carolina School of Medicine University of South Florida College of Medicine University of Tennessee Health Sc. Center College of Medicine University of Texas School of Medicine at San Antonio University of Texas Medical Branch School of Medicine University of Texas Medical School at Houston University of Texas SW Med. Ctr. At Dallas SW Medical School University of Utah School of Medicine University of Vermont College of Medicine University of Virginia School of Medicine University of Washington School of Medicine University of Wisconsin School of Medicine & Public Health Vanderbilt University School of Medicine Virginia Commonwealth University School of Medicine Wake Forest University School of Medicine The Warren Alpert Medical School of Brown University Washington University in St. Louis School of Medicine Wayne State University School of Medicine Weill Cornell Medical College West Virginia University School of Medicine Wright State University Boonshoft School of Medicine Yale University School of Medicine Colleges of Osteopathic Medicine Chicago College of Osteopathic Med. at Midwestern Univ. Des Moines University Kirksville College of Osteopathic Medicine of A.T. Still Univ. Lake Erie College of Osteopathic Medicine Michigan State University Coll. of Osteopathic Medicine Midwestern University Glendale Campus New York College of Osteopathic Medicine Nova Southeastern University- College of Osteopathic Ohio University College of Osteopathic Medicine Oklahoma State Univ. Center for Health Sciences Philadelphia College of Osteopathic Medicine Pikeville College School of Osteopathic Medicine The University of Health Sciences Touro University College of Osteopathic Medicine University of Medicine and Dentistry of New Jersey University of New England College of Osteopathic Medicine West Virginia School of Osteopathic Medicine

Notes _________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Notes

_________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Notes

_________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Notes

_________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Notes

_________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Notes

_________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Notes

_________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Notes

_________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Notes

_________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Notes

_________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Notes

_________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

Notes

_________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________