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Official Publication of the Pima County Medical Society

Vol. 48

No. 1


Pima County Medical Society Officers

PCMS Board of Directors

Snehal Patel, DO (Alt. Resident) Joanna Holstein, DO (Alt. Resident) Jeffrey Brown (Student) Juhyung Sun (Alt. Student)

Members at Large

Arizona Medical

Association Officers

President Melissa Levine, MD President-Elect Steve Cohen, MD Vice-President Guruprasad Raju, MD Secretary-Treasurer Michael Dean, MD Past-President Timothy Marshall, MD

Eric Barrett, MD David Burgess, MD Michael Connolly, DO Michael Dean, MD Howard Eisenberg, MD Afshin Emami, MD Randall Fehr, MD G. Mason Garcia, MD Jerry Hutchinson, DO Kevin Moynahan, MD Wayne Peate, MD Sarah Sullivan, DO Salvatore Tirrito, MD Scott Weiss, MD Leslie Willingham, MD Gustavo Ortega, MD (Resident)

Thomas Rothe, MD immediate past-president Michael F. Hamant, MD secretary

Richard Dale, MD Charles Krone, MD Jane Orient, MD

At Large ArMA Board

R. Screven Farmer, MD

Pima Directors to ArMA

Board of Mediation

Timothy C. Fagan, MD Timothy Marshall, MD

Delegates to AMA

Timothy Fagan, MD Thomas Griffin, MD Evan Kligman, MD George Makol, MD Mark Mecikalski, MD


William J. Mangold, MD Thomas H. Hicks, MD Gary Figge, MD (alternate)

Executive Director


Bill Fearneyhough













Editor Stuart Faxon Phone: 883-0408 E-mail: Please do not submit PDFs as editorial copy.

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Publisher Pima County Medical Society 5199 E. Farness Dr., Tucson, AZ 85712 Phone: (520) 795-7985 Fax: (520) 323-9559 Website:

SOMBRERO (ISSN 0279-909X) is published monthly except bimonthly June/July and August/September by the Pima County Medical Society, 5199 E. Farness, Tucson, Ariz. 85712. Annual subscription price is $30. Periodicals paid at Tucson, AZ. POSTMASTER: Send address changes to Pima County Medical Society, 5199 E. Farness Drive, Tucson, Arizona 85712-2134. Opinions expressed are those of the individuals and do not necessarily repre- sent the opinions or policies of the publisher or the PCMS Board of Directors, Executive Officers or the members at large, nor does any product or service advertised carry the endorsement of the society unless expressly stated. Paid advertisements are accepted subject to the approval of the Board of Directors, which retains the right to reject any advertising submitted. Copyright © 2015, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

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Dr. Melissa Levine: Our 2015 president introduces herself.


Milestones: What’s up with doctors Beiter, Marks, Katzenberg, and Moreno.


PCMS News: UofA researches cytomegalovirus.


Behind the Lens: Some Southern Arizonans, or maybe most, can’t get enough of those colorful winter sunsets–and sunrises.


PCMS Alliance News: The annual Alliance fund- raiser for Mobile Meals of Tucson had a full turnout Dec. 10.


Practice Management: Dr. Marc Leib warns about PQRS and VBPM.


Clinical Management: Chip Hardesty has some advice about quality care for your patients.


Pharmacology: Dr. Timothy Fagan discusses warfarin and those newer anticoagulants.


CME: Credits locally and out-of-town.

2 2 CME: Credits locally and out-of-town. On the Cover For 2015, Family Practitioner Melissa

On the Cover

For 2015, Family Practitioner Melissa Levine, M.D. Is PCMS’s 105th president. She introduces herself in this issue (Photo courtesy herself).

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Health, happiness, and the search for relevance

Health, happiness, and the search for relevance By Dr. Melissa Levine PCMS President “ B e

By Dr. Melissa Levine PCMS President

B e happy




all that matters” (said with

an Old Russian Jewish accent).

Actually, the original quote was, “Be Happy, Be Healthy, and Marry a Nice Jewish Boy.” But sometime in his mid-80s my Papa realized that last part wasn’t going to happen for his youngest granddaughter. So he adapted, and changed.

That really is the issue at heart: Adapting, and change. Medicine

is changing. Some changes are good, and some maybe not so

good, depending on your perspective. One thing is certain:

change is always difficult.

In April this year I will have been practicing medicine for 20 years.

I finished my residency in Family Medicine in 1995. Certainly half, and likely almost two thirds of my career is over. I have an 11-year-old, so I suspect I’ll be working another 12 to 15 years.

During these 20 years I have seen a few changes to the practice of medicine. When I was a third-year on surgery rotation at the UofA, they were still doing open cholecystectomies. Two years later as an intern on surgery, chole’s had been laparoscopic for more than a year, and an overnight stay in the hospital. Three years later, they were an outpatient procedure!

DVT treatment? It wasn’t that long ago that a DVT meant four to five days in the hospital on IV heparin and initiating Coumadin. Then it was Lovonox and Coumadin, and it’s now the newer, safer, anticoagulants.

Though they exist, significant changes in the practice of medicine are few. I’m sure there are advances in surgical techniques. There are new drugs out all the time, but true changes, I think I can count them on one hand. Most recently, the significant changes have been in how medicine is organized, or disorganized. And in how we get paid. And in scope of practice.

I have been an employed doc, a solo doc, worked urgent care for

a hospital group, and now I’m part of Arizona Community

Physicians. Each of those positions taught me different things about the practice of medicine, things I didn’t learn in medical

school—things about contracting, collections, ordering supplies, and paying the bills.

Through many of my solo years, I was on the Board of the Pima County Medical Society. I was working a lot, and honestly, there were many a third Tuesday on which I didn’t really feel like going to a meeting. But what I learned there was frequently helpful, relevant to running my practice. I met other doctors and learned what was going on in the medical community. The Noridian Medical Director, the ArMA representative from Phoenix, and the

Medical Director of AHCCCS were frequently at those meetings. The information I learned was invaluable.

The PCMS Board and the Executive Committee have struggled this year with the question of relevance. What can we do to make the Pima County Medical Society relevant to all the doctors in Pima County, and in Pinal?

Relevance means being connected with the matter at hand. Clearly we must adapt and change in order to stay connected. So, how is PCMS connected? How have we changed and adapted?

In 1918, PCMS helped fight the “Spanish Flu” influenza epidemic,

a scourge that killed an estimated 675,000 Americans.

Incidentally, the mortality rate was especially high in those aged 20-40. Today if you go to our website, you will find links to Ebola preparedness tool kits and CDC monitoring guidelines. You will find that the first case of influenza was diagnosed in Arizona last week, and there’s a link to the MMWR on Enterovirus D68.

In those early days PCMS was involved in enforcing the Medical Practice Act that identified uneducated practitioners and quacks who claimed to be physicians. Today, along with ArMA, we carefully monitor scope-of-practice issues and have created the “sunrise process” to evaluate requests from non-physicians to expand their practices. For example, legislation earlier this year that would have allowed optometrists to prescribe oral medications such as steroids, and a long list of others.

Jump ahead to 1960. Tucson had grown to 212,000 and had 214 physicians. PCMS advocated for an East Side hospital and helped fund-raising efforts for what is now Carondelet St. Joseph’s Hoapital. PCMS worked to get a medical school in Arizona. This year there has been a backlog to get new state medical licenses, due to new requirements for background checks and fingerprinting. PCMS and ArMA have been working with the Arizona Medical Board to find out the why’s of this, and to help decrease the backlog.

I have a list of things I would like to see PCMS do this year. I hope that many of you do as well, and I would love to hear them— things to stay relevant to doctors and our community at large. I urge you to go to the website, scroll down the member news, and glance over the information. You’ll see the latest in SGR negotiation, and 10 Medicare payment changes that are important to you. Most of all, in your search for what is relevant to you, may you also be happy and healthy.

Dr. Levine was born in Montego Bay, Jamaica. She graduated from the UofA College of Medicine in 1992. She did her Family Medicine internship at Phoenix Baptist Hospital 1992-93, and her FM residency there 1993-95. By our history reckoning, she is the 105 th PCMS president.



Dr. Katzenberg ‘plants’ ideas

Milestones Dr. Katzenberg ‘plants’ ideas W hen UA Sarver Heart Center presented its lecture series segment

When UA Sarver Heart Center presented its lecture series segment “Getting to the Heart of Good Food” in December at Canoa Hills Social Center in Green Valley, cardiologist and PCMS past-president Charles Katzenberg, M.D. was the speaker.

Sarver reminds the public that “Heart disease remains the leading cause of death in the U.S. Emphasizing a healthy lifestyle as the best prevention against heart disease.” Dr. Katzenberg encourages his patients to walk toward a plant-based diet, and run away from the SAD (Standard American Diet), so he teaches about eating a healthful diet that minimizes meat, dairy, and calorie- dense oils, as well as additional heart benefits that can be achieved from lifestyle changes and weekly exercise.

Dr. Beiter highlighted among nation’s physician hospital leaders

Amy Beiter, M.D., president and CEO of Carondelet St. Mary’s Hospital, was highlighted as one of the “100 Physician Leaders of Hospitals and Health Systems” in the United States by Becker’s Hospital Review for a second year, Carondelet reports.

The recognition was based on each physician leader’s healthcare experience, accolades, and commitment to quality care. Dr. Beiter is one of only two doctors who are also administrative leaders in Arizona

hospitals and one of only 10 women in the country on the list, Carondelet reported.

10 women in the country on the list, Carondelet reported. on the STARS Campbell Ave PRESENTED
on the STARS Campbell Ave PRESENTED BY THE Pima County Medical Society
Campbell Ave
Pima County
Medical Society


Save that date!

The date is April 18, 2015, and the reason is the return of Stars on the Avenue! It’s at St. Philip’s Plaza, 4280 N. Campbell Ave., 6:00–9:00 pm.

To purchase tickets, log onto www.pimamedicalsociety. org and click on “Purchase Stars on the Avenue Tickets” at the top of the home page. Sponsor packages are also available. Call the Society at 795-7985 to find out more. Look for more in months to come.

“Under Dr. Beiter’s leadership, St. Mary’s Hospital has expanded its clinical offerings and received numerous national awards for clinical excellence and patient safety. The Tucson West Side hospital is an accredited Chest Pain Center, a Designated Cardiac Receiving Center, and a Top Performing Hospital in the Midas+ Platinum Quality Awards. St. Mary’s is a Joint-Commission certified Primary Stroke Center and is also honored as one of the American Heart Association/American Stroke Association’s Gold-Plus Quality Achievement Award and Target Honor Roll Hospitals for Stroke Care.

“St. Mary’s offers comprehensive, compassionate, and state-of- the art care with a system-wide emphasis on quality,” Dr. Beiter said. “Our physicians with the Carondelet Heart & Vascular Institute are providing advanced cardiovascular care and attracting patients from all over Southern Arizona. Our Breast Center is reaching the highest national standards for excellence. And, our Emergency Center is leading the community in the time it takes for a patient to be seen and treatment initiated.”

Dr. Beiter is board-certified in internal medicine and pediatrics. She moved to Tucson in 1992 and began her medical practice at El Rio Community Health Center where she served as chief of staff and developed and managed a free clinic for teens. That year she joined the medical staff at St. Mary’s.

After leaving El Rio in 1999, she worked as a hospitalist at Carondelet. Seven years later, Dr. Beiter became the medical director of utilization management at St. Mary’s, soon followed by a position as chief medical officer in 2008. She was promoted to president and chief executive officer in 2012. In 2014, Dr. Beiter was named one of the “50 Most Influential Women in Arizona Business” by Arizona Business magazine.

Dr. Moreno leads in AHSC diversity

Francisco A. Moreno, M.D., professor of psychiatry at the University of Arizona College of Medicine–Tucson, whose “leadership has been instrumental as the deputy dean of diversity and inclusion at the college,” was recently named assistant vice- president for diversity and inclusion at the Arizona Health Sciences Center, the university reports.

“AHSC is committed to improving the diversity within the health sciences workforce. This commitment extends to the education, training, recruitment, and employment of a diverse faculty, staff and student body that is reflective of the Arizona communities it serves.

“In this new role Dr. Moreno will continue the work he began at the college and will work collaboratively with other diversity leaders at the UA colleges of Nursing, Public Health, Pharmacy, and the College of Medicine–Phoenix to create a comprehensive network of diversity-and-inclusion initiatives, meaningful diversity-and-inclusion programs, and strategies to improve the diversity of the healthcare workforce statewide.”

Dr. Moreno is responsible for promoting a “unified culture that values diversity and inclusion as vehicles for excellence at AHSC, the larger UA community, primary partners, and the region,” they said. “He will also be responsible for developing a unified vision

and the region,” they said. “He will also be responsible for developing a unified vision 6

and mission for diversity at AHSC, including leading strategic diversity planning efforts. He will work directly with the deans, directors and other university leadership to implement policies and initiatives and collaborate with human resources, deans/ directors, other health sciences leadership and university offices regarding AHSC diversity issues.”

Dr. Moreno also will seek to “infuse diversity into the instruction and content of new and existing courses, and coordinate and develop diversity training in collaboration with health sciences colleges and centers and other university departments. In addition, he will identify barriers to recruitment and retention of underrepresented populations and support strategies to overcome these barriers for students, faculty and staff.”

Dr. Moreno will continue to serve as professor of psychiatry at the UA College of Medicine–Tucson and oversee its Office of Diversity and Inclusion and Arizona Hispanic Center of Excellence.

A UA faculty member since 1997, Dr. Moreno

has served in a variety of roles at the UA College of Medicine–Tucson. He has served

as executive vice-chair, interim department head, and as director for inpatient, outpatient, residency and research programs

in the UA Department of Psychiatry. He has a

special interest in working with the under- served, and has established clinical, educational and research collaborations to decrease the gap of mental health services for immigrants in Arizona.

Since 2009, he has served as institutional representative to the Association of American Medical Colleges (AAMC) Group on Diversity and Inclusion (GDI). In 2010, he was elected Western Region Representative of the AAMC GDI. He also served as a member of the first elected GDI National Steering Committee from 2010 to 2012. In this capacity, he helped identify strategic priorities for diversity, inclusion and equity applicable to all AAMC U.S. and Canadian member colleges.

Originally from Mexico, Dr. Moreno earned his M.D. at the University of Baja California, then completed his psychiatry residency and research fellowship training in neuropsychopharmacology at the UofA. He has conducted extensive research in the biology and treatment of mood and anxiety disorders. As a psychopharmacologist he is involved in clinical, educational and consultative pharmacology.

Dr. Marks keeps on the move

Urologist, preparedness advocate, and PCMS past-president Dr. Sheldon H.F. Marks is so busy that you have to take him as a chronology.

In September 2014, he taught Tucson

Electric Power administrators and field workers in a course on Emergency Civilian Casualty Care (ECCC).

In October he was guest speaker at the Western Section of the American Urologic Association’s Practice Management kick-off session in Maui, Hawaii, on “Medical Practice Safety and Security—Risk Assessment and How to Prevent/Respond to Violent Encounter/Active Shooter” possibilities at your office, hospital, surgery center, or parking lot.

In Phoenix Nov. 7, Dr. Marks taught classes to 300 high school students interested in healthcare careers, on Ebola, disaster preparedness, and trauma training at the Arizona-wide annual HOSA conference. He taught a course on Ebola to Southern Arizona Red Cross Nurses Nov. 19.

Recently he taught two courses on Ebola tourniquets and disaster preparedness to several hundred high school students at the


annual state HOSA—Future Health Professionals.

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2050 will translate into 70 million people in the U.S. and more than 1 billion people in the world,” he said. “Our research group recently showed that infection with only CMV, and no other acute or persistent viruses, causes defects in immune responsiveness to other infections and causes alterations in the naïve T cell receptor repertoire and impaired effector T cell responses,” said Dr. Nikolich-Žugich, principal investigator for the study, “Impact of CMV Upon T-cell Aging and Immune Defense.”

“But the precise mechanism by which CMV affects naïve T cell responses remains incompletely understood. Our study seeks to define the cost, if any, of persistent CMV infection on immune function as we age and to begin to define ways to intervene against the negative effects of CMV in aging.”

Adverse impact of lifelong CMV infection on the aging of T cells—a type of white blood cell essential to immune system function—and development of new immune responses could be due to a number of factors.

“Improved control of CMV and/or reduction of CMV-specific EM accumulation could be beneficial for immune defense, such as immune responsiveness to vaccination. But it is also possible that the virus actually helps the immune system in the younger age, while impairing it in older adults,” Dr. Nikolich-Žugich said.

Researchers will assess the role of CMV in restricting T cell receptor (TCR) behavior and immune defense; the inhibition of protective immunity by CMV and/or by CMV-specific T cells; and whether improved control of CMV determines human immune responsiveness to vaccination.

Some people over age 65 control their CMV well and respond

well to vaccines, such as the influenza vaccine, while others do not, Dr. Nikolich-Žugich said. “The immune

system works hard to keep the dormant CMV in check. We hypothesize that efficient CMV control will correlate with strong and successful responses to vaccination in humans and that individuals who use vast resources to control CMV will be less likely to respond well to vaccination.”

UofA researches cytomegalovirus

Study called important to improving mortality odds

A virus that infects us when we’re young, and then hides in our cells

throughout our lives, without causing symptoms, may weaken the ability of our immune systems to defend against influenza, West Nile, or other viruses as we age, The Universty of Arizona reports.

CMV has been associated with impaired immunity, increased

morbidity due to cardiovascular disease, and reduced life and health spans—the length of life spent in good health.

How the cytomegalovirus (CMV)—one of the herpes viruses—

impacts the aging of our immune system is being studied by

researchers at the UofA College of Medicine—Tucson, funded by

a $2.3 million five-year grant from the National Institute on Aging/National Institutes of Health.

“It is critically important to understand the causes and consequences of lifelong CMV infection for immunity and aging,” said Janko Nikolich-Žugich, M.D., Ph.D. Dr. Nikolich-Žugich is chairman of the Department of Immunobiology, co-director of the UofA Center on Aging, Elizabeth Bowman Professor in Medical Research at the college, and member of the UA BIO5 Institute.

“CMV is present in 70 to 90 percent of people over 65, which by







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The research is supported by the National Institute On Aging of the National Institutes of Health under Award Number R01AG048021. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

MRCSA assesses local needs

By Tim Siemsen

Coordinator, Medical Reserve Corps of Southern Arizona

Medical Reserve Corps of Southern Arizona is working to better address the needs of the Southern Arizona community. One of the tools being implemented is a series Community Needs Assessments.

Our focus is on jointly establishing priorities

and planning efforts with Tucson metro area hospitals, community clinics, emergency response agencies, and the general public. The surveys are providing a current snapshot of community preparedness, and the awareness of MRCSA resources available for emergency and disaster response and recovery.

To date, in collaboration with students from the University of Arizona College of Nursing, we have learned from more than 300 community surveys that:

 65 percent of our neighbors expect to go to a hospital emergency room for care following a disaster.  42 percent think that contagious diseases are the greatest risk to the health and safety of the community, followed by terrorism and extended power outages.  TV and the Internet are, by far, the top choices for accurate information concerning a disaster or emergency.  Only 17 percent say that they have an emergency supply kit.  16 percent responded that members of their families or neighbors would require assistance to evacuate their homes or neighborhood.

These responses are only a portion of the survey results that will ultimately reach more than 1,000 Tucsonans during the first half of 2115.

Our hospital surveys tell us which specific skills and staffing positions would most likely be filled by trained and credentialed volunteers. MRCSA will work with each hospital to provide training to meet their needs and, if possible, pre-assigned teams. The hospitals will, whenever possible, incorporate MRCSA volunteers in their drills and exercises in order to create the familiarity necessary for seamless integration when responding to an emergency.

MRCSA will use the survey information to create a volunteer corps of physicians, nurses, pharmacists, mental health professionals, and others who can most effectively address the needs of Tucson and the greater Southern Arizona community.

Survey results will also be shared with appropriate response agencies and organizations. Since each survey is identified by the Zip Code of the respondent, we will have a significant community cross-section and can identify interests and concerns of individual neighborhoods within the county.

Our objective is to be stronger and better prepared in the event of any emergency situation through an investment in long-term community resiliency.

A ‘new normal’ in stroke patient treatment

By L. Roderick Anderson, M.D.

In pop culture the phrase “new normal” was born of the 2008 economic crisis as a way of describing new realities in our economy that individuals would need to become accustomed.

The phrase has since gone “viral” to the point of cliché, yet it can still be used in a hopeful, uplifting way if applied correctly. Treatment for a stroke is a great example, and at the Carondelet Neurological Institute at St. Joseph’s Hospital we have achieved a “new normal” which has enhanced treatment outcomes for our stroke patients.

According to American Heart/American Stroke Association guidelines, treatment for a stroke using t-PA, an intravenous thrombolytic agent or “clot buster,” should ideally be given within 60 minutes of a patient’s arrival at a hospital, a period often referred to as the “door-to-drug” time. Hospitals that are able to begin treatment after just 45 minutes are recognized for exceeding this standard.

With the recent implementation of its BAT Cave—short for Brain Attack Team—the Carondelet Neurological Institute (CNI) at St. Joseph’s is now posting an average door-to-drug time of 36 minutes, nearly half the national standard.

The BAT Cave consists of a dedicated and well-equipped evaluation and treatment area positioned in close proximity to the hospital’s emergency center entrance. Paramedics can transport stroke patients directly to the BAT Cave for an initial quick assessment, eliminating potential delays.

We are very proud of our team at the CNI, including our EMS partners, that has established a way to improve intervention times on behalf of our stroke patients. The BAT Cave enables a more rapid triage that saves time in administering treatment such as t-PA while helping protect stroke victims from devastating long-term disability. It gives our patients with stroke a chance at a better outcome.

We hope the move from a full hour to 36 minutes, in the fight to save patients who have suffered a stroke, is a “new normal” we can all celebrate.

Dr. Anderson is medical director of Carondelet Neurological Institute Stroke Center at Carondelet St. Joseph’s Hospital.

UofA gets $3.6 million HRSA grant for public health improvement

The University of Arizona Mel and Enid Zuckerman College of Public Health reports that it has received a $3.6 million, four-year grant from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services to establish a consortium of public health training centers called the Western Region Public Health Training Center (WRPHTC).

The project expands the reach of the UofA Arizona Public Health Training Center (AzPHTC) to provide training to HRSA Region 9 that includes Arizona, Nevada, California, Hawaii, and the U.S.- affiliated Pacific Islands. Staff will work with numerous groups in these states to assist with the establishment of their own Public Health Training Center (PHTC).

HRSA’s Public Health Training Center Program is aimed at improving the nation’s public health system by strengthening the technical, scientific, managerial and leadership competence of the current and future public health workforce. HRSA-funded PHTCs are partnerships between accredited schools of public health, related academic institutions and public health agencies and organizations. PHTCs assess the learning needs of the public health workforce, provide accessible training and work with organizations to meet other strategic planning, education and resource needs.

“The funding to expand our current Arizona Public Health Training Center to be a regional center is a testament to the

infrastructure that we have built and the accomplishments that we have had over the years,” said Douglas Taren, PhD, associate dean of Academic Affairs at the UA Zuckerman College of Public Health and project director for the WRPHTC.

The WRPHTC will work with The University of Nevada, Reno, School of Community Health Sciences; University of Hawai’i, Manoa, Department of Public Health Sciences; Pacific Island Health Officers Association; and University of California, San Francisco, California Area Health Education Center Program, to open PHTCs in their states.

Each PHTC will conduct competency driven training needs assessments and, based on findings, will deliver training programs across their state. The assessments will focus on rural

areas where health disparities are greatest and training opportunities are least available.

Dr. Taren added. “I am really pleased that we were recognized as a training center that is able to meet the needs in Region 9 for the Department of Health and Human Services. We will continue to work with our public health colleagues in Arizona and I look forward to working with our partners in the west to support the continual training of public health professionals.”

Feb conference addresses law, ethics for those with special needs

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The University of Arizona College of Medicine–Phoenix will host the three-day conference “The Law and Ethics of Those with Special Needs: Fair Is What Fair Is” on Feb. 18-20 on the downtown Phoenix campus.

The Department of Bioethics and Medical Humanism at the UA College of Medicine– Phoenix, in collaboration with the American Society of Law, Medicine and Ethics, hosts the conference. Physicians, nurses, academics, attorneys, social workers, therapists, family advocates, ethicists, and others are invited to hear from renowned leaders in the fields of law, ethics, medicine, family advocacy, and support groups.

“There continues to be a need for an increased awareness of the moral rights for those with special needs, different than the limited social rights that are now afforded them,” said David Beyda, M.D., chairman of the Department of Bioethics and Medical Humanism at the college. Dr. Beyda said that among key discussions will be the challenging world of those with special needs as they relate to ethics and law; examining issues beyond the boundaries of classical ethical questions; and exploring the relationship between the law and ethics as applied to those with special needs.

Former Phoenix police officer Jason Schecterle, who suffered third- and fourth- degree burns in a 2001 accident and has since launched a career as an inspirational speaker and author, is among the scheduled speakers. Others include Paul Lombardo, J.D., Ph.D. (A History of Discrimination: Disability and America’s Eugenic Legacy); Wendy Parnet, J.D. (Doubly Vulnerable: Non-Citizens with Special Needs); and Elizabeth Pendo, J.D., (Reducing Barriers to Care for People with Disabilities).

For more information or to register, please

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Behind the Lens Irresistible beauty By Hal Tretbar, M.D. T his is a great time

Behind the Lens

Irresistible beauty

By Hal Tretbar, M.D.

T his is a great time of the Tucson year: winter sports,

UofA basketball, and those colorful sunrises and sunsets. Weather fronts that blow through the Sonoran Desert with occasional snow or rain bring clouds that are the best for color in the sky, mornings or evenings.

I just looked at sunrises and sunsets that I have shot with my cell phone in the past year. If I’m away from home, I will take my Nikon 600 with me and will use it for any beautiful weather events. When at home, I just step outside the house into the street and shoot the colorful skies with my 41 mega-pixel Nokia 1200.

The Nokia has a very sharp f2.2 Zeiss lens. The settings are an ISO of 100 to 3200, shutter speeds from 1/16,000 second (not a typo) to 4 seconds, auto and manual focus from infinity to 2 inches, the usual

auto and manual focus from infinity to 2 inches, the usual Sunset taken Dec. 21, 2013

Sunset taken Dec. 21, 2013 at 5:22 p.m.

manual focus from infinity to 2 inches, the usual Sunset taken Dec. 21, 2013 at 5:22
Sunrise taken Dec. 2, 2014 at 6:37 a.m. white balance settings, exposure adjustment of -3

Sunrise taken Dec. 2, 2014 at 6:37 a.m.

white balance settings, exposure adjustment of -3 to +3, and on- demand focus light and flash. I usually have everything set on auto and adjust the exposure to about -2 to deepen the colors a bit. Most of the images can be tweaked a little in Photoshop and the size cropped to a more standard 4x6, 5x7 or 11x14 inches for printing.

Renowned outdoor photographer John Shaw says there are three “M’s” that interfere with shooting sunrises and sunsets:

Mornings, Meals, and Mates. In the summer it’s a challenge to roll out of the bed at 4 a.m. or so. In the winter it is rather chilly to

bed at 4 a.m. or so. In the winter it is rather chilly to Sunrise taken

Sunrise taken Feb. 19, 2014 at 6:50 a.m.

shoot the sunrise, particularly if you have a metal tripod.

Who hasn’t wanted to finish a nice meal with a glass of wine and then go out to see if the sunset is still hanging on? And what about the time your mate said, “What?! You want to go shoot another sunset? You already have lots of them!”

Of the 30 I have on my cell phone’s memory from the past year, here are some of the best during the winter months. I hope you all will go out soon and capture a prize-winning sunrise or sunset!

The Faces of Casa are the Dr. Ann Marie Chiasson Associate Medical Director “ Working
The Faces of Casa are the
Dr. Ann Marie Chiasson
Associate Medical Director
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practice both the science of medicine
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Hospice services are paid for by Medicare
Sunset taken Dec. 9, 2014 at 5:26 p.m. Sunset taken Nov. 29, 2013 at 5:08

Sunset taken Dec. 9, 2014 at 5:26 p.m.

Sunset taken Dec. 9, 2014 at 5:26 p.m. Sunset taken Nov. 29, 2013 at 5:08 pm.

Sunset taken Nov. 29, 2013 at 5:08 pm.

9, 2014 at 5:26 p.m. Sunset taken Nov. 29, 2013 at 5:08 pm. Sunset taken Dec.

Sunset taken Dec. 20, 2013 at 5:19 p.m.

29, 2013 at 5:08 pm. Sunset taken Dec. 20, 2013 at 5:19 p.m. Sunset taken Oct.

Sunset taken Oct. 15, 2014 at 6 p.m.

at 5:08 pm. Sunset taken Dec. 20, 2013 at 5:19 p.m. Sunset taken Oct. 15, 2014
at 5:08 pm. Sunset taken Dec. 20, 2013 at 5:19 p.m. Sunset taken Oct. 15, 2014
at 5:08 pm. Sunset taken Dec. 20, 2013 at 5:19 p.m. Sunset taken Oct. 15, 2014
at 5:08 pm. Sunset taken Dec. 20, 2013 at 5:19 p.m. Sunset taken Oct. 15, 2014

PCMS Alliance News

Story and Photos by Dennis Carey

Holiday Luncheon draws 100+

Story and Photos by Dennis Carey Holiday Luncheon draws 100+ Lupita Borboa and Reem Aussy chaired

Lupita Borboa and Reem Aussy chaired this year’s PCMS Alliance Holiday Luncheon at Fleming’s Steakhouse on Dec. 10.

There was truly something for everyone among the items donated for this year’s Pima County Medical Society Alliance Holiday Luncheon, beautifully flung Dec. 10 at Fleming’s Steakhouse & Wine Bar on North Campbell Avenue.

Items included a hand-tooled leather handbag, and gift cards for many local restaurants, spas, and exercise studios. A variety of gift baskets were available for raffle, including a University of Arizona Fan Basket, one filled with Godiva Chocolate items, and wine baskets for the connoisseur or casual taster.

Artwork included carved figurines, paintings, and a unique wooden peppermill handcrafted by PCMS Associate Dr. Philip Fleishman. Traditionally, one of the most popular items for sale were the labor-intensive Mrs. A’s Apples, the giant caramel apples made from the recipe of Alliance Board Member Kathy Armbruster.

from the recipe of Alliance Board Member Kathy Armbruster. Reem Aussy and Kynn Escalante take a

Reem Aussy and Kynn Escalante take a break from their host duties at the Holiday Luncheon.

With Alliance members, guests, and Mobile Meals of Tucson Board of Directors members, about 125 attended. Holiday Luncheon proceeds—derived from event ticket sales, raffle ticket sales for donated items, silent auctions, and sales of Mrs. A’s Apples—all benefit Mobile Meals, which delivers more than 100,000 meals annually to homebound adults.

more than 100,000 meals annually to homebound adults. Luncheon attendees examine some of the many items

Luncheon attendees examine some of the many items for the raffle and silent auction.

some of the many items for the raffle and silent auction. This year’s event organizers included,

This year’s event organizers included, from left, Kynn Escalante, Mobile Meals Executive Director Priscilla Altuna, Kay Dean and Joy Chapeskie.

Prac ce Management

PQRS and VBPM: Double-whammy waits in wings

By Marc Leib, M.D., J.D.

T he Physician Quality Reporting Initiative (PQRI), a voluntary quality reporting system for physicians, has become the now-

mandatory Physician Quality Reporting System (PQRS).

Incentive payments to physicians successfully reporting PQRS measures began at 2%, but in 2014, the last year of incentive payments, that amount has been reduced to 0.5%. From 2015 on, incentive payments are no longer available. Rather, failure to report sufficient numbers of quality measures will result in negative payment adjustments, CMS’ term for fee reductions.

Failure to report PQRS measures can have additional negative

repercussions. Beginning in 2013, groups of 100 or more eligible providers (EPs), which includes physicians and other qualified licensed providers, were required to report PQRS measure or be penalized 1% of its

Medicare payments in

2015. Groups of that size

that did not satisfactorily

report measures in 2013 have no way to avoid the mandatory cuts in

2015. For 2014, groups

of 10 or more EPs must satisfactorily report PQRS measures or face 2% fee reductions in 2016. Beginning in 2015, all physicians must report applicable PQRS measures or face similar reductions in 2017.

Satisfying the PQRS reporting requirements avoids the negative adjustment during the first year of the VBPM program (2015 for groups greater than 100, 2016

for groups of 10-99, and 2017 for all others). In subsequent years reporting PQRS measures alone may not avoid negative adjustments as the VBPM will be based on both quality and cost measures. Physicians or groups will be subject to positive, neutral or negative updates based on their actual quality and cost performance.

Depending on what happens in the “lame duck” session of Congress at the end of 2014 after the November elections or during the next congressional session beginning in 2015, the potential penalties for physicians could become even more severe. As part of the proposed repeal of the Sustainable Growth Rate (SGR) formula that failed earlier this year, PQRS, VPBM, and EHR Meaningful Use (MU) would have been consolidated into a new quality program, the Merit-based Incentive Payment System (MIPS). The potential negative adjustments for the poorest

Initially physicians received enhanced payments for services provided to Medicare beneficiaries for voluntarily reporting quality measures relevant to their practices and the services provided to Medicare patients. Now, however, physicians must report a sufficient number of quality measures or be subject to

fee reductions for those services. In addition, failure to report sufficient numbers of quality measures could result in fee reductions two years

after the year in which those measures were not reported.

Will My Group be Subject to 2016 VM?
Will My Group be Subject to 2016 VM?

This is slide No. 10 of the Value-Based Payment Modifier (VM) training presentation found on the CMS website at



To fully comply with the PQRS requirements, physicians must report nine measures across three different quality domains. Quality domains include patient safety; person and caregiver-centered experience and outcomes; communi- cation and care coordination; effective clinical care; community and population health; and efficiency and cost reduction. Specialists with fewer than nine measures or three separate domains must

report all available measures across all available domains to satisfy the PQRS requirements.

PQRS measures may be reported in a number of different ways:

1) on Part B claims submitted to Medicare; 2) via qualified registries; 3) directly from Electronic Health Records (EHRs); 4) through data submission vendors; or 5) through Qualified Clinical Data Registries (QCDRs). Groups may report their PQRS measures by each of the above methods, except that groups may no longer report as a group on claim forms (number 1 above) through the Group Practice Reporting Option (GPRO). Physicians in the group, however, may still report PQRS measures on claim forms as individuals. If physicians in a group report as individuals, CMS will determine whether more than 50% of the physicians in the group met the reporting requirements. If so, the entire group is deemed to have met the reporting requirements for that year.

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performing physician groups could eventually amount to fee cuts of up to 9%. Although both Democrats and Republicans support the repeal of the SGR formula, they could not agree on how to pay for the costs of doing so, dooming the bill to defeat in an election year. However, it appears that Congress will take up SGR repeal after the elections, either late this year or early next year. The MIPS program is likely to be a part of any SGR repeal bill.

Bottom line, all physicians are, or will soon be, subject to PQRS and VBPM requirements. Groups of 100 or more physicians that were already subject to these requirements cannot correct their failure to report in 2013. Those newly subject to the requirements in 2014 (groups of 10-99) may have some time left this year to report, but it may be difficult to meet the minimum requirements in the few months left in this year. All physicians will be subject to the reporting requirements next year. It is important that physicians report their quality measures to avoid future fee reductions and to understand the cost metrics that will, in part, determine whether they will have a positive, neutral or negative adjustment in future years. It is also important to understand whether any eventual SGR repeal will impose additional potential negative adjustments on top of the PQRS and VBPM fee reductions.

Marc Leib, M.D., J.D. is an anesthesiologist, attorney, ArMA past-president, and served as AHCCCS CMO July 2004 to July 2014. This article was first published in the Fall 2014 AZMedicine, the ArMA quarterly.


2014. This article was first published in the Fall 2014 AZMedicine, the ArMA quarterly. n 16

Clinical Management

Clinical Management Delivering quality care to your patients By Chip Hardesty “It’s not who you are

Delivering quality care to your patients

By Chip Hardesty

“It’s not who you are underneath; it’s what you do that defines you.”

– ‘Rachel Dawes,’ Batman Begins

T he Institute of Medicine’s March 2001 report from

paraphrase back to the patient to confirm that you understand what they’re saying? Schedule a training session.

To understand. The corollary to being heard is to understand. Do you and your staff confirm understanding by asking patients to paraphrase your instructions back to you? Provide a written synopsis for every patient.

To know and be known by the staff. Do you know your staff turnover rate? At 16.8%, turnover in healthcare is above average. Employees leave because of poor interpersonal relationships with supervisors or colleagues, lack of opportunities for growth and advancement, working conditions and benefits. Are you engaged with your staff? Hire professional office managers who can get the billing right and have strong interpersonal relationships.

Doctors to communicate with each other. How often do you communicate with colleagues? Medicine has become so specialized that patients and their caregivers have become their own case managers, a role for which they are woefully unprepared. Get a list of their other physicians and coordinate with them. [And get involved in PCMS.]

To be seen on time. Does your practice see patients in a timely fashion? Jerry Seinfeld famously lampooned the rental car industry for not knowing the meaning of a reservation, its primary function. He said: I think you know how to TAKE the reservation; you just don’t know how to HOLD the reservation. He could easily have been satirizing medical practices. You needn’t consult a dictionary to know that an appointment is an agreement to meet with someone at a particular time. Of course your time is valuable, as is that of those with whom you make appointments. Set a standard for a reasonable wait-time for your patients, track how well you’re doing, and take steps to improve.

Convey to all of your new employees that they are vitally important to the healthcare of our patients, and that the service we provide determines outcomes. Discuss customer service, but explain that our “customers” are not like customers of Starbucks or Safeway. Our customers don’t want to be customers. They’re customers because they’re sick, frightened, and/or confused. They are patients.

Most patient complaints these days can be diagnosed with an Internet search. But the Internet can’t hear patients and can’t communicate effectively with other clinicians the way we can.

To be a patient-centered practice, we must be better than a Google search.

Chip Hardesty is chief operating officer of Radiology Ltd. in

Tucson, where he has applied his clinical engineering and business experience for the past 20 years. He is a past-president of the Arizona Medical Group Management Association and remains


active on its board, with special interest in legislative issues.

its Committee on the Quality of Healthcare in America began by stating: “Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge.”

They then identified six aims for improvement; to be safe, effective, patient-centered, timely, efficient, and equitable. Progress has been made over the past 13 years, but achieving a patient-centered practice has proven elusive. The emergence of high- deductible health plans is converting patients into consumers who demand quality and value on their terms in a complex environment.

Quality is first defined as “a peculiar and essential character, an inherent feature.” Patients, payers, and hospital administrators assume quality and safety because of the physician’s academic success and rigorous training. Patients expect that their doctors will help them with their medical needs without causing them harm. They believe that care based on scientific knowledge without fear of harm is inherent to the profession, just as oxygen has inherent features of being a colorless, odorless, and tasteless diatomic gas.

Quality is defined second as “a degree of excellence, superiority in kind.” Physicians have earned an elevated position in society, It allows them to enjoy better homes, better cars, better wines, and to send their children to better schools. You have personal experience with superior quality and uncommon attention to detail, qualities we aspire to in our practices. How do we demonstrate this to our patients and create a patient- centered practice? We must define what is most important to our patients.

Defining what people want, and measuring to see if we are delivering it is a tricky business. The vision of the Patient- Centered Outcomes Research Institute, which Congress created in 2010, states: “Patients and the public have information they can use to make decisions that reflect their desired health outcomes.” I can’t argue with that definition, but science needs data to progress, and a soft definition doesn’t get us where we need to be. Medical practices must define “patient-centered,” find ways to measure it, and implement actions to improve it.

In my recent unscientific polling of individuals outside the healthcare field, when I asked about quality, the issue of education never came up. Neither did sentinel events. Both of these are extremely important, yet patients have no way of judging them. What they judge us on is how well we treat them. Patients want:

To be heard. Do you and your staff use active listening skills, to


The warfarin contradiction

By Stuart Faxon

A t what point is warfarin’s danger from bleeding worse than the danger from clots, stroke, and M.I. it is meant to prevent?

That’s one of the questions Dr. Timothy C. Fagan, M.D., F.A.C.P., Professor Emeritus of Internal Medicine and Pharmacology at the University of Arizona College of Medicine—Tucson, addressed Nov. 11 at a CME presentation for Pima County Medical Foundation. A PCMS past-president, his private practice is Camp Lowell Medical Specialists.

He wanted fellow physicians to be aware of the three new oral anticoagulants and their mechanisms of action, to know the agents’ efficacy and safety benefits compared to warfarin in DVT, PE, and joint surgery prophylaxis, and indications for their use and situations in which there are not enough data to recommend them.

The familiar anticoagulant compound that doctors and patients now use by the millions was named for

doctors and patients now use by the millions was named for Dr. Timothy Fagan explains the

Dr. Timothy Fagan explains the newer anticoagulants Nov. 11 at PCMS for Pima County Medical Foundation (Jeremy Snavely photo).

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WARF: Wisconsin Alumni Research Foundation + arin for coumarin, derivation of the brand name Coumadin. It acts by inhibiting Vitamin K-dependent activation of clotting factors II, VII, IX, X, and Proteins C and S. As we know, warfarin’s International Normalized Ratio or INR must be monitored in patients using it. “This can be as infrequently as monthly in stable patients without other medication changes,” Dr. Fagan said. “It may need to be monitored every few days during initiation of warfarin therapy and when other medications, which may interact with warfarin, are changed.”

Daily warfarin dosing can vary because of the long half-lives of Protein S (30 hours), Factor X (36 hours), and Factor II (50) hours. “The wide inter-individual range of effective doses averages 44-59 days depending on strategy and protocol, and loss of effect takes place two to five days after discontinuation,” Dr. Fagan said.

“Warfarin has multiple mechanisms for interaction with other drugs, and it should be assumed that any change in other medications may affect the INR. Warfarin effect may be decreased by high intake of Vitamin K-containing foods such as green

leafy vegetables, or increased by very low Vitamin K intake.” This is why reversal of

leafy vegetables, or increased by very low Vitamin K intake.” This is why reversal of warfarin anticoagulation can be done in 24-48 hours with low-dose oral Vitamin K, and reversal can be achieved in a few hours by intravenous fresh frozen plasma plus intravenous Vitamin K, or with use of clotting factor concentrates.

Looking at emergency hospitalizations of older Americans for adverse drug events, we find that there was an estimated 99,628 such hospitalizations per year in 2007-2009 in the U.S. in patients age >64, with 48% in patients age >79. “Warfarin was responsible for 33.3% of all these hospitalizations or 33,176 per year,” Dr, Fagan said.

He then discussed Dabigatran etexilate (Pradaxa), the newer Rivaroxaban (Xarelto), and still newer Apixaban (Eliquis). Big Pharma has done its usual mass media advertising of all three agents, followed by nearly the same amount of media from class- action lawyers seeking patients who claim adverse effects from all three.

Houston, Texas “bad drug lawyers,” the ironically named Pulaski & Middleman, have Xarelto, a Janssen Pharmaceuticals product licensed from Bayer HealthCare AG, as No. 2 on their hit list, saying in client-seeking TV ads that the drug has been “linked to” G.I. bleeding, stroke, M.I., and death. The newer anticoagulants’ main sales point is that they do not require regularly scheduled blood monitoring, and this point that seems to have more public appeal than mere therapeutic effect.

“Dabigatran and its active metabolites are direct inhibitors of thrombin,” Dr. Fagan said. “They inhibit both conversion of fibrinogen to fibrin and thrombin-induced platelet aggregation. aPTT provides an approximation of Dabigatran’s anticoagulant effect. Thrombin time and other, less available tests give more quentitative estimates. Dabigatran is dosed every 12 hours, and effect onset is 1-2 hours.

“Dabigatran’s plasma half-life is 12-17 hours. Elimination is 80% renal, and effect disappearance is 24-72 hours depending on renal function. The dose of Dabigatran should be reduced from 150mg BID to 75mg BID in patients with eGFR <30 ml/min, and should be avoided in patients with eGFR <15 ml/min, due to lack of data in these patients.

“In elderly patients, Dabigatran dosing should be adjusted for renal function. Dabigatran is not a substrate, inducer or inhibitor of CyP P450 enzymes; it is a P-glycoprotein (Pgp) substrate and is affected by inducers and inhibitors of Pgp.

“A specific antibody fragment for Dabigatran reversal has been highly effective in Phase 1 trials. Recombinant factor VIIa and activated prothrombin complex may be effective for reversal of bleeding due to Dabigatran. Prior to elective operations or invasive procedures, Dabigatran should be discontinued for 1-2 days in patients with eGFR >50, and 3-5 days in patients with eGFR <50.”

Rivaroxaban (Xarelto) acts by inhibiting Factor Xa, effect onset is 2-3 hours, and half-life is 5-9 hours, Dr. Fagan said. “Disappearance of effect is 24-48 hours, depending on renal function. Rivaroxaban has different dosing regimens for each indication. Its use in patients with eGFR <15 ml/min should be avoided, due to lack of data in this group.

“Rivaroxaban is a substrate for Pgp and Cyp 3A4/5. Activity may be decreased by inducers of Pgp and Cyp 3A4/5, such as ketoconazole, ritonavir, clarithromycin, erythromycin and fluconazole Bioavailability is markedly increased in patients with significant liver disease. Dosing in the elderly should be adjusted based on renal function.”

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For reversal treatment of Rivaroxaban-induced bleeding, activated prothrombin complex concentrate and four-factor prothrombin complex concentrate may be useful, Dr. Fagan said. “Rivaroxaban should be discontinued for at least 24 hours prior to operations or invasive procedures.”

In outcomes of major bleeding with Rivaroxaban vs. warfarin, Dr. Fagan’s statistics were:

 Randomized: 7,111 with Rivaroxaban vs. 7,125 with warfarin.  Major bleeding: 395 vs. 386.  Hospitalizations: 101 vs. 91.  Transfused >2u: 184 vs. 149.  Received FFP: 45 vs. 81.  Deaths: 86 vs. 105

Chronologically third of the newest three anticoagulants is Apixaban, brandnamed Eliquis. Like Rivaroxaban, Apixaban acts by inhibiting factor Xa.

“It is dosed every 12 hours at 5mg in most patients. It is dosed at 2.5mg in patients with at least two of: age >80; weight <60kg (132 pounds); serum creatinine >1.4 mg/dl. Effect onset is 2-4 hours, and plasma half-life is 12 hours. Effect disappearance is 24-48 hours. There are no good data on reversal of bleeding.

“Renal excretion only accounts for 27% of total clearance. Effects of moderate hepatic impairment on Apixaban are unclear. Apixaban is a substitute for both Pgp and Cyp 3A4/5.

“Clearance is decreased by strong inhibitors of both Pgp and Cyp 3A4/5, such as rifampin and phenytoin.

of both Pgp and Cyp 3A4/5, such as rifampin and phenytoin. Clearance is increased by strong

Clearance is increased by strong inducers of both Pgp and Cyp 3A4/5, such as ketoconazole, ritonavir, clarithromycin, erythromycin and fluconazole.”

Dr. Fagan compared treatment of acute thromboembolic disease (deep vein thrombosis and pulmonary embolism) aimed at preventing further DVT and PE. Pradaxa and warfarin were found equally effective, and the rates of major bleedinng were not significantly different between the two treatments.

Studies compared treatment with Pradaxa or warfarin of patients at high risk for recurrent DVT or PE for 44 months with the goal of preventing recurrent DVT or PE. Treatments were found equally effective and did not have different rates of major bleeding. However, there was significantly more clinically relevant non-major bleeding with warfarin.

In comparison of treatment of patients at low risk for recurrent DVT or PE, for five months with Pradaxa or placebo to prevent recurrent DVT or PE, significantly more DVT and PE were found with placebo. Major bleeding was the same with Pradaxa and placebo, but there was significantly more clinically significant non-major bleeding with Pradaxa.

Comparisons for the other medications were similar. “For treatment of acute DVT/ PE, dabigatran/Pradaxa, rivaroxaban/Xarelto, and apixaban/Eliquis are all non-inferior to enoxaparin/warfarin, and apixaban causes less major bleeding,” Dr. Fagan said. “For prevention of recurrent DVT/PE, dabigatran [Pradaxa] is non-inferior to enoxaparin/ warfarin, and causes less clinically significant non-major bleeding.

Cumulative Rates of the Primary End Point (Stroke or Systemic Embolism) in the Per-Protocol Population and in the Intention-to-Treat Population:

Population and in the Intention-to-Treat Population: “For prevention of recurrent DVT/PE” all three are

“For prevention of recurrent DVT/PE” all three are “more effective than placebo, and do not cause significantly more major bleeding. For prophylaxis of DVT/PE after major joint replacement, rivaroxaban and apixaban are more effective and do not cause more major bleeding than enoxaparin/warfarin.”

“In patients with A-fib, the newer anticoagulants are not recommended after intracoronary stent placement due to lack of their data with these patients,” he said. The same applies to patients with A-fib and ACS without stent placement, and patients with A-fib prior to cardioversion.

“You can’t really prove these because they’re not head-to-head,” Dr. Fagan said, “but the

safety as far as bleeding is the same. So we have three agents, all approved for A-fib and thromboembolic disease; only Pradaxa is not approved for prophylaxis with major joint replacement. All three are easier to use, equally effective for these indications, and as safe or

safer than warfarin.”


Warfarin: almost 60 years old and still causing problems

A 2006 British Pharmacological Society above-titled

article by Munir Pirmohamed notes that in the 1920s, cattle in the Northern U.S. and Canada were afflicted by an unusual disease outbreak, characterized by fatal bleeding, either spontaneously or from minor injuries.

“Mouldy silage made from sweet clover (Melilotus alba and M. officinalis) was implicated, and L.M. Roderick in North Dakota showed that it contained a hemorrhagic factor that reduced the activity of prothrombin,” the story said. “However, it was not until 1940 that Karl Link and his student Harold Campbell in Wisconsin discovered that the anticoagulant in sweet clover was 3,3′-methylenebis (4-hydroxy coumarin).

“Further work by Link led in 1948 to the synthesis of warfarin, which was initially approved as a rodenticide

in the USA in 1952, and then for human use in 1954.

“Warfarin is now the most widely used anticoagulant in the world. Given the recent demise of ximelagatran, the first oral thrombin inhibitor, it is likely to maintain its place for many years to come. In the U.K. it has been estimated that at least one percent of the whole

population and eight percent” of those 80 or older “are taking warfarin. Increase in its use over the last decade can undoubtedly be traced to overwhelming evidence of its effectiveness in preventing embolic strokes in patients with atrial fibrillation.

“The main adverse effect associated with warfarin is bleeding. Major and fatal bleeding events occur respectively at rates of 7.2 and 1.3 per 100 patient- years, according to a meta-analysis of 33 studies. Warfarin is also number one on the list of drugs implicated in causing hospital admission through adverse effects.

“Warfarin’s narrow therapeutic index makes it difficult to maintain patients within a defined anticoagulation range. A recent analysis of 6,454 patients with atrial fibrillation taking warfarin showed that for almost 50% of the time, the INR was outside the target range of 2–3. An INR higher than 3 increases the risk of bleeding, while an INR less than 2 increases the risk of thrombotic events. The problem is further compounded by the fact that individual dosage requirements vary widely between and within individuals.”


Local CME from Pima County Medical Foundation

Pima County Medical Foundation, a 501(c)3 nonprofit organization derived from and separate from PCMS, presents Continuing Medical Education lectures by our members and others, for our members and others, on second Tuesday evenings monthly at PCMS headquarters. Dinner is at 6:30 p.m. and the presentation is at 7. Tentative 2015 schedule is:

Feb. 10: Hormonal Replacement Therapy with doctors Jonathan Insel and Robert Kahler.

March 10: Breast Reconstruction Surgery—Implants and Complications with doctors Swen Sandeen and Richard Hess.

April 14: Cancer of the Lung—Newer Treatments and Cancer Screening with physicians from Radiology Ltd.

May 12: Healthcare Reform 2015—“What the Hell is Happening??” with several speakers coordinated by Dr. Timothy C. Fagan. Foundation Awards are presented at this time.

June 9: Heart-Healthy Diet with cardiologists Dietmar Gann and Charles Katzenberg.

Sept. 8: Vasectomy Reversals and Impotence with Dr. Sheldon Marks.

Oct. 13: Common GI Viral Diseases—Diagnosis, Mechanisms of Action, and Treatment with Claire Payne, Ph.D.

Members’ Classifieds

SHARED SPACE FOR RENT: Active Neurology office in Northwest Tucson has office space to lease. Renter does not need to be in Neurology field. If interested, contact Mike at Northstar Neurology at 520-229-1238 or e-mail and refer to Space for Rent.

or e-mail and refer to Space for Rent. November 10: Pharmacogenomics—How Medicines Affect

November 10: Pharmacogenomics—How Medicines Affect Differing Demographics of Patients with Dr. Timothy C. Fagan.


Jan. 23: Clinical and Multidiscplinary Hematology and Oncology 2015: The 12 th Annual Review is at the Westin Kierland Resort, 6902 E. Greenway Pkwy., Scottsdale 85254. CME credits pending.

Course targets hematologists, oncologists, NPs, RNs, PAs, and all interested in comprehensive update of diagnosis and treatment of hematologic and oncologic disorders. Course presents “new disease classification, treatments, and challenging cases in key hematologic diseases (dysproteinemias, acute and chronic leukemias, lymphomas), key solid tumors (breast, thoracic, GI, GU), and overlap topics of supportive, ancillary and diagnostic care. Includes breakout sessions for one-on-one interaction with faculty.”

Website: oncology Contact: Lilia Murray, Mayo School of Continuous Professional Development, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323.

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Now featuring NeuroQuant ® Brain Image Analysis Radiology Ltd. is pleased to share a new
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2014 MICA announces tenth consecutive year of dividends. MICA’s Board of Trustees is pleased to
2014 MICA announces
tenth consecutive
year of dividends.
MICA’s Board of Trustees is
pleased to announce a $27 million
dividend for the 2014 policy year.
This is our 10th consecutive
dividend and our 24th dividend
since MICA’s founding.
Medical Professional
Liability Insurance
(602) 956-5276
(800) 352-0402
Dividends declared for a given policy year
reflect the Company’s financial performance
during that year. Past performance does not
guarantee future dividends.