Sombrero

Pima County Medical Society

Home Medical Society of the 17th United States Surgeon-General

JANUARY 2015

Dr. Fagan on the

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Alliance fund-raises
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SOMBRERO January 2015

Sombrero
Pima County Medical
Society Officers

Official Publication of the Pima County Medical Society

PCMS Board of Directors

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)

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

Executive Director
Bill Fearneyhough
Phone: 795-7985
Fax: 323-9559
E-mail: billf 5199@gmail.com

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

Advertising
Phone: 795-7985
Fax: 323-9559
E-mail: dcarey5199@gmail.com

Art Director
Alene Randklev, Commercial Printers, Inc.
Phone: 623-4775
Fax: 622-8321
E-mail: alene@cptucson.com

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SOMBRERO January 2015

ABR, CRS, GRI

Arizona Medical
Association Officers
Thomas Rothe, MD
immediate past-president
Michael F. Hamant, MD
secretary

Members at Large
Richard Dale, MD
Charles Krone, MD
Jane Orient, MD

At Large ArMA Board

R. Screven Farmer, MD

Pima Directors to ArMA

Timothy C. Fagan, MD
Timothy Marshall, MD

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

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

Printing
Commercial Printers, Inc.
Phone: 623-4775
E-mail: andy@cptucson.com
Publisher
Pima County Medical Society
5199 E. Farness Dr., Tucson, AZ 85712
Phone: (520) 795-7985
Fax: (520) 323-9559
Website: pimamedicalsociety.org

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 represent 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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Inside
5 Dr. Melissa Levine: Our 2015 president
introduces herself.

6 Milestones: Whats up with doctors Beiter,

Marks, Katzenberg, and Moreno.

8 PCMS News: UofA researches cytomegalovirus.

11 Behind the Lens: Some Southern Arizonans, or
maybe most, cant get enough of those colorful
winter sunsetsand sunrises.

14 PCMS Alliance News: The annual Alliance fundraiser for Mobile Meals of Tucson had a full
turnout Dec. 10.

15 Practice Management: Dr. Marc Leib warns about

PQRS and VBPM.

17 Clinical Management: Chip Hardesty has some

advice about quality care for your patients.

18 Pharmacology: Dr. Timothy Fagan discusses

warfarin and those newer anticoagulants.

On the Cover
For 2015, Family Practitioner Melissa Levine, M.D. Is PCMSs 105th
president. She introduces herself in this issue (Photo courtesy herself).

22 CME: Credits locally and out-of-town.

WE ANSWER FOR YOU!

Live Answering

Remote Receptionist
Appointment Scheduling
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SOMBRERO January 2015

Health, happiness, and the search for relevance

By Dr. Melissa Levine
PCMS President

e happy...be healthy...thats
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
wasnt 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 Ill 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, choles 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 wasnt 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 its now the newer, safer,
anticoagulants.
Though they exist, significant changes in the practice of medicine
are few. Im 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 Im part of Arizona Community
Physicians. Each of those positions taught me different things
about the practice of medicine, things I didnt learn in medical
schoolthings 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 didnt 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
SOMBRERO January 2015

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 theres 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. Josephs
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 whys 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. Youll 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

105th PCMS president.
n
5

Milestones

Dr. Katzenberg plants ideas

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 caloriedense oils, as well as additional heart benefits that can be achieved
from lifestyle changes and weekly exercise.

Dr. Beiter highlighted among

nations physician hospital
leaders
Amy Beiter, M.D., president and
CEO of Carondelet St. Marys
Hospital, was highlighted as one
of the 100 Physician Leaders of
Hospitals and Health Systems in
the United States by Beckers
Hospital Review for a second
year, Carondelet reports.
The recognition was based on
each physician leaders
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.

STARonSthe
l Ave

el
Campb

AVENUE
PRESENTED BY THE

Pima County
Medical Society

Save that date!

The date is April 18, 2015, and the

reason is the return of Stars on the
Avenue! Its at St. Philips Plaza,
4280 N. Campbell Ave., 6:009:00 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.
6

Under Dr. Beiters leadership, St. Marys 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. Marys is a Joint-Commission certified Primary Stroke
Center and is also honored as one of the American Heart
Association/American Stroke Associations Gold-Plus Quality
Achievement Award and Target Honor Roll Hospitals for Stroke Care.
St. Marys offers comprehensive, compassionate, and state-ofthe 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. Marys.
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. Marys, 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
MedicineTucson, 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 MedicinePhoenix 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
SOMBRERO January 2015

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.

In October he was guest speaker at the Western Section of the

American Urologic Associations Practice Management kick-off
session in Maui, Hawaii, on Medical Practice Safety and
SecurityRisk Assessment and How to Prevent/Respond to
Violent Encounter/Active Shooter possibilities at your office,
hospital, surgery center, or parking lot.

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.

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.

Dr. Moreno will continue to serve as professor of psychiatry at the

UA College of MedicineTucson 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 MedicineTucson. 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 underserved, 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).
SOMBRERO January 2015

Recently he taught two courses on Ebola tourniquets and disaster

preparedness to several hundred high school students at the
annual state HOSAFuture 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
nave T cell receptor repertoire and impaired effector T cell
responses, said Dr. Nikolich-ugich, principal investigator for the
study, Impact of CMV Upon T-cell Aging and Immune Defense.

PCMS News

UofA researches
cytomegalovirus

Study called important to improving

mortality odds

But the precise mechanism by which CMV affects nave 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.

A virus that infects us when were 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.

Adverse impact of lifelong CMV infection on the aging of T

cellsa type of white blood cell essential to immune system
functionand development of new immune responses could be
due to a number of factors.

CMV has been associated with impaired immunity, increased

morbidity due to cardiovascular disease, and reduced life and
health spansthe 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 MedicineTucson, funded by
a $2.3 million five-year grant from the National Institute on
Aging/National Institutes of Health.

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-ugich said.

It is critically important to understand the causes and consequences

of lifelong CMV infection for immunity and aging, said Janko
Nikolich-ugich, M.D., Ph.D. Dr. Nikolich-ugich 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.

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
CMV is present in 70 to 90 percent of people over 65, which byBUZZING
well to vaccines, such as the influenza vaccine, while others do
TINNITU
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not, Dr. Nikolich-ugich said. The immune
BUZZING
system works hard to keep the dormant CMV
TINNITUS
in check. We hypothesize that efficient CMV
control will correlate with strong and
TINNITUS
TIN
successful responses to vaccination in
NIT
US
BUZZING
humans and that individuals who use vast
resources to control CMV will be less likely to
respond well to vaccination.
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The research is supported by the National

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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
SOMBRERO January 2015

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 clich, 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. Josephs Hospital we have achieved a
new normal which has enhanced treatment outcomes for our
stroke patients.
SOMBRERO January 2015

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 patients 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 Caveshort for Brain
Attack Teamthe Carondelet Neurological Institute (CNI) at St.
Josephs 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 hospitals 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. Josephs 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
theWestern 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).
HRSAs Public Health Training Center Program is aimed at
improving the nations 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
9

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 Hawaii,
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

MedicinePhoenix 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 fourthdegree 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 Americas
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
log onto www.aslme.org .
n
SOMBRERO January 2015

Behind the Lens

Irresistible beauty
By Hal Tretbar, M.D.

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

SOMBRERO January 2015

11

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

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

white balance settings, exposure adjustment of -3 to +3, and ondemand 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.

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

Renowned outdoor photographer John Shaw says there are three

Ms that interfere with shooting sunrises and sunsets:
Mornings, Meals, and Mates. In the summer its a challenge to
roll out of the bed at 4 a.m. or so. In the winter it is rather chilly to

Of the 30 I have on my cell phones 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!

Who hasnt 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!

The Faces of Casa are the

Dr. Ann Marie Chiasson

Associate Medical Director

Working in hospice allows me to

practice both the science of medicine
and the art of medicine. Put simply,
wonderful holistic patient care focused
on comfort allows patients to live longer
and more comfortably.

520.544.9890 | www.casahospice.com
Hospice services are paid for by Medicare

12

SOMBRERO January 2015

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

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

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

SOMBRERO January 2015

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

13

PCMS Alliance News

Story and Photos by Dennis Carey

Holiday Luncheon draws 100+

There was truly something for everyone among the items donated for this years
Pima County Medical Society Alliance Holiday Luncheon, beautifully flung Dec. 10
at Flemings 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.

Lupita Borboa and Reem Aussy chaired this years

PCMS Alliance Holiday Luncheon at Flemings
Steakhouse on Dec. 10.

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. As
Apples, the giant caramel
apples made from the
recipe of Alliance Board
Member Kathy Armbruster.

With Alliance members, guests, and Mobile Meals of Tucson Board of Directors
members, about 125 attended. Holiday Luncheon proceedsderived from event
ticket sales, raffle ticket sales for donated items, silent auctions, and sales of Mrs.
As Applesall benefit Mobile Meals, which delivers more than 100,000 meals
annually to homebound adults.

Luncheon attendees examine some of the many items for the

raffle and silent auction.

14

Reem Aussy and Kynn Escalante take a break

from their host duties at the Holiday Luncheon.

This years event organizers included, from left, Kynn Escalante,

Mobile Meals Executive Director Priscilla Altuna, Kay Dean and
Joy Chapeskie.
SOMBRERO January 2015

Pracce Management

PQRS and VBPM: Double-whammy waits in wings

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

he Physician Quality Reporting Initiative (PQRI), a voluntary

quality reporting system for physicians, has become the nowmandatory Physician Quality Reporting System (PQRS).
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.

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.

Will My Group be Subject to 2016 VM?

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; communication and care
coordination; effective
clinical care; community
Satisfying the PQRS
and population health;
reporting requirements
and efficiency and cost
avoids the negative
reduction. Specialists
adjustment during the
This is slide No. 10 of the Value-Based Payment Modifier (VM) training
with fewer than nine
first year of the VBPM
presentation found on the CMS website at www.cms.gov/Medicare/Qualitymeasures or three
program (2015 for groups
Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014_
separate domains must
greater than 100, 2016
GPRO_VM_Training.pdf.
report all available
for groups of 10-99, and
measures across all
2017 for all others). In
available domains to satisfy the PQRS requirements.
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
PQRS measures may be reported in a number of different ways:
positive, neutral or negative updates based on their actual quality
1) on Part B claims submitted to Medicare; 2) via qualified
and cost performance.
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
Depending on what happens in the lame duck session of
measures by each of the above methods, except that groups may
Congress at the end of 2014 after the November elections or
no longer report as a group on claim forms (number 1 above)
during the next congressional session beginning in 2015, the
through the Group Practice Reporting Option (GPRO). Physicians
potential penalties for physicians could become even more
in the group, however, may still report PQRS measures on claim
severe. As part of the proposed repeal of the Sustainable Growth
forms as individuals. If physicians in a group report as individuals,
Rate (SGR) formula that failed earlier this year, PQRS, VPBM, and
CMS will determine whether more than 50% of the physicians in
EHR Meaningful Use (MU) would have been consolidated into a
the group met the reporting requirements. If so, the entire group
new quality program, the Merit-based Incentive Payment System
is deemed to have met the reporting requirements for that year.
(MIPS). The potential negative adjustments for the poorest
SOMBRERO January 2015

15

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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.

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SOMBRERO January 2015

Clinical Management

Delivering quality care to your patients

By Chip Hardesty
Its not who you are underneath; its what you do that defines you.
Rachel Dawes, Batman Begins

he Institute of Medicines
March 2001 report from
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 physicians 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.

paraphrase back to the patient to confirm that you understand

what theyre 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 dont know how to HOLD the reservation.
He could easily have been satirizing medical practices. You
neednt 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 youre doing, and take steps to improve.

Defining what people want, and measuring to see if we are

delivering it is a tricky business. The vision of the PatientCentered 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 cant argue with that definition, but science needs
data to progress, and a soft definition doesnt get us where we
need to be. Medical practices must define patient-centered,
find ways to measure it, and implement actions to improve it.

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 dont want to be customers. Theyre customers because
theyre sick, frightened, and/or confused. They are patients.

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 a patient-centered practice, we must be better than a

Google search.

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

SOMBRERO January 2015

Most patient complaints these days can be diagnosed with an

Internet search. But the Internet cant hear patients and cant
communicate effectively with other clinicians the way we can.

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.
n
17

Pharmacology

The warfarin contradiction

By Stuart Faxon

t what point is warfarins danger from bleeding

worse than the danger from clots, stroke, and
M.I. it is meant to prevent?
Thats 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 MedicineTucson, 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

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, warfarins 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
SOMBRERO January 2015

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.

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 classaction lawyers seeking patients who claim adverse effects from
all three.

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.

Opening January 2015

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 Dabigatrans 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.
Dabigatrans 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.

Dr. Thomas S. Kang & Dr. R. Jonathan Lara

office: 520-775-3333 fax: 520-775-3334

www.sonoranent.com
6340 N. Campbell Ave., Ste. #256 Tucson, AZ 85718

SOMBRERO January 2015

19
Sombrero January 2015 Ad.indd 1

12/16/14 11:10 AM

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.
Fagans 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.
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.

20

SOMBRERO January 2015

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

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 cant really prove these because theyre
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.
n

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.

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.

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).

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 patientyears, 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.

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

SOMBRERO January 2015

Warfarins 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 23.
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.

21

CME

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 SurgeryImplants and
Complications with doctors Swen Sandeen and Richard
Hess.
April 14: Cancer of the LungNewer Treatments and
Cancer Screening with physicians from Radiology Ltd.
May 12: Healthcare Reform 2015What 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 DiseasesDiagnosis,
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
clhmaxwell@aol.com and refer to Space for Rent.

November 10: PharmacogenomicsHow Medicines

Affect Differing Demographics of Patients with Dr. Timothy
C. Fagan.

January
Jan. 23: Clinical and Multidiscplinary Hematology and
Oncology 2015: The 12th 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: http://www.mayo.edu/cme/hematology-andoncology Contact: Lilia Murray, Mayo School of Continuous
Professional Development, 13400 E. Shea Blvd., Scottsdale
85259; phone 480.301.4580; fax 480.301.8323.
mca.cme@mayo.edu http://www.mayo.edu/cme

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SOMBRERO January 2015

Radiology Ltd. is pleased to share a new quantitative

brain image analysis tool called NeuroQuant, which
brings accurate and fully automated advanced MRI
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NeuroQuant is useful in the evaluation of patients from
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To learn more about NeuroQuant, visit our website at www.radltd.com. Please consult with
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23

MICA_Sombrero01'15ad_MICA_Sombrero05'04ad 12/17/14 4:33 PM Page 1

2014 MICA announces

tenth consecutive
year of dividends.
MICAs 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 MICAs founding.

Medical Professional
Liability Insurance
(602) 956-5276
(800) 352-0402
www.mica-insurance.com

Dividends declared for a given policy year

reflect the Companys financial performance
during that year. Past performance does not
guarantee future dividends.

24

SOMBRERO January 2015