Fields of Care: Spring Edition 2024 : simplebooklet.com

FROM THE CEOWe are excited for the first edition of our quarterlymagazine. This magazine is intended to capture thesights and sounds of the incredible work being doneby our providers and the rural hospitals we partnerwith, and provide visibility into the latest updates,news, and relevant topics in the industry andthroughout Rural Physicians Group (RPG). I have been with RPG since August of 2022. Prior tocoming on board with RPG, I had the privilege ofbeing the CEO at two rural hospitals for 12 years,one in Arizona and the other in Colorado. Beforethat, I was a hospital CFO in rural Colorado andcentral Wyoming for a total of 6 years. I alsoworked on the financial side of the parks andrecreation industry in Salt Lake City, UT as well asthe health insurance industry for 10 years. I havebeen married to my beautiful wife, Rachel, for 29years and we have 6 children.I am truly blessed to be a part of RPG and haveenjoyed getting to know our hospitals andphysicians since coming onboard. Over the last yearand a half we have worked hard to build thesupport infrastructure of the company with theintention to add more value to our partner hospitals,clinicians, and ultimately, our patient communities. In January 2023 Dr. Matt Pappy took over as ourChief Medical Officer, working with our hospitalsand physicians, and Dr. Sandra Guidry moved intothe Chief of Staff role, working with our internalstaff. We immediately moved to revamp ourRegional Medical Director (RMD) and ChiefHospitalist (CH) responsibilities to provideopportunities for growth and leadership, drivepositive impact, and elevate the quality of ourservices. We put together a team of RegionalProgram Directors (RPD) with four exceptionalpeople, to work in a diad model with the RMD’s insupporting our hospital partners and providingquality management of each hospital program. Webuilt amenities such as a self-scheduling tool for ourproviders to have more ownership of their work-lifebalance, and an internal billing department tomaximize reimbursements for our providers andallow them to focus on what they do best –delivering high quality care to their patients. We also rebuilt our recruitment team to selectivelycontract with only the best providers across themarket with a rural focus, and promoted ourschedulers to Provider Operations Coordinator(POC) to be increasingly focused on bettersupporting our clinicians through a revampedonboarding process and ongoing quarterly check-ins. We hired a new sales team and brought on twofantastic people to help us grow our hospitalpartnerships. In the Fall of 2023 we had our first ever LeadershipSummit where we invited our RMD’s and CH’s tocome to Denver, CO to provide their input into thedirection and future of the company, and it was agreat success! We evaluated our mission, vision, andvalues and revised them to help us stay focused onwhat is most important – the patients, our hospitalpartners, and our providers. Thank you for being apart of RPG and for helping us to fulfill our missionand vision!CHIEF EXECUTIVE OFFICERMike Patterson02SPRING EDITION

Page 4

FROM THE FOUNDERDear Reader,As you peruse the inaugural edition of Fields of Care, pleaseconsider the following: This effort was accomplished by a group of busy professionals,who are great at doing more than just working hard. They areamazingly creative and possess a distinct vision. Congratulations to the team! My hope is that as you go through various articles, you will notonly find a few answers but also become curious and have a lotof new questions. The answers to these questions will be partof a mindful response to the healthcare crisis that threatens ourrural communities. At RPG, we are committed to seeking and manifesting aneffective approach to rural health. Please join us in this effortthat literally affects and changes lives across rural USA.FOUNDER & EXECUTIVE CHAIRMANDr. Sukhbir PannuFIELDS OF CARE03SPRING EDITION

Page 5

Medicine and society are in a constantstate of evolution. In my journey ofpracticing medicine, I’ve discovered mypassion lies in providing healthcare in ruralcommunities, who cherish thefundamentals of life. Rural America isenriched with quality family time, hardwork, faith, and caring individuals. It’simmensely gratifying to offer healthcarewith autonomy to these critical accesshospitals, ensuring patients can remainsurrounded by loved ones duringchallenging times.I feel incredibly fortunate to be a part ofRural Physicians Group, which allows meto forge connections with these uniquetowns and help contribute to building theirhealthcare systems. As a RegionalMedical Director, my goal is to assemble ateam of compassionate yet skilledphysicians dedicated to servingcommunities like Prairie du Chien, WIIn rural medicine, each community has itsown quirks and challenges. Butrespecting, adapting, and learning fromthe great minds in these rural communitiesis where the real value lies especially forhealth care providers. I was very lucky and happened to stumbleupon rural medicine by accident. At thetime I wasn't looking for anythingpermanent as we were about to move butit ended up being the dream job I neverknew I wanted. Despite moving half-wayacross the country, I have kept that sameposition but now travel includes anairplane ride instead of just a car ride. Through working in rural hospitals, I havebeen able to return to the joy of medicine-something I thought I had lost through thegrueling years of residency and thenworking in a large hospital system where Ifelt very limited in what I could offer mypatients. Rural medicine has allowed me tocare for my patients to the fullest extentof my knowledge and experience. I am sograteful to RPG for recruiting me in thefirst place and I am very supportive oftheir mission to continue to provide ruralareas of the US with exceptional medicalcare. I look forward to the future of RPGand their overall commitment to theseoften-neglected areas of our country.DR. JAY AFZALREGIONAL MEDICAL DIRECTORDR. JACOB KALLIATHREGIONAL MEDICAL DIRECTORDR. CAITLINBRANDSDORFERREGIONAL MEDICAL DIRECTORLEADERS IN ACTIONI am grateful for the sense of joy andpurpose that my career in medicine bringsme. It’s become increasingly apparentthat a growing number of my medicalschool peers are experiencing burnout.They often inquire if I have consideredalternative career paths outside ofmedicine, as they seek different avenuesfor income. It is disheartening to witnessthe erosion of passion for medicine amongmany colleagues. The encroachment oflarge hospital systems on physicianautonomy and the prioritization offinancial gain over patient careexacerbate this issue. However, I am fortunate to work withRPG and our hospital partners, who sharea unified goal: to deliver exceptional careto our community. Rural communitiesprioritize people over profit. I can attestthat with consistent effort, hard work,and a genuine interest in the well-being ofthe community, hospital administration willprovide robust support for your success.As the regional medical director, myaspiration is to foster a work environmentwhere such supportive relationships arenot the exception but the norm, ensuringthat physicians not only succeed but alsorediscover the joy in their vocation.04SPRING EDITION

Page 6

I enjoy rural medicine because I feel inthis day and age it’s the purest form ofphysician centered inpatient care withoutthe limitations and complexities unique tolarge hospitals. The smaller setting isactually advantageous because it allowspatients to get more direct andpersonalized care from their physician. I chose rural medicine because it is unlikethe larger hospital setting, whereproviders are reduced to feel like just acog in the wheel, and quantity seems moreimportant than quality. In critical accesshospitals, physicians have clinicalautonomy, operating at the helm ofpatient care - from admission todischarge, and everything in between,doing what’s best for their patients. I am grateful for the opportunity to workwith Rural Physicians Group. The work/lifebalance is second to none. What is mostsatisfying about my job is knowing that Iam making a significant impact on mypatients' well being, while alsocontributing to improvements in clinicalworkflow, protocols, and patienteducation. Working alongside our clinicalstaff, together as a team, we are able tooptimize the hospital's reach and betterserve our community. I enjoy rural medicine because of thesmall town atmosphere. A large majorityof hospital staff grew up in the town andare obviously deeply invested in thequality of healthcare to their friends andfamily. I genuinely enjoy becominginvolved as much as I can in thecommunity while I’m serving. I appreciate RPG and the overall vision ofkeeping local patients local. Our mission isto bring rural hospitals and providerstogether to enhance the care of theircommunity. RPG provides us the groupresources needed to be successful on thefront lines.DR. FARAAZ OSMANIREGIONAL MEDICAL DIRECTORDR. FRED WORKMANREGIONAL MEDICAL DIRECTORLEADERS IN ACTIONFIELDS OF CARE05SPRING EDITION

Page 7

Page 8

EXCELLENCEWORLD CLASS EXPERIENCEPURPOSEAt RPG, we are honored to bea tried and true solution to theRural Healthcare Crisis thatmany hospitals face today, andthe threat it poses to manycommunities across thecountry. We thrive at thecrossroads where passionmeets purpose. A point of focus for RPG this past yearcentered on a genuine commitment toperpetually building a world-class experiencefor our Hospitalists, Surgeons, AdvancedPractice Providers, and Hospital partners. Weare expanding clinical capabilities to betterserve our patients, while adding value to ourhospital partners, and passionately drivingpositive change in rural healthcare throughinnovation, collaboration, and staying true toour vision: “We keep local patients local.”In October of 2023, wehosted our first LeadershipSummit – the official venuebringing RPG’s administrativeand clinical leaders together,under one roof, to connect toour purpose, strengthenrelationships with each other,collaborate to form creativesolutions, and to discuss thevision for the future – allwith the intention of addingvalue to each other and thepatient-communities that weserve. We are excited aboutseveral key projects beingimplemented as a result.07SPRING EDITION

Page 9

The Presidential Award of ClinicalExcellence (Doctor of the Year award)was presented to Dr. Tim Hockenberry. From left to right: Dr. Fred Workman(RMD), Mike Patterson (CEO), andJessica Steinat (VP of Operations).The Presidential Award. ofExcellence in Advanced Practicewas presented to Sandy Harman,DNP. From left to right: MikePatterson (CEO), Cameron Byers (VPClinical Services), Dr. CaitlinBrandsdorfer (RMD).Congratulations to Kittitas Valley Healthcare in Ellensburg,WA! From left to right: Abby Krone (RPD), Dr. JacobKalliath (RMD), Mike Patterson (CEO), Michele Howard (VP ofOperations).AWARD WINNERSHOSPITAL PARTNER OF THE YEAR08SPRING EDITIONDr. Pannu Founder’s Award ofExcellence was presented to Dr.Madhuresh Kumar. PRESIDENTIAL AWARD OF EXCELLENCEPRESIDENTIAL AWARD OF EXCELLENCEFOUNDER’S AWARDOF EXCELLENCE

Page 10

Page 11

INGREDIENTSINGREDIENTS& DIRECTIONS& DIRECTIONSLEMONS8-11Roll your lemons across thecounter before squeezingthem to release the mostjuice possible.LIQUID STEVIA1.5 TSPOr substitute with yourpreferred sweetener --Simple Syrup, Honey,Maple Syrup, etc.ENGLISH CUCUMBERS2-4English Cucumbers areseedless or have verylittle seeds. Squeeze lemons until you have 2 cups of juice. Remove any seeds andset the lemon juice aside.Peel and chop the cucumbers, then use a blender to liquify them, andstrain the purée - You need 2 cups of cucumber juice. If you have juicerthat would work as well for this step.Fill a pitcher with 2 cups of cold water, pour in your cucumber & lemonjuice, and stir. Next, add in the liquid stevia (or your preferred sweetener) a tiny bitat a time. Stir and taste test between each addition. You can also addmore cold water now to dilute the lemonade if you prefer.Keep refrigerated until ready to serve. Serve in glasses filled withfrozen melon balls or ice cubes.Garnish Ideas: Cucumber & lemon wedges or freshmint for an extra bit of fresh flavor!10SPRING EDITION

Page 12

DearDr. Abby“I don’t have access to agym which makes itharder to exercise. Isthere anything I can doat home to exercise?” Of course! My advice is tostart simple and stayconsistent. For those who like to clean:set a timer for 15 minutes andsee what you can clean. Thatway, not only are you gettingyour heart rate up and stepsin for the day - but the placestays fresh and clean! If the weather is nice, go for awalk after a meal- it helpsyour body digest food betterand walking also helpspromote regular bowelmovements. A good startingpoint is 30 minutes per day,and work your way up to 60minutes. “I’m not ready to make abig change in my diet.What are simple things Ican do to develop healthyhabits?”Invite the neighbors to goalong with you. It helps passthe time away, and keepsyour brain stimulated andhealthy by engaging inmeaningful social interactions. Exercising could be a familyevent. Take the kids out forany outdoor activity - as longas you are moving, it counts! Take a look at a few of myfavorite exercises, easy to doat home (on the followingpage).If you’re not ready to make acomplete change – that’sokay! Look at making smallchanges 11SPRING EDITIONWelcome to Dear Dr. Abby! Here you will find a dedicated space toall things wellness and something Iconsider advice from your “loving bigsis.” The column will showcasequestions from “you”, the readers, witha compassionate response along with adash of clinical expertise to support ouradvice. My hope is, you are able totake away a nugget of knowledge andmotivation to learn something new; andnurture any desire to become a betterversion of yourself by practicing thewellness tips and tricks provided. If you have anyquestions forDear Dr. Abby,please scan theQR code or youcan email me atDearDrAbby@ruralphysiciansgroup.com BY ABBY KRONE

Page 13

sauce. You can also make your ownmeatballs and incorporate veggies in. If your kids like a sweet treat, see ifthey’d like a smoothie. Once again,sneak a handful of spinach in. “How much water do weactually need to bedrinking?“Water makes up approximately 60%of your body, and is necessary tocarry out critical functions such as: cardiovascular health and bloodflow, maintaining your bloodpressure, flushing out waste productsand toxins from your body,regulating body temperature,maintaining your digestive system,and is vital for brain health, amongmany other processes. There is no easy answer or singlecorrect answer to the question ofhow much water a person shoulddrink per day, because it depends onmany factors – your age, gender,weight, health conditions, how activeyou are, where you live, the weather,and the list goes on. “I have a family of pickyeaters. This makes itchallenging to find healthymeals that we all can enjoy.How can I find healthiermeals that even my kids andfamily will enjoy?“ Feel free to get a little sneaky! Youcan find ways to incorporate veggiesinto the meals your kids already enjoy.For example, if your kids like spaghettiand meatballs, you can dice or blendzucchini or other veggies into the 12SPRING EDITION with what you have. Mindful eating isa great start! Drink a full glass ofwater before you have your meal. Thishelps prevent overeating.Intentionally put your fork down 3times during a meal and pause for aquick break. Sometimes your stomachdoesn’t realize it’s full until it’s too late. Use a smaller plate. This helps remedythe natural human tendency to fill upthe plate. This is an easy way to limityour portion size. However, first and foremost, makesure to follow any specificinstructions from your doctorregarding water intake (especially ifyou have certain health conditionssuch as heart failure or kidneydisease). Otherwise, as a general rule ofthumb, proper hydration includesdrinking small amounts of waterthroughout the day. For some, 8-10glasses per day is adequate(approximately 64 ounces). Forothers, that is too much or notenough. Therefore, as anothergeneral way to know your hydrationis probably adequate is if your urineis colorless or light yellow, or if yourarely feel thirsty. A helpful way to track your waterintake is to get a reusable waterbottle (indicating the ounces), thatyou can refill each morning andcontinue to drink and refillthroughout the day.

Page 14

Using an exercise mat will giveyou enough padding to becomfortable on all fours. Improves postureStrengthens the back Strengthens the coreDecreases risk of injury to thespine Improves flexibilityPLANKSBENEFITSThe goal is to move your body - not set a personal record for weight lifting! Here are a fewexercises you can do at home and it all begins with a timer. Set a timer for ONE minute and seehow many of these exercises you can do. As this becomes easier, add more time! Begin in the plank position seenin the photos, face down withyour forearms and toes on thefloor. Your elbows are directlyunder your shoulders and yourforearms are facing forward.You should be looking at thefloor. Avoid tilting your headupward.Keep your torso straight,engaging the abdominal muscles,and your body in a straight linefrom your ears to your toes. Donot let your shoulders creep uptoward your ears. Keep yourheels over the balls of your feet. Do not arch your back or sagyour hips. Over time, work your way up to30, 40, 50, or 60 seconds.Hold this position for 20 seconds.Relax to the floor.13SPRING EDITION

Page 15

Improves your cardiovascularhealthIncreases the strength of themuscles in your chest and armsStrengthens the back anddecreases risk of injury to thespineImproves your posturePUSH UPSBENEFITSBegin in the starting position withpalms down on the floor, armsstraight at the elbows, and bodystraight like a board.Place hands slightly wider thanshoulder width apartLower your body to the ground,bending at the elbows, keepingyoru body straight, and gettingas low to the floor as you canwithout touching itUsing your hands, push off theground to lift your body back upto the starting position, keepingthe body straight through theentire motionStart out by trying to do 10repetitions. Gradually work yourway to higher repetitions as youbecome more advanced.14SPRING EDITION

Page 16

Start with your legs slightlywider than shoulder width apart,and toes pointed slightlyoutward for support. Strengthens the back, glutes,and thighsBurns calories and fatImproves digestion Improves circulationHelps get rid of cellulite Strengthens the jointsImproves flexibility Strengthens the bonesSQUATSBENEFITSSlowly bend your knees to asclose to a seated position as youcan (as if there were an invisiblechair behind you - but be carefulnot to bend too far and fall). Your thighs should be parallel tothe floor.Keep your back straight andshoulders up through the entiremotionStart out trying to do 10repetitions and then rest. Repeat this again, and then rest. Repeat it one last time and rest. 15SPRING EDITION

Page 17

Growth, Elevation, and Evolution; three interconnected forces that shape the trajectory forboth a successful career, and a trusted healthcare network. Rooted in small town tradition,Crossing Rivers Health Medical Center (CRH) in Prairie du Chien, Wisconsin, is a critical accesshospital home to a population of just over 6,000 wholesome people. Located in the heart of theDriftless area of Southwest Wisconsin, this beautiful settlement is the second oldest in the state. This beautiful Critical Access Hospital, with about 25 hospital beds, serves a population thatincludes committed tourists from Iowa and Minnesota. For some, this may translate as “smalltown medicine”, however, the leaders at CRH through strategic foresight have led the way tosustainable success. The hospital’s consistent pursuit of excellent patient care and outcomes,tailor shaped by a unified front of Clinic, ED, Inpatient, and Surgery service lines all convergeto form the essentials that hold the keys to trusted healthcare.MOVINGTHENEEDLE SPRING EDITION 16KERIANNE WRIGHTJESSICA STEINATJAY AFZAL, MDMATT PAPPY, MD

Page 18

At one point in years past, thehospital was facing the challengesmany rural hospitals face – theconstant revolving door of medicalproviders. However, with astuteleadership and cultural rejuvenationexemplified by the CRH administration,through a strategic partnership withRural Physicians Group (RPG), ahealthcare management and serviceline development company, they wereable to successfully implement aHospitalist program, featuring directaccess to an onsite/in-house physician24/7, solely dedicated to inpatient care.That was a vital step towards providerretention, stability, and growth. Prior tothe collaboration with RPG, theinpatient coverage was provided by atraditional model with supplementalnocturnist coverage, and the ensuingfallout of providers caused instability,and a lack in continuity of care. RPGwas able to assist with recruiting skilledproviders, aligned with the hospital’svision, and embedded into the cultureof the community. The Chief Executive Officer of CRH,Chris Brophy who previously served inthe role of Chief Financial Officer at thehospital, describes the inpatient team ashaving the mentality of “being owners,not renters.” For example, theHospitalist team leaders havedeveloped effective rapport withdirectors of the various specializedservice lines which has helped withpatient/staff education, reducingcommunication SPRING EDITION 172023 Crossing Rivers Health Medical Executive Committee (left to right): Maranda Record, MD; Kristen Huber,MD; Mohammad Afzal, MD; Kevin Klean, DO; Anna Myklebust, MD; Not pictured: Paul Mariskanish, MD.

Page 19

gaps, streamlining workflows, andperpetually improving the overallhospital work experience. Focus wasalso placed on the need to enhancepatient experience from clinic to ER tomedical floor to Surgery and finallyhome, with post-discharge follow-upcare also a priority. Director of CareCoordination, Amanda Schultz, shares“... the physicians are integrated into ourorganization like an employee. They area part of committees, they are activelyengaged in supporting the nursing staff,and they care about the quality ofpatient care provided in our inpatientdepartment.” The Chief OperatingOfficer, Nicole Martin alwaysemphasizes on the concept of, “…bringing in multipliers and notdiminishers.” The idea is to cometogether as an organization and knoweverybody plays an intricate part of thehospital’s success. At the heart of this team, is AngelaBollman, Director of Inpatient Servicesand Shanon Mergan, Chief ClinicalOfficer, both of whom leverage theirlocal roots and healthcare expertise tofoster a unified patient care approach.They emphasize personal andprofessional development, whichresonates deeply within the close-knitcommunity. Angela is a prime exampleof the hospital’s investment in fosteringgrowth locally, as she started as aregistered nurse, then transitioned tothe house supervisor role, obtained herMasters degree and eventually herDoctorate, and was ultimatelypromoted to her director position. Shehas played a pivotal role providingleadership and clinical support, as wellas integrating nursing care with theHospitalist and Surgical programs. RPGbrought a paradigm shift in patientcare, and SPRING EDITION 18

Page 20

within that context, Angela shares thatthis was directly proportional to thedevelopment and confidence of nursingstaff. Nurses now have the availabilityof dedicated physicians around-the-clock fostering a synergy that enhancespatient outcomes and patientsatisfaction. The partnership with RPGsupports the development of currentand prospective nurses. SouthwestTech, a nursing school local to theregion, has aligned with Crossing RiversHealth, and it has been a greatopportunity for nursing students toprecept and receive invaluable hands-on experience from the physicians aswell. The hospital has created a collegialenvironment and experience to thosebeginning their nursing career andaspiring to take care of patients in theirhometown. Chris (CEO) highlights recruitment andretention as pivotal challenges,countered by fostering a sense ofownership and dedication among thestaff. For example, Dr. Jay Afzal, RPGChief Hospitalist, also serves in a dualrole as Vice Chief of Staff, exemplifyingcommitment, and ensuring deep ties toboth the hospital and the widercommunity. Practicing medicine is morethan just taking care of your patient. Itis about creating a collegialenvironment that supports and addsvalue to one another, checking in withadministration, and activelyparticipating in leadership opportunities,such as attending meetings, assistingwith conflict resolution, and overallhospital success. From a holisticperspective, Hospital Medicine is justone piece of SPRING EDITION 19

Page 21

the puzzle; a piece that must fit well withPrimary Care, Emergency Medicine,General Surgery, and of course all othersub specialties. Nine years since the inception of theRPG Hospitalist program at CrossingRivers Health, in the Fall of 2023, camean opportunity to expand clinicalservices by offering a full time GeneralSurgery program. RPG provided amethodical onboarding process toconstruct a step-by-step plan, workingbackwards from a designated programlaunch date. General Surgeons wererecruited with a focus on ruralhealthcare needs, offering a uniqueblend of surgical skills, patient care, anda diverse caseload. Other highlyrecognized components to a valuedprogram are the active participation incommunity outreach with local PrimaryCare Physicians, effectivecommunication, providing education tostaff, and fostering a team dynamicwithin the hospital. The arrival ofsurgeons like Dr. Steven Miller and Dr.Joel Meyers has been instrumental inthis expansion of the RPG/CRHrelationship. The camaraderie andloyalty amongst physicians in alldepartments have brought anintegrated care approach with shareddecision making in treatment strategies. It is here, in Prairie du Chien,Wisconsin, at Crossing River’s Health,where “critical access medicine” hasperpetuated a culture of Growth, Elevation, and Evolution.This is a tribute to the leadershipexcellence by the administrative teamcoupled with the collaborative efforts ofmany clinical providers and staff, instanding up a Hospitalist program andGeneral Surgery program, to meet theneeds of the community by elevatingthe quality of care and keeping localpatients local. They are..... Moving TheNeedle. SPRING EDITION 20

Page 22

LEADERSGO FIRSTOver 130 rural hospitals have been forced to close their doors in the past decade,and over 600 more are at risk of closing, which threatens a population of 60million people across the country. Many rural hospitals are fighting for theirsurvival, almost entirely caused by burdensome regulations, decreasingreimbursements, increasing costs, and challenges related to the recruitment andretention of physicians, advanced practice providers, nurses, and the like. Thisposes a threat to population health and can have negative downstream effects onrural economies. Although this crisis is complex and has many tentacles, there is noquestion that the single greatest determinant of each hospital’s destiny, is directlyproportional to the level of excellence in leadership at every turn. 21SPRING EDITION BY MATT PAPPY, MD

Page 23

Unfortunately, we have created a culture inwhich administration exists within a box, andclinicians exist within a separate box. We are in atime where the margin of error is razor thin, andthe decisions that leaders make – administratorsand clinicians alike – will be the differencebetween thriving and barely surviving. While it isimportant to aggressively pursue solutions at thestate and federal legislative level, often heldcaptive by the paralysis of politics and red tape,there exists an incredible opportunity for leaders tocreate the momentum needed to steer the directionof rural healthcare true north. More pointedly, inthe race against time, there should be a sense ofurgency for administrative leaders and clinicalleaders to tap into one of their most underratedassets – bridging the “opportunity gap” betweenclinicians and their personal development towardsbecoming transformational leaders. The return onthat investment is immediate and long enduring forhospitals, administrations, and patients alike. In this article, we hope to dive into the differentand unique perspectives of both administratorsand clinicians, and equip each with several 22SPRING EDITION proven strategies/recommendations that may helpunderstand the relationship better, collaboratecohesively, close the opportunity gap, and createa leadership culture that is crisis proof. CLINICIANS ARE THE CATALYST Rooted in rural towns across the country is theinnate ability for people to band together, outsideof their comfort zones, to overcome crisis, throughresilience and carrying a sense of ownership – therural hospital environment is no different.In timesof need, clinicians in rural hospitals can generallybe counted on to roll their sleeves up, dig deep,and work with staff towards a united goal.Clinicians can be a powerful catalyst for change,that administrators can utilize in times of need, tothe benefit of the hospital and patient-community.However, there are several distinct barriers in theway of ever making this a reality. Firstly,administrators should accept the realization thatany efforts to reaching goals, meeting targets,achieving metrics, etc are futile in the long-run,without buy-in and active participation from thosethat work at ground zero – the clinicians.Therefore, priority must be placed on achieving

Page 24

their buy-in. In some instances, success is realized,despite lack of buy-in from clinicians; however, becareful to note this is often just coincidental andtransiently short-lived. Because they work in the trenches, clinicianshave the keen ability to provide unique insight withaccuracy and precision, that administrators wouldnot otherwise be able to obtain from any othersource. Their input could save the organizationfrom making preventable mistakes, identify keybottle necks or choke points in the system, identifykey opportunities for clinical expansion based ontheir direct contact with patient care needs in thecommunity, and help strategize ways to achieve acommon goal that administrators have set out todo. Clinicians could carry the message fromadministrators more effectively to other providers,nurses, and staff due to their position, theirworking relationships, and their trust capital. Theyhave the potential to drive excellence on theclinical side, which theoretically should translate tothe side of quality, metrics, patient experience,hospital ratings, and communication scores, etc aslong as strategy is properly implemented. 23SPRING EDITION START WITH WHAT YOU ALREADY HAVE Secondly, to my administrative colleagues, youmay very well have some talented clinical leaders,that just have yet to emerge, never beingchallenged or approached. Some clinicians areoverlooked and underestimated, but are actuallydiamonds in the rough. They say diamonds aremade from pressure, and simply by virtue of therigors of medical training across many years,clinicians have been exposed to high pressure forextended durations – the high expectations ofacademia, the high demands of the healthcaresystem, the highest scrutiny from patient reviews,and the high-stakes of patient mortality. In otherwords, they could handle some pressure, theycould handle problems that arise, and find a wayto solve them. Afterall, they listen to patients’problems, diagnose them, and reach a treatmentsolution for a living. They can also handle “straighttalk.” In other words, tell them exactly what youmean, what you think, what you want and need.They will meet or exceed the expectation; they areusually wired that way. If not, consider re-framingyour message or delivery to them.

Page 25

In other cases, clinicians are overlooked ordeemed unfit to be leaders, based on theirreputation or past response to directives handeddown by administrators. Below the surface, manyclinicians possess leadership capabilities, but haveflown under the radar over the years, siloed into aclinical role only, causing regression of theirinterests and skills in leadership. This is simplybecause the traditional culture within thehealthcare system, from a clinician’s uninformedperspective, is that administrative leaders “exist topush their metrics onto clinicians, to meet somequota or goal.” This is of course untrue, and aresult of a lack in communication andunderstanding. Clinicians too are oftenmisunderstood in much the same way, where alack of communication created a disconnect,leading to an unfavorable impression ofthemselves. However, they can be “rehabilitated”or “refurbished” to become incredible leaders, ifgiven the opportunity, and if rooted in a wellnurtured hospital environment. You can identifythem easily – just ask them directly whether or notthey are interested in spearheading a project orleadership opportunities, and they will let you 24SPRING EDITION know pretty quickly. Don’t be surprised if they arestartled by your inquiry, as they may never havethought in a million years any administrator wouldever ask them for their input or interest. If they areinterested, give them a chance, and you will see agood return on that investment. MEET CLINICIANS WHERE THEY ARE Thirdly, as an administrator or hospital leader,when planning to implement a new protocol orstrategic initiative that involves or affects cliniciansand patient care, involve them before you get toofar into the weeds. If you take just a few minutesto explain what you are hoping to achieve, andyou are seeking out their input, you will gain theirrespect and buy-in immediately. It doesn’t takemuch. Make sure to meet clinicians where they are;in other words, they lack expertise in your area ofhospital administration. For example, topics likeoperating margin, DRG, CMI, % admissions fromER, readmission rates, regulations, etc feel like aforeign language to even some of the mostexperienced providers. It is important to providethe necessary background, data, and details forbuy-in to take place. By seeking out their input on

Page 26

how to achieve the goal, you will pique theirinterest, create ownership in their quest to solutionthe problem, and transform their “work” into“purpose” which fuels motivation, as opposed touninspired work from a directive they never quiteunderstood to begin with. Seek to create aprofessional culture that is relational, nottransactional. You will not regret it. EXPLAIN “THE WHY” Fourthly, oftentimes hospital leaders ordepartment leaders fail to explain “the why”behind certain initiatives that are being carriedout. The problem is, without understanding thereasons for a particular directive, clinicians oftenfeel confused, detached, undervalued,overworked, all of which leads to burnout andpoor compliance. In all fairness, no one wants totake on an increased workload of time-consumingitems – unless there’s a good and justifiablereason to do so. That’s all it takes, most of the time– just explaining “the why.” Most clinicians arereasonable people and will go the extra mile if ithelps the hospital, administration, or patient. Consider the example, when approaching aclinician with the new hospital initiative to “improvedocumentation.” The dietary team identifies apatient has “severe protein calorie malnutrition”and wants the clinician to support that in theirprogress note. If simply told to document it, aclinician may view that diagnosis as insignificant,chronic in nature (patient’s baseline), and not thereason for why the patient is hospitalized, andtherefore reluctant to take the extra time andeffort to identify the diagnosis, add it to theproblem list in the EMR, and document it in thenotes, with a proper assessment and plan.However, what if we took the time to explain “thewhy” to the clinician? For example, “The cost ofhealthcare related to patients with malnutrition issignificant, and cited as high as $49 billion,because they typically have a longer length ofhospital stay, higher occurrence of surgical siteinfections, and higher in-hospital mortality. It isoften under diagnosed and undocumented, 25SPRING EDITIONhowever, if it were appropriately diagnosed anddocumented, it can have an impact on DRGassignment, and therefore higher reimbursements.In a recent study, 68 cases were diagnosed andthen documented, leading to an estimatedadditional reimbursement of $571, 281.” Thisprovides the necessary education to the clinician,explains “the why” behind the request for the”extra” documentation, establishes relevance, andinitiates a degree of ownership and responsibility inthe matter. “The why” will essentially guaranteebuy-in and compliance from the clinician, not just inthe short-term, but from that point forward. INVEST IN THEIR LEADERSHIP PATHWAY Invest in their leadership journey. For example,consider sending your clinical leaders to variousleadership conferences that teach and serve thepurpose of growing leaders and teaching them 2

Page 27

how to adapt to the ever-evolving landscape thatis rural healthcare (leadership track).Equip yourclinicians with the necessary tools and resources tooperate at the highest degree of effectiveness. Beas transparent with the financials or issues as youcan so they can fully understand the situation andoperate from there. Create leadership roles forclinicians to serve and engage in; trust theirleadership. Open communication and frequentcommunication with clinicians go a long way. Set astanding meeting with your clinical leader at afixed cadence (ie. monthly). This shows that youvalue their input and relationship, despite yourbusy days full of meetings. These are the elementsof investment that develop ordinary clinicians intotransformational leaders, which I believe is one ofthe most underrated resources, and essentialingredients to sustainable success.THE ERA OF TRANSFORMATIONAL LEADERS The time is now for administrators to beintentional and reach out to their hospitalproviders, to identify, grow, and develop theminto transformational leaders, not only at the 26SPRING EDITION patient’s bedside, but also in the board room oraround the conference table where decisions aremade. Transformational leaders surrender theirimmediate self-interests, and work with teams orfollowers, to identify areas that need change,shape the company culture, help create the visionforward, influence and inspire others on thejourney through change, and foster autonomybalanced with accountability. This creates anownership mentality and approach, where self-sacrifice is innate and loyalty to the administrationor organization is born. With proper mentorshipand guidance by hospital administrators from aleadership perspective, ordinary clinicians have thepotential to be the driving force affecting changethat has long been sought after, while bringingmany of the staff with them on that journey, in away that administrators may not be able to do. Reciprocally, the time is now for clinicians inrural hospitals, to step outside their comfort zone ofsolely practicing medicine, and to answer the callto leadership excellence. Take opportunities to addmore value to your hospitals and patient 1

Page 28

communities – by joining any number of hospitalcommittees, or taking part in the development oftreatment protocols, or teaming up with colleaguesto develop strategies to achieve quality metrics, orcollaborating with the ER director to identify waysto reduce the unnecessary transfer of patients, ormeeting with nursing staff to optimize workflowefficiency, or connecting with administration todiscuss potential expansion of clinical capabilitiesbased on community needs – and the list goes on.To lead effectively, clinicians need to be equippedwith a deeper understanding of the healthcaresystem from a CEO’s perspective, the financialchallenges, the rural landscape, etc so they cantake part in fiscal responsibility, and work from theinside-out on ways to lower costs and improvereimbursements (via quality documentation,reducing readmission rates, etc). 27SPRING EDITION LEADERS GO FIRST During periods of success within a hospital (orany organization for that matter), great leadersmay choose to lead from the back of the room,humbly deferring the credit and recognition toemployees and staff, focusing the lens on them asthe “main character.” However, during challengingtimes of adversity, hardships, or when a criticalchange in direction is needed, these same greatleaders reflexively shift to a different posture –leading from the front. When facing turmoil orcrisis, great leaders fully understand the vauntedtask of needing to initiate a strategical pivot, whichinnately transfers the heavy burden ofresponsibility and risk onto their own two shoulders– the risk of financial loss to the hospital, or closureof departments, or cancellation of services, ornegative impact on patients, or negativecommunity perception, or employee attrition, oreven personal termination. Leading from the front is a road much morechallenging, as all eyes are on you, and yourdecisions are under the microscope, laid bare toeither scrutinized criticism or praise, depending onthe outcome. It requires their trust in your abilitiesas a leader, and requires faithful buy-in from manypeople with differing views, converging towardsone vision, married to the mission, to reach theintended destination ahead. It is critically importantfor administrators and clinicians alike, as leaders, to“go first” – to make the first move, one towardsthe other, administrator to clinician and vice versa.Clinicians should not wait passively on the sidelinesfor a hospital leader to come seek their guidanceor insight. Instead, they should “go first,” take theinitiative, proceed with self-directed leadershipopportunities. This means clinicians should make theeffort to ask to meet with administrative leaders atthe hospital, and find out what they can do to help,learn, and grow; seek out ways that they can addvalue to the hospital. In the same way, administrators should avoidfalling into the mistake of overlooking the valueclinicians may bring to the strategic side of hospitalinitiatives, and instead, make the walk to

Page 29

subject matter expert when it comes to providingguidance and insight from ground zero; but it doesno good if you don’t make the time or take theopportunities to join committees and spread thewealth of information, or actively participate inimproving the conditions around you. It is wise toapproach each opportunity (committees, etc) withthe intent to learn, first and foremost, and notnecessarily to provide insight. Set goals that arerealistic and within a certain timeframe, andreverse engineer the strategy to achieve them.Take ownership in the successes and failures of theplan and strategy; it will challenge you, and growyou, more than you can imagine. the inpatient unit, seek out the providers, invitethem to meetings, or simply to their office for afew minutes. The overwhelmingly largepercentage of clinicians will not be “seeking out”leadership roles – but have the necessary insightand skillset to play a significant role in creatingmeaningful impact. Because clinicians do notgenerally seek out opportunities outside of patientcare, they need to be “brought in” byadministration. Most of the time, clinicians will feelempowered and valued when they have been toldby administration that their insights are valued,appreciated, and they are trusted. This is the wayof transformational leaders, who lead from thefront, and “go first.” WORDS OF ADVICE TO CLINICIANS To my clinical colleagues, I would advise you tobe open minded to learning and discussing thecritical issues that plague our rural hospitals today.You are an important part of the solution.Approach the situation with an attitude focusedon “what we CAN do” and resist the temptation tofall back on the default notion of “what we CANTdo, or what we DON’T have.” Whatever barriersor obstacles you identify, be transparent with theadministration, and creatively find ways toovercome and solve for them. Your words andyour actions have power to influence thosearound you; be responsible with them. Know thatyou have a unique perspective, and are the 28SPRING EDITION

Page 30

perilous gap that exists between hospitaladministrative leaders and their hospital providers;the former striving to meet the financial andoperational challenges of the healthcare system,while the latter narrowly focusing on meeting thedemands of patient care to provide the bestoutcomes. While the responsibilities ofadministrators and providers are both necessary,without understanding the intricacies andchallenges across both spheres, the chances arehigh that common goals will not be achieved. Aswe look ahead to a brighter future, lets commit tobridging the “opportunity gap” between cliniciansand their development towards becomingtransformational leaders with fresh, creativesolutions to address the failures of the currentsystem head-on, flipping them into successes thatwill ultimately save rural hospitals and communities. GO BE GREATAlthough the rural healthcare crisis narrative feelslike we are fighting a losing battle, the opposite isactually true – there have been incremental wins,and there has never been a more exciting time tobe committed to the cause of rural healthcare. Thepeople of our great country have alwaysengineered solutions in the face of adversity. Inthe face of the rural healthcare crisis today, Ibelieve in the two most influential factors thatbring us hope for a brighter tomorrow: the reachand power of innovation coupled with the growthand rise of promising leaders. As it pertains toinnovation as a key driver, there are excitingdiscoveries in medical research, pharmaceuticals,surgical procedures, and advancements intechnologies like telehealth and artificialintelligence, just over the horizon and here to stay.On the other hand, as it pertains to leaders playinga key role, there remains a 29SPRING EDITION 1. White S. What is transformational leadership? A model for motivating innovation. 10 Oct 2022.2.Levy BE, Castle JT, Wilt WS, Fedder K, Riser J, Burke ED, Hourigan JS, Bhakta AS. Improving physician documentation for malnutrition: A sustainable quality improvement initiative. PLoS One.2023 Aug 10;18(8):e0287124. doi: 10.1371/journal.pone.0287124. PMID: 37561733; PMCID: PMC10414681.

Page 31

Increased Risk of MajorBleeding Associated withConcomitant Use of SelectiveSerotonin ReuptakeInhibitors (SSRIs) and OralAnticoagulantsAs physicians, we frequentlyencounter situationsnecessitating delicatedecision-making whereineach option carries itsinherent complexities. Suchscenarios often arise whendetermining theappropriateness ofreintroducing anticoagulantsfollowing a gastrointestinal(GI) bleed. A recent study published inJAMA has underscored asignificant risk factor contributingto an elevated risk of majorbleeding—namely, the concurrentadministration of selectiveserotonin reuptake inhibitors(SSRIs) with oral anticoagulants.The study findings demonstrateda 33% increase in the risk ofmajor bleeding when SSRIs andoral anticoagulants werecombined. Consequently,substituting SSRIs withalternative antidepressantagents, where feasible, forpatients requiring anticoagulationcan mitigate the likelihood ofmajor bleeding events.. SSRIs, commonly prescribedantidepressants, are well-documented in the literature fortheir propensity to heighten therisk of major bleeding. A meta-analysis conducted in 2017reported a minimum 36% increasein overall bleeding risk associatedwith SSRI use. However, it ispertinent to acknowledge thatthe absolute risk remainsrelatively low. A 2014 meta-analysis revealed a numberneeded to harm of 3,177 forupper GI bleeding in low-riskpopulations and 881 for high-riskpopulations. The underlyingmechanism behind this heightened risk is believed tobe twofold. Firstly, SSRIs impedeserotonin storage in plateletdense granules. While thesemedications obstruct serotoninreuptake in brain pre-synapticterminals, they also diminishserotonin storage within platelets.Given serotonin's pivotal role invasoconstriction and plateletactivation, reduced serotoninrelease from activated plateletsultimately culminates in impairedhemostasis and diminishedplatelet aggregation. Secondly,the increased gastric acidity JACOB KALLIATH, DOBY1234Serotonin reuptake in presynpaticterminalsAxons, dendrites, and synapses forming neuronal networkSPRING EDITION 30

Page 32

1induced by SSRIs may contributeto gastritis and peptic ulcerdisease, further elevating the riskof bleeding. Despite the relatively lowabsolute risk of severe bleedingin most individuals on SSRIswithout additional risk factors,the concurrent use of SSRIs withoral anticoagulants warrantscloser examination. A recentstudy published in JAMA hasshed light on this matter. Theresearchers conducted a nestedcase-control study involvingpatients with atrial fibrillationinitiating oral anticoagulants(both direct-acting oralanticoagulants and Vitamin Kantagonists) between January 2,1998, and March 23, 2021. Thestudy encompassed patients fromapproximately 2,000 generalpractices in the UK contributingto the Clinical Practice ResearchDatalink. Among 42,190 cases ofmajor bleeding matched to1,156,641 controls, the findingsunveiled a 33% increase in therisk of major bleeding associatedwith concomitant use of SSRIsand oral anticoagulantscompared to the use of oralanticoagulants alone.Results from the Study "There were 42,190 patients withmajor bleeding (mean [SD] age,74.2 [9.3] years; 59.8% men)matched to 1,156,641 controls(mean [SD] age, 74.2 [9.3] years;59.8% men). Concomitant use ofSSRIs and OACs was associatedwith an increased risk of majorbleeding compared with OACslone (IRR, 1.33; 95% CI, 1.24-1.42). The risk peaked duringa the initial months of treatment(first 30 days of use: IRR, 1.74;95% CI, 1.37-2.22) and persistedfor up to 6 months. The risk didnot vary with age, sex, history ofbleeding, chronic kidney disease,and potency of SSRIs. Anassociation was present bothwith concomitant use of SSRIsand direct OACs compared withdirect OAC use alone (IRR, 1.25;95% CI, 1.12-1.40) andconcomitant use of SSRIs andVKAs compared with VKA usealone (IRR, 1.36; 95% CI, 1.25-1.47)." SUMMARYIn summary, clinicians shouldexercise caution whenprescribing SSRIs alongside oralanticoagulants considering thepotential impact on bleeding risk.Close monitoring andindividualized assessment areimperative to optimize patientsafety, particularly during theinitial months of concurrent use.1)Rahman AA, Platt RW, Beradid S, Boivin J, Rej S, Renoux C.Concomitant Use of Selective Serotonin Reuptake InhibitorsWith Oral Anticoagulants and Risk of Major Bleeding. JAMANetw Open. 2024;7(3):e243208.doi:10.1001/jamanetworkopen.2024.32082)Laporte S, Chapelle C, Caillet P, et al. Bleeding risk underselective serotonin reuptake inhibitor (SSRI)antidepressants: A meta-analysis of observational studies.Pharmacol Res. 2017; 118:19-32.3)Anglin R, Yuan Y, Moayyedi P, Tse F, Armstrong D,Leontiadis GI. Risk of upper gastrointestinal bleeding withselective serotonin reuptake inhibitors with or withoutconcurrent nonsteroidal anti-inflammatory use: asystematic review and meta-analysis. Am J Gastroenterol.2014 Jun;109(6):811-9. doi: 10.1038/ajg.2014.82. Epub 2014 Apr29. PMID: 24777151.4)Edinoff AN, Raveendran K, Colon MA, Thomas BH, TrettinKA, Hunt GW, Kaye AM, Cornett EM, Kaye AD. SelectiveSerotonin Reuptake Inhibitors and Associated BleedingRisks: A Narrative and Clinical Review. Health Psychol Res.2022 Nov 3;10(4):39580. doi: 10.52965/001c.39580. PMID:36425234; PMCID: PMC9680839.5)Andrade C, Sharma E. Serotonin Reuptake Inhibitors andRisk of Abnormal Bleeding. Psychiatr Clin North Am. 2016Sep;39(3):413-26. doi: 10.1016/j.psc.2016.04.010. Epub 2016Jun 28. PMID: 27514297.51Activated platelets aggregating to site of vascular ruptureSPRING EDITION 31

Page 33

Jay Afzal, MDContributorFields of CarePublication Date29th March, 2024It’s Never“Just AtrialFibrillation”TODAY’S FOCUS:A brief overview ofthe latest guidelineshospitalizations, subject patients to a poor qualityof life, and continued deterioration of their health. Understanding Atrial Fibrillation: AModern EpidemicAtrial Fibrillation (AFib) is the most common typeof serious heart arrhythmia, affecting millionsworldwide. It occurs when the heart's upperchambers (the atria) beat irregularly and out ofcoordination with the lower chambers (theventricles), leading to a clinical picture rangingfrom asymptomatic (11% per 2015 data) topalpitations, dizziness, shortness of breath, chestpain, and fatigue. This condition significantlyincreases the risk of stroke, heart failure, andother heart-related complications. The incidence Patient comes into the ER via EMS for variouscardiovascular symptoms and is in AtrialFibrillation with rapid ventricular rate. The ERphysician quickly orders labs, imaging, andmedications to control the heart rate. TheHospitalist is then called upon to admit the patientto the hospital for further management of atrialfibrillation (AFib). Treatment with rate-limingmedication and anticoagulation is only the bareminimum. The central question we must always askourselves in the management of Afib is: “Why didthis event occur in the first place?” Perhaps thereexists an underlying condition or precipitatingfactor that should be properly diagnosed andeffectively treated. Failure to do so has thepotential to increase the risk of complications suchas stroke, trigger recurrent SPRING EDITION 32

Page 34

and prevalence of AFib has increased over thepast 20 years, and is on pace to continue toincrease over the next 30 years.The 2023 ACC/AHA/ACCP/HRSGuidelines: A New Direction in theManagement of Atrial Fibrillation The latest guidelines for the management andtreatment of Atrial Fibrillation reflects a shifttowards a more personalized and integrated careapproach. Previous guidelines focused on durationof the arrhythmia whereas now the focus is on thecontinuum of disease and classification across 4stages. These guidelines emphasize earlydetection, prevention, the importance of lifestylemodifications, and the treatment plans tailored tothe patient.The new guidelines advocate for:Risk Assessment and Early Detection The use of advanced screening tools and riskassessment models to identify AFib in its earlystages, particularly among high-risk populations.Integrated Care ApproachEmphasis on the need for a multidisciplinary teamthat includes cardiologists, primary careproviders, and specialists in diet and physicaltherapy to create a personalized care plan uniqueto each patient.Lifestyle ModificationLifestyle changes are considered criticalcomponents of treatment plans in managing AFib,including weight management, regular exercise,limiting alcohol intake, and smoking cessation.Anticoagulation TherapyLatest guidelines and updated recommendationsfor anticoagulation therapy provide clearerguidelines on the use of novel oral anticoagulants(NOACs) over warfarin for stroke prevention inmany patients. Assessment for bleeding risk isalso crucial in the consideration of overalltreatment strategy and potential complications. Tomitigate this, consider a left atrial appendageclosure device (Watchman) in nonvalvular AFibpatients with contraindication to anticoagulation.Key Updates in the Guidelines for AtrialFibrillation SPRING EDITION 3312Classification / Stages:Stage I: At risk for Atrial Fibrillation (Diabetes, Obstructive Sleep Apnea,Hypertension, Obesity, Tobacco abuse)Stage II: Pre-Atrial Fibrillation (Structural heart disease)Stage III: Active Atrial Fibrillation (Paroxysmal, Persistent, Long standing persistent,Successful ablation)Stage IV: Permanent Atrial Fibrillation

Page 35

Rhythm ControlThere is new evidence on emphasizing earlyrhythm control to minimize the burden on theheart, caused by AFib. One way to accomplish thisis by Catheter Ablation. Guidelines nowrecommend considering catheter ablation earlier inthe treatment process for some patients,particularly those with symptomatic AFib not well-controlled by medication.Management of Underlying Conditions There is a stronger focus on the treatment ofconditions that may contribute to AFib, such asinfection, alcoholism, volume depletion,hypertension, diabetes, thyroid disease,pulmonary disease, acute coronary syndrome, andsleep apnea, recognizing that controlling theseconditions can significantly impact themanagement of AFib.Implications for Healthcare Providers andPatients SPRING EDITION 34For healthcare providers, these guidelinesnecessitate remaining cognizant of the latestdiagnostic tools, treatment modalities, and riskassessment models (C2HEST/CHARGE-AF,CHADS2VASC) to provide the best care forpatients with AFib. It also involves a commitmentto a holistic care model that addresses the entirespectrum of the patient's health. As it pertains to patients, the new guidelines stressthe importance of actively participating in theirtreatment plans, particularly regarding Conclusion: A Step Forward in AtrialFibrillation Management The latest guidelines for AFib management mark asignificant step forward, adopting acomprehensive and personalized approach to care.By focusing on early detection, integrated care,and tailored treatment strategies, these guidelinesaim to improve the quality of life for patients withAFib and reduce the risk of serious complications.It is crucial for healthcare providers to look forunderlying conditions that can prevent furthercomplications. If no overt cause is found, thenclose follow up with cardiology is still essential toevaluate for intrinsic heart disease and overallshared decision-making in the various options formanagement. As we move forward, it is crucial for bothhealthcare providers and patients to workcollaboratively to navigate the challenges of AtrialFibrillation in the modern era and to remember thatit’s never just atrial fibrillation.1 Lippi G, Sanchis-Gomar F, Cervellin G. Global epidemiology of atrial fibrillation: Anincreasing epidemic and public health challenge. Int J Stroke. 2021 Feb;16(2):217-221. doi:10.1177/1747493019897870. Epub 2020 Jan 19. Erratum in: Int J Stroke. 2020 Jan28;:1747493020905964. PMID: 31955707.2 Joglar J. C Clinical Practice Guidelines: 2023 ACC/AHA/ACCP/HRS Guideline for theDiagnosis and Management of Atrial Fibrillation: A Report of the American College ofCardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.Volume 149, Issue 1, 2 January 2024; Pages e1-e156.lifestyle changes, and the management ofcomorbidities. Recent clinical data has also calledout a relation between poor sleep and increasedrisk of AFib episodes, and therefore encouragesactions to improve sleep quality as a greatmodifiable risk factor.2

Page 36

10ISSUE 01 April 2024by Michelle Pappy, MDAPRIL 2024PRECISIONMEDICINE MEETSCARDIOVASCULARDISEASECardiovascular disease encompasses a groupof disorders of the heart and blood vessels, andranks as the leading cause of mortality in theUnited States, of which in 2020, coronary heartdisease accounted for 41% of those deaths,stroke 17%, high blood pressure 13%, and heartfailure 9%. On average, someone dies of astroke every 34 seconds! Between 2018 and2019, the total cost of cardiovascular diseasessurpassed $400,000,000,000!As a matter of determining effective treatmentand prevention strategies for patients withcardiovascular disease, medical providers andspecialists routinely investigate their variousunderlying risk factors, to tailor management,specifically targeting them. One of the mostcommon lab tests ordered to investigate this isthe standard lipid panel, primarily to check theLDL (low-density lipoprotein) level, which iscommonly referred to as “bad cholesterol.” While an elevated LDL level promotes the build-up of fats and cholesterol on the inner walls ofblood vessels causing arterial occlusion 1 1 1Precision medicine is a relatively newand exciting approach to modern daypatient care that is becomingincreasingly popular and has beenshowing great promise. It uses modernmedical and technological capabilities,to obtain and analyze a patient’s owngenetics (ie. through DNA analysis, orlabs/tests unique to each individual),and then using that information toapply the art and science of medicine -ultimately diagnosing, preventing, andtreating diseases using the mosteffective and personalized approach.INTRODUCTION35SPRING EDITION1

Page 37

atherosclerosis) and ultimately heart attacksand strokes, you may find it surprising thataround 50% of heart attacks resulting in suddendeath happen among individuals with normalcholesterol levels! In other words, using lipid-lowering medicationsto simply lower a patient’s LDL levels, althougheffective, may not be enough to mitigate therisk of death caused by cardiovascular disease. This gives rise to the notion that although thestandard lipid panel provides valuableinformation about cardiovascular risk (ie. LDLlevel), it may not offer a complete or accuratepicture of an individual’s true risk – at least inthe context of fatal cardiovascular disease. Forthat reason, a more comprehensive assessmentis essential and potentially life-saving. More precisely, medical providers shouldstrongly consider advanced lipid testing, whichcan provide meaningful qualitative andquantitative information, and thereby moreintelligently inform management strategy.Advanced lipid testing includes checking:Cholesterol plaques (yellow) adhering to theinner walls of blood vessels, reducing bloodflow (red cells), leading to heart attacks andstrokes.Let’s unpack each of these labs a little furtherto understand their application. Understandingthe relationship between LDL particle numberand LDL size is crucial for a comprehensiveevaluation of cardiovascular risk. Morespecifically, evidence has shown that smalldense LDL particles, known as Pattern B, areassociated with a higher risk of cardiovasculardisease. These particles can penetrate theendothelial wall more readily, adhere together,and contribute to the development ofatherosclerotic plaque, which then increasesthe likelihood of developing cardiovasculardisease, heart attacks, and strokes.PRECISION LABS & ANALYSIS:LDL SMALL PARTICLE SIZE236SPRING EDITION ADVANCED LIPID TESTINGApolipoprotein BLipoprotein ALDL particle numberLDL particle sizeLDL pattern

Page 38

37SPRING EDITION Cholesterol plaques adhering to the walls ofthe blood vessels in the heart, leading toreduced flow, setting the stage for animpending heart attack. On the other hand, large buoyant LDL particles,known as pattern A, have a lower likelihood ofpenetrating the endothelial wall, thereby reducingthe risk of clot formation and damage. Researchhas shown that individuals with a higher presenceof large buoyant LDL particles have a decreasedrisk of atherosclerosis compared to those withsmall dense LDL particles. However, it should benoted that even if an individual has large buoyantLDL particles, there can still be an increased riskof cardiovascular disease if the number of LDLparticles happens to be elevated. Therefore, it iscrucial to take into account both the overallnumber and size of LDL particles, when assessingrisk factors.PRECISION LABS & ANALYSIS:LDL LARGE PARTICLE SIZE

Page 39

38SPRING EDITIONApolipoprotein B is the main apolipoproteinfound in chylomicrons, VLDL, IDL, and LDLparticles, making it a key marker for measuringthe number of these lipoproteins in the body. More specifically, elevated levels ofApolipoprotein B can lead to an increased riskof cardiovascular disease by up to three-fold,which would prompt providers to deploy moreaggressive and timely preventive or treatmentmeasures, if obtained. International guidelineshave recently recognized Apolipoprotein Blevels as the most accurate measure oflipoprotein associated cardiovascular diseaserisk, especially in those on statin therapy,diabetics, and obese patient populations. Lipoprotein A is a specific type of low-densitylipoprotein (LDL) that is genetically linked to ahigher incidence of cardiovascular diseasebecause it attaches to the vascularendothelium, leading to endothelial dysfunctionand rendering LDL more prone to oxidation. Furthermore, it hinders the breakdown of bloodclots, increasing the likelihood of clot formationand the subsequent risk of heart attacks andstrokes. It is important to check Lipoprotein Alevels because it cannot be controlled byexercising, or healthy dietary habits, or lipid-lowering medications; currently, the onlyapproved treatment is apheresis (similar todialysis in which a machine removes it from theblood). PRECISION LABS & ANALYSIS:LIPOPROTEIN APRECISION LABS & ANALYSIS:APOLIPOPROTEIN B3765456

Page 40

39SPRING EDITIONIn summary, medical providers should stronglyconsider advanced lipid testing (in addition to astandard lipid panel), because the risk of deathassociated with cardiovascular disease cannotbe overstated, and these additional labs offera more sophisticated method to assess risk withhigher precision. This is a simple practice thatcan save many lives, because it allowsproviders to take a proactive approachthrough early identification of risk factors andtailor their management accordingly, before apatient suffers a stroke or heart attack, asopposed to the traditional reactive approach ofchecking the limited standard lipid panel aftera patient has already suffered the damages 7and complications from a heart attack or stroke– that is if they even survive it. While advanced lipid testing may or may not bereadily available in some inpatient settings,calling them out in the patient’s hospitaldischarge summary as a recommendation totheir outpatient primary care provider (PCP),can at the very least equip the PCP withinvaluable information to better understandtheir patients' individualized cardiovasculardisease risk factors, which lends itself topersonalized care of each and every patient asopposed to a “one size fits all” approach – theirloved ones are truly depending on it!41Lloyd-Jones DM, Allen NB, Anderson CAM, Black T, Brewer LC, Foraker RE, Grandner MA, Lavretsky H, Perak AM, Sharma G, et al; on behalf of the American Heart Association. Life’s Essential 8:updating and enhancing the American Heart Association’s construct of cardiovascular health: a presidential advisory from the American Heart Association. Circulation. 2022; 146:e18–e43. doi:10.1161/CIR.00000000000010782Sachdeva A, Cannon CP, Deedwania PC, et al; for the Get With The Guidelines Steering Committee and Hospitals. Lipid levels in patients hospitalized with coronary artery disease: an analysis of136,905 hospitalizations in Get With The Guidelines. Am Heart J. 2009;157(1):111–117.e2.3Fogelstrand P, Borén J. Retention of atherogenic lipoproteins in the artery wall and its role in atherogenesis. Nutr Metab Cardiovasc Dis. 2012 Jan;22(1):1-7. doi: 10.1016/j.numecd.2011.09.007.4McCormick SP. Lipoprotein(a): biology and clinical importance. Clin Biochem Rev. 2004;25(1):69-80.5Undas A, Stepien E, Tracz W, Szczeklik A. Lipoprotein(a) as a modifier of fibrin clot permeability and susceptibility to lysis. J Thromb Haemost. 2006 May;4(5):973-5. doi: 10.1111/j.1538-7836.2006.01903.x6Faghihnia N, Tsimikas S, Miller ER, Witztum JL, Krauss RM. Changes in lipoprotein(a), oxidized phospholipids, and LDL subclasses with a low-fat high-carbohydrate diet. J Lipid Res. 2010;51(11):3324-3330. doi:10.1194/jlr.M0057697Cole J, Jialal I, Remaley A, Wolska A, Zubiran R.Use of Apolipoprotein B in the Era of Precision Medicine: Time for a Paradigm Change? J Clin Med. 2023 Sep; 12(17): 5737. Published online 2023 Sep 3.doi: 10.3390/jcm12175737CONCLUSION

Page 41

BASIC DEFINITIONSAnemia is defined by the world health organizationin adults as a hemoglobin of less than 12 g/ dL inwomen and 13 in men. In the United States wegenerally use 12.5 for women and 13.5 for men, butkeep in mind that at higher altitudes or in smokersthese numbers may actually reflect anemia.Sometimes, the etiology is obvious, such as a patientbeing admitted for a G.I. bleed, but often theetiology is not so straightforward. INITIAL WORK-UPTo be cost-effective, of course we should start offevery work up with a thorough history and physicalexamination, and tailor our laboratory exam towardthe most likely etiology. Sometimes a thoroughhistory and physical will simply give you the answeras in a patient with melena for the last severalweeks or someone who has a family history of thalassemia. In reality, however, in thehospital it is common practice to order B12, folate,CMP, iron profile, peripheral blood smear,reticulocyte count, and a stool for occult blood tostart the work up. Often if the anemia is severe, theED Physician will start blood transfusion. Be sure toget these studies on pre-transfusion blood.The results of this initial work-up will usually lead youto the underlying etiology, but if it does not, it atleast rules out some of the most common problems.All of these studies are very common, widelyavailable, and quite inexpensive, and it is reasonableto start here while the patient is in the hospital.. At this point, our differential is dependent mainly onthe MCV and reticulocyte count taken together, butit is convenient to look first at the MCV. On the inpatient side of medical pratice, the patient who is found to have an incidentalanemia compared to the patient who has an admitting diagnosis of symptomatic or acuteanemia, oftentimes takes on a differing approach - but we should be careful not to let“incidental” turn into “overlooked.” by Tim Hockenberry, MD40SPRING EDITIONTHE CASE FORINPATIENT WORKUPOF ANEMIA

Page 42

accompanied by nutritional deficiencies such as ironor B12. BRIEF SUMMARYIf this initial work up does not show the etiology ofthe anemia, the workup from there becomes muchmore complicated and more expensive. It would beunusual to perform this further work up in thehospital since the workup may involve bone marrowbiopsies, hematologic referral, genetic testing, etc.The workup above will generally show us etiologiespertinent to an inpatient stay. CAVEATS TO CONSIDERBelow are a few caveats and unique circumstancesthat I think require special considerations for, andare useful to inpatient medicine in a patient withanemia: Microcytic, hypochromic anemia should beconsidered as chronic G.I. blood loss (coloncancer) until proven otherwise. LOW MCVIf a patient has microcytic anemia, that is bleedinguntil proven otherwise. Stool for occult blood mustbe tested. If the iron studies are normal, the secondmost common etiology is thalassemia which issuggested by an RDW greater than 21% and a highRBC count despite anemia. While it is helpful toestablish the etiology of the anemia, actuallydiagnosing thalassemia in the hospital withexpensive, send out genetic testing is generally nottoo important, but ruling out GI bleeding ismandatory. Keep in mind that anemia of chronicdisease can also be microcytic. HIGH MCVIf the patient has macrocytosis, this may simply befrom alcohol use and vitamin deficiencies, and it isvery important to check B12 and Folate as well as areticulocyte count. Reticulocytes are larger thanmature RBC’s, so anything that increases theReticulocyte count such as hemolysis will increasethe MCV. Hypothyroidism can also causemacrocytic anemia, so checking a TSH may behelpful. If hemolysis is suspected, indirect bilirubinwill likely be elevated, LDH will be high at least inacute hemolysis, and haptoglobin will be low. If allthese tests are normal, serum copper and perhaps abone marrow biopsy to check for myelodysplasticsyndrome may be needed, but this will generally bedownstream from an inpatient admission. NORMAL MCVNormocytic anemia is the most common finding inanemic adult males and postmenopausal females.The causes are numerous and may be multifactorial,and it can be difficult to identify. Nutrientdeficiencies, especially in combination such as ironand B12 deficiencies, may produce normocyticanemia. Anemia of chronic disease/inflammation,cancer associated anemia, myelodysplasticsyndrome, and aplastic anemia may all benormocytic. Acute blood loss doesn’t change theMCV until about a week after the event, and thenthe MCV may actually rise transiently due to theincreased production of reticulocytes. Hemolyticanemia may be normocytic if it is not accompaniedby increased reticulocyte production. Also anemia ofchronic kidney disease tends to be normocytic unless Blood Transfusion in a patient with anemia.41SPRING EDITION

Page 43

Red flags include severe pancytopenia,blasts on peripheral blood smear,pancytopenia with hemolysis, thrombosis, orbleeding, and microangiopathic hemolyticanemia with schistocytes on the peripheralblood smear. These may all constitute a truehematologic emergency and needhematology referral.In a patient with severe anemia of unknownetiology being seen in the emergencydepartment, make sure to get B12, folate,reticulocyte count, and iron studies on bloodinitially drawn in the emergency departmentbefore any blood transfusions have beengiven. If hemolysis is suspected, haptoglobinand LDH will also be affected by red bloodcell transfusion. Macrocytosis with thrombocytopenia, withor without anemia, is very commonly due toalcohol abuse.Patients with reticulocytosis and indirecthyperbilirubinemia, or sustainedreticulocytosis are considered to have ahemolytic disorder until proven otherwise. Autoimmune Hemolytic Anemia. Cold agglutininsdisease, RBCs clump together (agglutinate) at lowtemperatures. Anisocytosis, Anisochromia withmacrocytes and echinocytes seen. In a patient getting oral replacement foriron deficiency anemia, have them take theiriron with something acidic such asgrapefruit juice, orange juice, coffee, etc.and it improves the absorption dramatically.Anemia of chronic disease/chronicinflammation is a diagnosis of exclusion andother causes need to be sought.If a patient had a sudden blood loss severaldays prior to admission, they may actuallyhave macrocytic anemia due to the increasein reticulocytes circulating in their system. Iron-rich dietary options for patients with irondeficiency anemia.42SPRING EDITION

Fields of Care: Spring Edition 2024

Page 1

Page 2

Page 3