Health for life

ACOs at work.

According to this Bloomberg news release, some of Medicares Accountable Care Organizations (ACOs) are already achieving cost savings. Mt. Sinai and Coastal Carolina are reducing emergency room visits while Hackensack is reducing costs.

All three institutions are using two key ingredients:

1) information technology-based risk stratification to identify the persons at greatest risk and

 2) dedicated full-time nurses who perform telephonic and in-person outreach, coordinate care and provide patient coaching that, in turn, is tailored to that risk.

To the DMCB, the good news is that ACOs are using the two approaches that define modern-day disease and population health management. That industrys success will be Mt Sinais, Coastal Carolinas and Hackensacks success.

The bad news is that the news release only addresses half the question: did any savings exceed the institutions cost of the risk stratification and the nurse-FTEs? If the early answer is no, then avoided ER visits and reduced costs could turn out to be much like Governor Christies lap band: so far so good but its still risky and could ultimately be all for naught.

And on an unrelated note, this just-published New England Journal article makes note of "not made in America" health care innovations from overseas that could hold important lessons for the United States. In particular, the authors point out that Germanys DRG hospital payment system includes 30-days of post-discharge care and includes the physician payment. Readmissions within that 30 day window are, with a few exceptions, not covered and physician payment is possible because docs are often employees of the hospitals.

"Interesting!" says the DMCB, but is reminded that Germany is hardly a model for reducing inflationary cost trends.   It also specifically recalls hearing Germanys Minister of Health, Daniel Bahr, express impatience with his countrys DRG system just last week. He criticized it for not advancing enough quality in his keynote address at the HauptKongress in Berlin.

Months ago, the caffeine-addled Disease Management Care Blog reviewed with the spouse how to pre-set the kitchen coffee brewer for a pot of fresh coffee for the next morning. After listening politely to its earnest instructions, the DMCB spouse rarely set up the brewer.

Which is why the DMCB wasnt surprised by an Iowa Chronic Care Consortium (ICCC) study of how its newly minted medical home coach trainees were being deployed in the real world. The ICCC is a not-for profit organization that was founded in 2002 and offers a training program that prepares health professionals to be members of a medical home team.
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The Consortium surveyed 318 graduates from their program. Of that number, there were 164 responses, yielding a 54% response rate. 83% of the respondents were nurses, while the remainder were medical or office assistants, diabetes educators, dietitians, social workers, physicians, pharmacists or administrators.
 
The good news is that care-management caffeine was available. The majority of respondents reported that they were using their skills to coach patients for self management, care coordination, planning visits and supporting registry use.  The majority also found their work professionally rewarding.

The bad news is that these professionals were not being supported for maximum effect:

55% were still "building support for the position."

48% reported that "office work" was given a "higher priority," often due to physician and administrator resistance.

73% reported that their coaching duties were part time and was in addition to their more traditional roles.

Only 8% were involved in office "change management."

Only 11% enjoyed a pay differential that rewarded their coaching skills.

The Consortiums paper concludes - paralleling the DMCBs coffee-making travails - that a good idea accompanied by well-meaning training is not enough to overcome established clinic routines, business roles and local culture.  The authors recommend that provider payments "change," coaching functions be "operationalized," training programs be "advanced," outcomes be "demonstrated" and that roles be "clarified."

While the DMCB ponders coffee change, operations, advances, demonstrations and clarifications, the DMCB has a far more more fundamental concern for the medical home:

With friends like this, the fledgling medical home movement doesnt need any enemies.

If the clinics that took the time and the money to train these individuals are unable to leverage their skills, disappointing outcomes could end up snatching usual care from the jaws of primary care clinic transformation.

The DMCB has three recommendations:

History Repeats: Years ago, established "disease management" companies had to go on record and oppose start-ups that were offering "faux" telephonic patient counseling programs. The medical home and population health management community, including the PCPCC, likewise cant afford to have clinics going to market with diluted medical home programs that deliver empty process instead of hard outcomes.  All health care is local, and much of the buy-in for the medical home will ultimately be won or lost at that level.  Speak up!
 
Buyer Beware: Payers and insurers need to be wise to the possibility that having a trained health coach on staff with credentials is not the same as having a health coach on line with the patients. On site credentialing may be in necessary that includes review of policies, job descriptions, pay scales and staff interviews.

Build or buy: Primary care clinics need to know that when they buy patient counseling services from a population health management vendor, you get full time on a plug and play basis. That may be a better option for a clinic that is not prepared to both train and fully use an on-site health coach.

A cure for diabetes?

Mrs. Jones (name changed) was obese. Her weight remained persistently high despite education and entreaties about diet and exercise. She hated taking all those medications. She dreaded bathing suits.

And then.... she had bariatric surgery. She shed pounds faster than Supreme Court justices spanking a health insurance mandate. Instead of having a corpulent and unhealthy patient, the Disease Management Care Blog had a svelte and healthy patient.

Based on witnessing first hand patient transformations like this, the DMCB knows that bariatric surgery for obesity works.

Despite clinical anecdotes, however, obesity surgery skeptics have pointed out that the evidence has been marred by the lack of any prospective randomized clinical trials. Looking backwards at outcomes data cant rule out the possibility that something else was going on to account for the surgerys apparent success. Most of all, this includes self-selection bias where patients, who are destined to independently do well, select surgery. By leaving assignment to chance, docs and patients are out of the decision-making. This randomization helps researchers be more confident that the surgery, and nothing else, accounts for any observed outcomes.

Enter the New England Journal of Medicine, which published the results from two landmark prospective and randomized trials that compared obesity surgery to conservative medical management:

1. Geltrude Mingrone and colleagues screened 72 and then randomly assigned 60 diabetic persons with a BMI of 35 to either a) conventional medical therapy (targeting an A1c of 7% using a multidisciplinary team with visits every 3 months for a year and then one additional visit at two years) or b) gastric bypass or c) biliopancreatic diversion.  The study occurred at Romes Catholic University. Follow-up lasted two years. At the end of the study, 56 patients data were available for analysis. 15 of the 20 patients who had gastric bypass, 19 of the 20 patients who had the diversion and zero of the medically treated patients were off diabetes medications and had normal blood glucoses. As expected, surgery resulted in a whopping decrease in the BMI down to approximately 29.  In contrast the mean BMI was 43 in the medically treated group. Two patients had the surgical complications of hernia and obstruction

2. Philip Schauer and colleagues screened 218 patients and randomly assigned 150 diabetic obese persons with BMIs ranging from 27 to 43 to either a) medical therapy (life style counseling, weight management home glucose monitoring and medications with diabetes specialist clinic visits every three months that targeted an A1c of 6%) or b) "Roux en Y" bypass or c) sleeve gastrectomy. The study occurred at Cleveland Clinic. Follow-up lasted one year and 140 patients data were available for analysis. 5 of 41 patients in the medical therapy group vs. 21 in the 50 assigned to gastric bypass and 18 of 49 who had the sleeve achieved the A1c of 6%. Whats more, most of the surgery patients who achieved the targeted A1c were off all diabetes medications.  As expected, the surgery groups decreased their BMI down to the 26-27 range, while the medically treated patients BMI remained essentially unchanged.  In contrast to Rome, there was a wider range of complications that included 4 reoperations and 1 patient that developed a gastrointestinal leak with peritonitis.

Based on these data plus less pristine studies, its clinical experience and common sense, the DMCB is convinced that bariatric surgery works. These two studies are an important step forward in building the case for the use of this approach in persons with obesity and diabetes.

That being said, there is still room for some skepticism. That lingering doubt could be enough for a commercial insurer to limit coverage. It may be enough to prompt a PCP to recommend that an obese patient with diabetes should still hold off on surgery a bit longer. It may be enough for patients and families to wait another year until there are more confirmatory studies.

Heres why:

1. The studies were not "blinded." The purpose of "blinding" is to keep patients and doctors from being swayed by a "placebo effect." While thats intuitively silly, there is a possibility that having abdominal surgery made those patients believe they were going to lose weight and be cured of diabetes. After all, sham surgery has been known to help angina chest pains.

2. The studies are not necessarily "generalizable." Both studies were conducted by teams of surgeons from single institutions. While we can take Rome and Clevelands word for it, we dont know if obesity surgery done at Bumkinvilles Our Mother of Holy Deficit Hospital will have the same success and low rates of complications.

3. Speaking of complications, both studies were not adequately "powered" to fully assess mishap rates. While there were small single digit differences in the rates of complications, the small numbers may not tell the whole story. Having more patients enrolled in these studies would have increased the ability to meaningfully quantify all the possible bad outcomes.  That was one of the lessons of the Vioxx catastrophe.

4. Last but not least, the success of the surgery may have been inflated by the relatively poor performance of the non-surgical comparison groups. We know very little about the "intensity" of the medical treatment, other than they had the benefit of accessing a multidisciplinary clinic every three months. Population health management experts know that lifestyle change requires an intense program that includes engagement in a personalized and multidimensional care plan that includes far more frequent in-person and telephonic coaching. We dont know if the medical therapy group achieved this level of excellence.

Despite these limitations, however, the DMCB is more convinced that, for patients in whom nothing else works, bariatric surgery can reverse diabetes.

What didnt work? The idea to substitute fruit for binge ingredients. It really just kind of made things worse. The thing about carbs and craving and binging is that, what you ate a little while ago, or the previous meal, will have an effect on your next meal, or hunger episode. Hello!! Thats why they call it a "binge." Trying to substitute fruit was the same idea as doing medical meth for other drugs. You are still hooked on drugs. I was still hooked on sweets.

I was still out of control, but, oddly enough, my A1C turned out to be 5.5 which is pretty good and below the pre-diabetes level. I was really surprised to see that. That proves to me that I dont need to worry about cooked vegetables as much as I had been lead to believe. Live and learn.

That did not help the weight gain, though, which is the thing that is still haunting me. I have now put back on twenty pounds and am really flabbergasted by that. It happened in one months time and feels like a train wreck to me.

I finally heard the message at church that I needed to turn THIS over to the Lord and ask Him to do for me what I could not do for myself. God is so amazing. I also asked him to point out to me the effects of the binging so I would not forget and begin to think it was OK again.

The first thing I noticed was during a binge on bridge mix and spice drops that I could feel my heart beating in my whole body. My body felt like it was throbbing to the beat of my heart. I purposefully began taking deep relaxing breathes which helped things to calm down. That was the reminder of the "pressure" that is associated with craving and binging. The whole concept of craving is the idea of being forced to go get the item that is being pictured in the head. The pressure is real. The pushing, craving, gnawing is real. Taking deep relaxing breathes helped to reduce the felt pressure.

That night when I tucked into bed, I suddenly noticed my heart felt like it was fluttering very quickly and when I checked my pulse I could not find one. It lasted only a few short seconds, and I have not had one since, but it really shocked me. God was showing me what binging does to my body. That is what I had asked for: knowledge and experience that would not allow me to continue down the wrong path.

The next morning He inspired me with a new concept -- at least it is new for me. I looked and noticed that there is a difference between the lusting pressure for food, (picture the open mouths of little birds clamoring to be fed) and how a mother feeds her family (mother bird feeds properly). The operative word being "feed." I know that if I had had children I would have insisted on feeding them to the highest degree of healthy eating knowledge that I had attained -- just as my own mother did. It involves a responsibility to the ones you are feeding. I believe I would use the guidelines that I know and I would orchestrate the feeding of my family according to it. I realized that that is what I want to do for myself. Instead of "eating", I would be "feeding" me. Feeding also implies healthy and well managed with purpose.

Im not sure I can explain the difference so that someone else will understand what that means to me, but I shall attempt it. This is certainly my own subjective experience but I shall try to shine a light on it, in case it helps some one else, and also so I can remember it myself. So what I need to keep a tight reign on is the difference between the experience of eating which involves, consuming, smelling, tasting, chewing, swallowing, and repeating for the unbridled pleasure of it -- and the idea of feeding myself properly. This is completely subjective. It also involves other feelings in my body that I associate with eating and craving and enjoying food.

So Im choosing to use the terms "consuming", and "feeding." Feeding being a well managed plan, executed in a balanced and healthy manner. Consuming being the act of eating which may include craving and/or binging. Consuming is taking in -- Feeding is watching over and giving.

Ive unconsciously thought of "feeding" as something you do for someone else. You feed your kids. You feed your family. You feed your friends. I, for some odd reason, had never though of "feeding" in a relationship between me and myself. Feeding involves a plan and a purpose. Consuming is about pleasure.

So why could I not get pleasure from a plan and a purpose for feeding me, in the same way I would do for feeding others?

The first time I put the plan into operation was when I went to a buffet with a friend. We both had talked about out of control eating at a buffet which, for me, is the experience of knowing I can choose as much as I want of anything I want, and then being lead only by my eyes -- or the appeal of the presentation. If I saw it and liked it, it would go on my plate (even though I usually still avoid starchy carbs). I did have a sense that I needed salad but the fact that I like it, helped to get it onto my plate. There is also pressure to think that you want to "get your moneys worth."

So we both decided to do it another way. On the outside it probably appeared to be the same, but it was really different inside. We made a point to talk about what each one of us was planning to do, after we paid to get in, but before we began choosing food. In fact we actually made the plan in the car on the way over. My plan was simply to eat only vegetables and meat. His plan was to eat more vegetables and smaller portions.

Then God inspired us to pray for His help to make the right choices and stick to our individual plan. So we were not doing the blessing on the food (yet) we asked God to be in charge of us and our plates before anything was placed on them.

Then we went our separate ways and filled our plates and met back at the table. I did my usual heaped up salad  and realized that I did usually follow the plan up to this point. For me the point of departure in the past was always afterwards and involved more portions and desserts. But I had a new plan this time, with the help of God.

When we met at the table we examined each others plates and talked about it a little. He had more vegetables and color on his plate than I had ever seen before. He said he had gone for more vegetables and less meat. Mine looked like it always did, except that I had included some blue cheese dressing mixed with Ranch. I was happy to be on track, and so was he.

Then when the salad plate was done, I decided, before I left the table, that I was going to get some steamed broccoli and meat loaf. I came back with the broccoli and also some brussels sprouts and the aforementioned meat loaf with spaghetti sauce on it for flavor. (I forget what he did.) When I was done eating, leaving a small amount of leftovers (very unusual), my stomach signaled that it was full, and I heard and obeyed. I had no reason to go get any dessert, and actually, it did not seem appealing. I was glad. Thank you Lord.

So the key is the prayer and trusting God -- and the plan and the decision to feed me properly and not eat indiscriminately is what He gave me. Thank you Lord! He never leaves us! Praise God!

Be back soon,

Marcia

Eating fish may reduce the risk of heart attack, but it is important to steer clear from the type of fish that contains the most amounts of mercury, according to experts from Umeå University in Sweden.

The researchers have worked together with teams from Finland and other countries in order to assess whether the advantages of heathy fatty acids outweigh the risks of mercury proportion.

Previous research has said that individuals who consume fish have a decreased risk of heart disease, compared to those who eat none or very little. However, certain types of fish carry pollutants from the environment, which can be detrimental to the health of humans.

Methyl mercury, which can be found in many types of fish, may actually raise the risk of cardiovascular disease. Theore, consuming fish with a lot of mercury, or with ample amounts of pollutants, can severely increase the risk of heart problems. However, if people are too health conscious of fish, they increase their risk of the disease because they are not receiving the benefits of healthy fish.

A recent study said that tuna, which has high levels of mercury, should be given to children less often.

The current research, which will be published in the October 2012 issue of American Journal of Clinical Nutrition (AJCN), was carried out with the intention of finding a middle point between not eating any fish and eating too much, or types that are unhealthy.

The authors analyzed why heart attack risk is linked to the amount of mercury and omega-3 fats in the body due to fish consumption. They did so by measuring hair and blood samples of volunteers who had been involved in other trials in eastern Finland and northern Sweden. The blood samples of the Swedes were taken from the Medical Biobank in Umeå. Researchers compared blood from the patients who had suffered a heart attack after their check-up appointments and those who remained in good health with no heart attacks.

They found that while mercury content increased the chance of heart attack, omega-3 fatty acids decreased the risk. The researchers noted that higher risk of heart attack due to mercury consumption was only prevalent when there was a large amount of pollutants found in the body. If there was a high level of omega-3 fatty acids, the risk was low.

The findings suggest that it is important and beneficial to reach an equilibrium between healthy and unhealthy content found in fish. In this particular study, the environmental pollutant used was mercury. However, in regards to organic pollutants, such as dioxin and PCD, the results are the same. The authors note, though, that there has been no trial done thus far concerning these substances.

According to the Swedish National Food Agency, 2-3 servings of fish should be consumed per week. However, Swedes tend to eat predatory fish, which have a high amount of mercury and should not be eaten on a regular basis. In addition, a study conducted by the National Food Agency revealed that 7 out of 10 people in Sweden do not eat enough fish.

A 2011 study said that people who eat fish on a regular basis have lower blood glucose concentrations, and a lower risk of cardiovascular disease and type 2 diabetes. The researchers conclude that it is safe, as well as beneficial, to eat fish, but staying away from fish with high levels of pollutants is important in avoiding health problems.

Low vitamin D blood levels are linked to greater risk of heart disease in whites and Chinese, but not in blacks and Hispanics, according to a study appearing this week in JAMA, a journal published by the American Medical Association.

Growing evidence has suggested that low blood levels of 25-hydroxyvitamin are associated with higher risk of developing coronary heart disease among whites. Few of these studies included substantial numbers of people from other races.

Vitamin D levels tend to be lower among people from other racial and ethnic minority groups, and some of these populations have higher rates of heart disease. However, after correcting for other risk factors for heart disease in their large, multi-ethnic study group, the researchers reporting in the JAMA paper did not find an association between low vitamin D and cardiovascular events in their black and Hispanic study participants.

"Our study suggests that the results of ongoing vitamin D clinical trials conducted in white populations should be applied cautiously to people of other racial and ethnic backgrounds," said Cassianne Robinson-Cohen, the lead author for the JAMA paper. The senior author is Ian deBoer, University of Washington assistant professor of medicine, Division of Nephrology.

Robinson-Cohen is an affiliate instructor in epidemiology at the UW School of Public Health and a researcher at the Kidney Research Institute, where her team explores the genetic, metabolic and epidemiological factors related to heart and kidney disease.

She noted that the findings in their recent JAMA paper came from an observational study, not a randomized clinical trial, and could not guarantee cause and effect.

"Our future studies will examine the genetics affecting the levels and use of Vitamin D in the body to try to figure out why the link between low vitamin D blood levels and heart disease varies by race and ethnicity," she said. "We dont know for sure, but perhaps genes affecting the need for and use of vitamin D could have evolved to adapt to different levels of sun exposure in places where various ethnic subgroups of people originated."





IMAGE: Researchers will be studying genetic variations to try to understand why there are racial and ethnic differences in the need and use of vitamin D.
Click here for more information.



Her team plans to look for variations in genes known to mediate Vitamin D activation and metabolism. She said these genes have been identified, but at present scientists havent determined how gene variation influences susceptibility to the adverse effects of low vitamin D.

The report published this week was from one of the projects within the Multi-Ethnic Study of Atherosclerosis. MESA is a major, long-term medical research effort sponsored by the National Heart Lung and Blood Institute of the National Institutes of Health. More than 6,800 men and women from six regions across the United States are participating in MESA. They were a diverse study group that was 38 percent white, 28 percent black, 22 percent Hispanic, and 12 percent Chinese. Robinson-Cohen and her team studied 6,436 MESA participants who enrolled between July 2000 and September 2002.

All participants were free of any known cardiovascular diseases at the time they enrolled, and had their blood levels of V25-hydroxyvitamin D measured. The mean age of participants at the start of the study was 62 (range 45 to 84 years) and slightly more than half were women.

The mean blood concentrations for whites was 30.1 ng/ml, Chinese 26.7, Hispanic 24.6, and blacks 19.2, The researchers tested the association of Vitamin D levels with the first incidence of coronary heart disease events – myocardial infarction, angina, cardiac arrest, or death from coronary heart disease — occurring from the start of the study until May 2012. During the eight-and-a-half year study, 361 participants had such an event. The researchers used several statistical risk analyses to check to see if links between blood vitamin D levels and coronary heart disease differed among white, black, Chinese and Hispanic populations.

"The differences in associations across race-ethnicity groups were consistent for both a broad and restricted definition of coronary heart disease and persisted after adjustment for known risk factors for coronary heart disease," the researchers noted in their paper.

Robinson-Cohen believes the strengths of the study are its size, duration, the use of several statistical analyses, the rigorous definition of heart disease events, and the efforts made to control for many confounding risk factors, such as age, gender, smoking, diabetes, blood pressure, cholesterol levels, physical activity, kidney disease,C-reactive protein concentrations, educational attainment, income and so on. A main weakness of the study, she said, is that it is observational, and theore cant be ascertain cause and effect.

"To determine cause and effect, a large, multiethnic, randomized control clinical trial would need to be conducted," she said.

Robinson-Cohen pointed out, that beyond these specific results, the nature of the findings show the importance of designing medical research that includes a diverse ethnic and racial makeup of participants. Such multi-ethnic studies would help prevent cases where findings from one group are incorrectly applied to other groups.

"We need to make a bigger effort to design and fund medical studies with large enough representation of various racial and ethnic backgrounds that we dont draw ungrounded conclusions based on one group," Robinson-Cohen said.