Health for life

1. ________ is the most common cause of kidney failure in the US.

2. ________ is the second most common cause of kidney failure in the US.

3. ________ is the most common cause of acute liver failure in the US.

________
Answers:

1. Diabetes is the most common cause of kidney failure in the US.
(See Kidney Disease of Diabetes.)

2. High blood pressure (hypertension) is the second most common cause of kidney failure in the US.
(See Your Kidneys And How They Work.)

3. Acetaminophen, active ingredient in Tylenol and the most widely used pain reliever in the US, is the most common cause of acute liver failure in the US.
(See Acetaminophen Poisoning Now Most Common Cause of Acute Liver Failure in the USA.)

Are you helping your e-patients?

(The Disease Management Care Blog welcomes the Nursing and Physician Leadership Congress attendees.  By the way, heres the link it mentioned.)

The Disease Management Care Blog got to hear a compelling conference keynote presentation by Dave deBronkart, a.k.a. "e-Patient Dave."    Think of this as an ePost from the eDMCB about the eBusiness implications of ePatients.

By the way, a more suited moniker may be "Remarkable Dave." Hes survived Stage IV kidney cancer thanks to a an interleukin based treatment regime that he wouldnt have known about if it werent for his use of the internet.  Thanks to his laptop and a remarkable degree of determination, he was able to network with similarly "empowered, engaged, equipped and enabled" cancer patients.  Now a multi-year survivor, hes a go-to patient advocate for the Washington DC cognoscenti, is a co-founder of the Society for Participatory Medicine and a tireless advocate for acor.org.

While the DMCB could never capture the scope of e-Daves presentation in this blog, there were some insights that may be of use to the disease management and population health management service community:

The "Soup" of Information: As more medical information becomes available on-line, patients, families and friends will be "swimming" in social networks that will yield more insights about possible diagnosis and treatment options than an average physician could ever know about.  This is not about reading on-line content.  This is the two-way sharing of information in community networks of like-minded individuals who spend a lot of time and effort becoming experts.  They ultimately produce value, not consume it.

Population Health Management (PHM) Implications: ePatients with chronic conditions are going to be unlikely to settle for the recommendations in your pre-fab care plans.  Be prepared to accommodate new inputs that will complicate and enrich self-management.  If a e-patient asks about an unknown treatment option out of "left field," the best answer may be "dont know, well find out more and get back to you."

Under the Garbage Theres Gold: When you consider that as many as 1 in 5 romances start with an on-line dating service that involves hundreds of options and many poor fits before couples find each other, it should be no surprise that much on-line medical information is likewise ill suited to an individual  patients circumstances.  Thats OK, because if patients keep digging, theyll find that key piece of information that they really need.

PHM Implications: An emerging value proposition: being a trusted advisor and catalyzing ePatient information networking and mining.

Wisdom of Crowds on Steroids:  The best source of that information?  Other patients who, unlike many of their physicians, have a lot of time and motivation to do "deep dives" in personally relevant research that would otherwise take years to enter mainstream clinical practice.  Theyll also share their personal experiences with each other.

PHM Implications:  Have you thought about not only helping your patients find an on-line community but hosting one?

Vaccine Airheads: Yes, there is a lot of potentially harmful information on the web but much of it is the fault of the medical community.  The spurious link between vaccines and autism, for example, was the result of fraudulent research and faulty peer review.  Compare the "death rate from Googling" to the "To Err Is Human" death rate of 98,000 per year, and you get the picture.

PHM Implications: As you accommodate an on-line community, expect some crazy points of view.  Thats the price of doing business.

Jerks Google Also:  If a hateful (maybe a less provocative term would be difficult) patient is using the internet to torpedo a doctor-patient relationship, chances are theyd torpedo the relationship without Googling.  Use of the web is an innocent bystander.

Some other DMCB take aways:

There is ample research on shared decision making (plus a good article here) that shows that when patients get all the information they need, most not only choose wisely, they choose conservatively.  While some may chose the "wrong" option, thats the price of patient empowerment.  From a population-based level most of the curve shifts to the left. The good outweighs the bad.

Once again, we are witnessing the breakdown of "credentials" that separate knowledge-based professionals and self-trained amateurs.  This is a disruptive innovation that represents an important threat to "cognitive" physicians.

Electronic health records that rely on a walled garden to try to capture patients will lose.  Electronic health records that can accommodate the messy world of eDaves will survive.  Electronic records that can enable it will win.

The ePatient movements benefits outweigh harms, is self-enforcing and impossible to regulate.  That doesn mean that someone is going to try to do it.

One last closing insight from eDave: If you are reading this, think about what would happen if you developed a serious or life-threatening condition.  You would start searching the internet. 

You are already an ePatient.

Image from an HHS web site

Goin goin gone!

The Disease Management Care Blog recalls years ago when it was walking with some residents and students through a decommissioned wing of a hospital as a short-cut between patient floors.  Our footsteps echoed off the dreary beige tile while we chatted up the likelihood that we could get the next patient home this afternoon.  Then the  DMCB paused and took in the eerie fluorescent silence. "What you see around you," it mused, "is some valuable and unused capital."  The team then resumed the pace. Thats when the DMCB looked at the young docs and said "If we keep it up, theyll need to close another wing!" 

The fly in the ointment.  The monkey in the wrench.  The docs raised hand at a hospital board of trustees meeting.  Call it what you like, but sometimes our most cherished assumptions and best laid plans have a way of going all akimbo.  True to that tradition, curmudgeonly Dartmouth authors Stephen Rauh, Eric Wadsworth, William Weeks and James Weinstein examine the "illusion" of  expecting "lower costs" to come out the back end of a health system system after "quality" is put in the front end. 

The authors real focus is on hospitals and define "quality" as any intervention that reduces the utilization of health care services (versus other definitions). Despite the narrow view, the Disease Management Care Blog believes the article makes an important and yet obvious point: large and small health care organizations have rigid cost structures that cannot be flexed.  As a result, any increase in quality - such as reducing length of stay, admissions, readmissions or surgeries -  mostly results in additional dead space capacity, not bottom line savings.

Clinical improvement can reduce costs is in the general category of supplies and medications.  Unfortunately, those costs are at the margins.  Just because there are fewer readmissions wont mean all those expensive operating rooms. equipment, personnel costs and other administrative overhead will simply go away.  They dont.  Theyll be idle and cost just as much.

Some economists will argue that hospitals can take beds off line and furlough nurses.  Its also been pointed out that multiple health systems can regionally consolidate high-cost low-frequency services.
Unfortunately, the quarter to quarter business cycle facing the typical hospital administrator doesnt really accommodate that kind of wishful thinking.  The only way out is to find other revenue by either charging more or providing other services.

Despite many valiant attempts, the DMCB never managed to close another hospital wing.

You sure about that?

According to the White House, the Affordable Care Act (ACA) is obviously responsible for the significant decrease in health care cost inflation over the last three years.
The respected health economist Victor Fuchs, writing in the New England Journal, disagrees.  He points out:

1) there is a strong relationship between growth in the U.S. gross domestic product (GDP) and growth in health care spending: for the last 60 years, when one goes up, the other follows suit.  While the prevalence of illness drives the consumption of health care, it turns out that the prevalence of illness plus a rising income is a stronger driver of health care consumption*.

Its far more likely that the lackluster economy has been responsible for the low rate of inflation.

2) Two to three years is not enough time to guage the impact of any single intervention on health care spending. In his NEJM article, Dr. Fuchs presents a graph showing the relationship between a two year period of spending and what follows over the next twenty years.  It turns out its a very poor predictor.

So, even if the ACA could have an impact, its far too early to tell.

In the meantime, skeptics like Bob Laszewski, are pointing to richer mandated insurance benefits and are confidently predicting that health care costs are destined to increase.  Former CBO Director Douglas Holtz-Eakin worries young healthy adults wont sign up, which could further fuel health insurance premium increases.

Who to believe?  A partisan White House?  Skeptics who want a return to market-based insurance?  The DMCBs solution is to believe Dr. Fuchs and confidently state it doesnt know which way things are going to go.

*The only exception to the association between GDP and health care costs was during the mid-1990s when managed care had its stranglehold on the delivery system

Image from Wikipedia

As I was browsing Facebook the other night, just about to go to bed, I came across an interesting link that fired me up and kept my up far past my bedtime... an article called "Vegetarianism Demystified by a Toddler". It links to a YouTube video, which Ill just embed here for your convenience... voila!



The video has received overwhelmingly positive feedback from YouTube users. Nearly every comment praises this child for being an irresistible, sweet little boy with a big heart...  See?? Hes only 3, even a TODDLER knows its wrong to eat animals!! What an inspiration!!!

Okay. Fine. Thats your opinion. I, on the other hand, saw it differently. Here is how I interpreted his message...

Little Luiz Antonio is just sitting down to eat his octopus gnocchi, when he begins to question the ethics of eating an animal. After a little back and forth with his mother, Luiz decides we shouldnt be eating animals because theyre cute, and because every living thing deserves to be a winner in life... all of them all at the same time. If theres one thing Luiz is sure of, this is it. It would just be so great if we could all live forever and ever, and we could all live with the animals and pet each other and cuddle. Everyone could be friends. Everyone in the entire world. Well be pen pals and Skype friends and tweet each other and eat grass and well never have any reason to fight. For ever and ever.

Realistically, this is whats going through this little tykes head. Does he sound like an inspiration now? Does he make you want to throw out all your meat and slide headfirst into veganism!? I hope not. Hes a 3-year-old... He has a 3-year-old brain. Is it adorable? Yes. Very. But is it groundbreaking? Inspiring? Life-changing?? No. Get your head out of your ass.

The crux of this argument, what it really comes down to, is whether its human nature to want to be a vegetarian. Thats one of the main points of contention the article brings up. Is it really possible that were naturally vegetarians? Are we herbivorous animals? Is meat-eating just a social construct?

The answer is really very simple. No. No to all three. Big no to all three.

Ive explained my position on vegetarianism before...

1. Humans are not herbivores.
2. Avoiding animal products will not save the environment.
3. Avoiding animal foods doesnt save animal lives.
4. The people most likely to adopt a vegan diet are the people who need animal products the most.
5. Veganism is a very recent phenomenon.

You should probably read the linked article yourself for a little more explanation. Going vegetarian isnt the answer to your problems, and it wont save the world. If youre really honest with yourself, I think thats pretty clear.


I applaud your intent, vegetarians, but I think you need a reality check.
Dont get me wrong, I do understand the rationale behind vegetarianism. Many vegetarians view cessation from animal foods as a sort of "next step in the evolution of humans". In other words, we no longer have to hunt and gather and rely on animal foods to get by, so we can choose to sustain ourselves on plant foods that are less damaging to the environment. We have plenty of plant food for everyone. And of course theres the compassion factor... we no longer need to carry out the "barbaric", "uncivilized" act of eating something that once had a cute face.

Where the vegetarians go wrong here, in my opinion, is in their assumption that an animal-food-free diet is a healthy diet. If we as a species were ever to decide to spontaneously switch to veganism, we would likely kill off a HUGE chunk of our population over the first few generations. What survives long-term would be, in my estimation, a very small fraction of humans, if any.

Dont believe me? Look what happened to this poor infant, who died at just 11 months... born of vegan parents, this little girl died of vitamin deficiencies from her mothers nutrient-depleted, vegan-borne breast milk.
Are you prepared to kill off most of the human race as some sadistic form of forced "evolution" in the name of veganism? Okay that statement was a little dramatic. But seriously, shit just wouldnt work out. Itd be traumatic. We have physiological, biological needs as humans, and some of those needs are only fulfilled through animal foods. Its not morally wrong to eat animals... its just how life works. There is no life without death and vise versa. Its the circle of life. Like the Lion King.


Okay back to Little Luizs video.
Back to reality land, and that cute little cherub. To set the record straight, I do not have kids. Although I do want to have kids some day, I dont want kids at this particular moment, and I dont claim to be any sort of child-rearing expert. I do adore the innocent, naivety of Luizs mind, though. At the age of 3, Im sure a lot of kids have this same peachy outlook on life, and if I were a parent, Id probably like to preserve this blissful ignorant phase for a long as I could. I also dont ever want to force my child to eat anything he uses to eat. Good nutrition is of the utmost importance to me, but so is letting my child have some autonomy. I want to support his/her in life, not get in the way of it.

But thats neither here nor there. Im all about the tangents today.

To sum this all up, theres just no reason for Luizs thoughts on meat-eating to be taken as an affirmation for vegetarianism. For crying out loud, hes a 3-year-old child.

Its a cute video. Lets just leave it at that.

People think Im crazy.  When I say things like "grains arent healthy" or "saturated fat might even be good for you", people probably tend to ignore me; everyone knows grains should be the foundation of a healthy diet, and saturated fat causes heart disease.  Today, Id like to bring up a few historic examples of the ridiculous "facts" we used to know.  Brace yourself.

1.  Doctors dont need to wash their hands.  Before the 1920s, it was not common practice for doctors to wash their hands with soap before working with a patient, or even between surgeries.  Doctors didnt realize its importance until a Hungarian physician, Ignaz Semmelweis, discovered it was an effective means of preventing common diseases.  Could you imagine a doctor performing a surgical procedure on you, right after he had his hands all up inside another patient?  It used to happen.

2.  Frontal Lobotomy for mental illness.  In the mid 1900s, a procedure called the lobotomy was used in an attempt to cure mental illness.  In fact, Antonio Egas Moniz received the Nobel Prize for Physiology or Medicine in 1949 for his discovery of the therapeutic value of the procedure in treating certain conditions.  So what exactly is a frontal lobotomy?  Doctors would impale a patients head with a large needle, forming a rather large hole from the inside of the left eye socket all the way to the prontal cortex of the brain.  Yes, they literally stabbed patients in the head.  The procedure may have been somewhat effective in reducing symptoms of mental illness, but it predictably had side effects.  As many as 3% of patients were killed by the procedure, according to the 1970 Psychiatric Dictionary.  But besides that, it essentially made the patients easier to control by reducing their mental capacity.  Good for nurses in the psychiatric ward, bad for humanity in general.

If youre interested in learning more about the latest U.S. health care cost trends, everything you need to know is in this article in the January 2013 issue of Health Affairs.

Or you could rely on the Disease Management Care Blog to point out the articles 7 most important points.  Use them to impress your colleagues and stymie your foes:

1) The data only go up to 2011; well have to wait another year before well know about 2012.

2) 2011 health care spending, as a percent of gross domestic product, remained at 17.9%.  The overall economy was slow and that took its toll on the health care sector.

3) That comes out to $2.7 trillion or $8,680 in health care spending per person.

4) While the percent remained stable, the economy experienced modest growth in 2011. The health care sector, thanks to an overall growth rate of 3.9%, kept pace. Prices for services grew less than the demand for services.  As we grow older, demand is likely to grow.

5) Medicare and private insurance grew faster than the economy, which was offset by Medicaid cost cutting by the states.

6) If the past is any guide, when the U. S. economy rebounds, health care spending is likely to accelerate and resume its march toward becoming 20% of GDP.

7) The relative stabilization of 2011 health care costs is independent of the Affordable Care Act.  Many of its important provisions (such as the mandate) dont kick in until 2014.

Thanks to Managed Care Magazine, the Disease Management Care Blog can post this interesting 25 minute interview with Princeton healthcare economist Uwe Reindardt.  Suitable for desk-bound meal-break viewing by overachieving DMCB readers, the modest and insightful Dr. Reindardt gets it mostly right:

No, the slowdown in the U.S. rate of health care costs cannot be ascribed to passage of the Affordable Care Act.  It started wayyyy before Obamacare was passed and is more likely due to the economic slowdown and increased consumer cost-sharing.

Accountable Care Organizations remain an "iffy" experimental proposition because they "dont go all the way like Kaiser."

Republican proposals to let health insurers sell their products across state lines are hardly a health orm panacea, because prices (and theore premiums) are not a function of where the insurer is domiciled, but where the care is rendered.  Texas insurers would still have to pay New York prices.

Americans use fewer pills, occupy less bed-days and see fewer doctors, but we pay more because providers can charge more.  Despite being relatively small vs. the behemoths like Aetna and Cigna, regional hospitals have considerable market power that translates into take-it-or-leave it local single seller monopsonies.   Europeans, in contrast, have lower prices because their system is dominated by single purchaser monopolies.

Were headed toward a three-tier system comprised of 1) the indigent safety-net public programs, 2) the middle class "erence pricing" "networks" where consumers pay the difference if they want to buy up and 3) "boutique" health care for the 5%.

Theres reason to be optimistic about the next five years thanks to a sluggish labor market (making it easier to impose networks and even more cost sharing) and innovation (computational capacity is putting meaningful quality measurement within reach, while techy gizmos are making self-care simultaneously cheap and fun). 

Plus, theres reason to be of good cheer.  Compared to the U.S. education and the legal systems, health care is far more efficient and consumer-friendly.  Stop beating up on yourselves.

(The DMCB didnt quite agree with Dr. Reinhardts views on worksite wellness.  He finds the notion counterintuitive and intrusive, perring that insurers own wellness.  He neglects to mention that the employers who invest heavily in wellness are typically self-insured and that employers have an arguable stake in improving the quality of their human capital.)

Always warm up first."To improve range of motion and avoid injury, you do need to stretch, but dont ever do it when muscles are cold," warns orthopaedic surgeon William Levine, MD, director of sports medicine at Columbia University Medical Center in New York City. "Always start with some mild aerobic warm-ups to get blood to the tissue before doing any stretching."

Holcomb recommends brisk walking or slow jogging for about five minutes, rather than stretching before exercise. "Warming up increases blood flow, which increases the temperature in the muscle, which makes the collagen fibers more elastic like a rubber band," he explains.

After warming up, do dynamic (not static) stretches. Dynamic stretching means slow, controlled movements rather than remaining still and holding a stretch. They may include simple movements like arm circles and hip rotations, flowing movements as in yoga, or walking or jogging exercises like those mentioned below. While studies have not clearly proven this, increasing numbers of experts agree that dynamic stretching is the best stretching routine before a workout or competition. Levine warns, however, that proper technique is key. "Poor technique that is not anatomically correct puts you at higher risk for injury."


Holcomb recommends three all-purpose dynamic stretches for your lower body:

    * Goose-step march: Slowly lift your leg straight out in front of you, alternating as you walk with your normal stride length. While others may think youre doing a Monty Python skit, it is an effective hamstring stretch.
    * Knee lifts: As youre jogging or walking, bring knees up toward your chest. For a variation, as your right knee comes up, twist the lifted leg gently to the left and your upper body gently to the right for a spinal twist. Repeat on each side as you jog or walk (warning: you may be mistaken for a Rockette).
    * Butt-kick: As you jog or walk, bend one knee and lift it behind you as if you were trying to kick yourself in the butt. Its not punishment; it stretches the quadriceps.

Do several repetitions of 30 seconds each at your own pace. The point is to do the movements in a controlled way. Stop if you get tired so you still have energy for your workout.

Consider yoga. "Isnt it interesting that this new research is figuring out what yoga teachers have known for thousands of years?" says Mary Pullig Schatz, MD, a retired surgical pathologist, yoga expert, and author of Back Care Basics. If youre familiar with yoga basics, she suggests, you can use those moves as dynamic stretches before, say, a run or a long bike ride. Try two minutes of sun salutations to stretch multiple parts of the body. Or make downward-facing dog dynamic by pedaling your feel or lifting alternate legs.

"Improving your flexibility allows you to put your body in good ergonomic alignment," Schatz says. "Yoga can help you combine flexibility and strength, breathe properly, reduce head, neck, and back pain, and put the body back in balance."

After your workout or competition, then do static stretches. "Too many people do static stretching before and then nothing after," says Holcomb. "Thats the most common mistake I see." This is where youll lengthen muscles and improve your flexibility. Hold static stretches for about 30 seconds.

Learn warm-ups and stretches particular to your sport. Levines team takes care of 29 varsity teams, so hes seen every kind of sports injury there is.

"For example, football linemen are vulnerable to shoulder tears," he says. "Runners may suffer knee problems and shin splints. For golfers, the lower back is often the hot spot."

New research shows its a good move to learn stretching routines customized for your sport and to help prevent the injuries most common to it. The Santa Monica Orthopedic and Sports Medicine Research Foundation in California studied women soccer players who are subject to ACL tears and created a program called Prevent Injury and Enhance Performance (PEP). The program (which can be downloaded at http://www.aclprevent.com/pepprogram.htm) includes a warm-up and stretches (as well as strengthening and agility exercises) specifically designed to prevent ACL injuries.

 Never stretch to the point of pain. Forget the phrase "no pain, no gain. "You do not want pain when youre doing dynamic stretching," says Holcomb. "It should be gentle to start and then progress." When youre doing your static stretching afterward, you should go to the point of slight discomfort and intensity, he says, to improve your flexibility. But if youre making a face, your muscle is contracting to protect itself, which is counterproductive.

Stretch to de-stress. These are stressed-out times, and stretching can help. "As you know, your mind affects your body, and your body affects your mind," says Dean Ornish, MD, founder of the Preventive Medicine Research Institute in Sausalito, Calif., and author of The Spectrum. "During times of emotional stress, the muscles in your body contract. This is an adaptive response to acute stress, as it fortifies your body armor so that in times of danger, if you get hit, for example, your muscles help to protect you.

"However, in times of chronic stress, these same mechanisms that have evolved to protect us can create problems -- chronically tensed muscles, especially those in the back and neck, predispose to chronic pain or injury. Thus, stress management techniques can help prevent this. Also, gentle stretching of chronically tensed muscles provide relaxation to the mind as well as the body."