Health for life

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.

Today the DMCB caught up on some reading of the medical literature. 

The first article is an example of how researchers risk thresholds dont match patient perceptions.

The second article is an example of media innumeracy. 

The third article is likely to be ignored by everyone.

1. Should Cardiac Telemetry Not Be Used for Patients with Only a Three Percent Chance of a Problem?

Suppose, asks the Disease Management Care Blog, your elder family member mysteriously passed out and was seriously injured?  You would wonder if a cardiac problem could be the cause. While the likelihood of that is typically low, even the small chance of something being "wrong with the heart" is enough to make patients and their families worry.

But suppose the chance of a heart problem was only.... 10%?  Or 5%? Or 1%?    

Once a decision is made to admit a patient with loss of consciousness to a hospital, doctors typically arrange for "cardiac telemetry." That broadcasts the electrocardiogram on an ongoing basis to a monitoring unit.  Unfortunately, however, the demand for a hospital telemetry "slots" is high and the monitoring requires additional personnel.

As a result, clinical guidelines like these have been developed.  They define high risk patients who warrant telemetry and low risk patients who dont.  For example, patients who have had a recent heart attack are vulnerable to unstable heart rhythms, while patients with stable atrial fibrillation can probably be safely managed off telemetry. Patients who have passed out and are stable on telemetry after 3 days are considered low risk.

Enter Evan Benjamin and colleagues who applied the guidelines to a retrospective audit of how telemetry was used for 501 consecutive patients at four Massachusetts medical centers.  Since patients could transition from high to low risk as the days passed, the unit of measure was "patient-days" (if two patients were each on telemetry for 4 days, that yielded eight "patient-days"). 

38% of the total 1559 patient-days were low risk. Among the high risk patients, a heart problem was detected in 21 out of 100 patient-days.  In the low risk patients, a problem was detected in 3 out of 100 patient days. 

The authors argue that these data show that better enforcement of guidelines that restrict access to telemetry would result in more cost-effective care.  The DMCB isnt so sure, because it intuitively thinks most patients and doctors would consider a 3% (3 out of 100 patient-days) a low enough threshold to warrant monitoring.

Good luck, says the DMCB, enforcing that. 

2. Just How Bad is the Link Between Red Meat and Diabetes?

"Yikes!" said the DMCB after listening to this NPR broadcast and reading this WSJ article.  It appears that increasing red meat consumption increased the risk of diabetes among previously healthy people "by 50%!"  While its first impulse was to throw away those frozen strip steaks, the DMCB took a deep breath and did something the reporters neglected to do: read the article.  It turns out that the approximate risks went from approximately 0.2% to 0.3%.  More than 99% of the carnivores did fine.  Once again, the reporters failed to discern that while the relative risk was high, while the absolute risk was vanishingly low.

3. A Reminder that the Annual Check Up is a Waste of Time and Money

After reviewing 16 studies involving over 180,000 participants, the authors in this JAMA study concluded:

.... general health checks were not associated with lower rates of mortality or morbidity.  However, general health check may increase the number of diagnoses and the use of medications.

The irony is that The White House and CMS profess to being evidence-based while remaining simultaneously committed to "wellness checks."

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