Health for life

The study showed that older women, non-white women, women who do not have insurance, and women who are not treated at a teaching facility where a plastic surgeon is more likely to be on hand are less likely to undergo reconstruction.

The study was presented at the annual meeting of the American Society of Breast Surgeons (ASBS) in Las Vegas.

About 40% of Early Breast Cancer Patients Undergo Mastectomy
Although studies have shown that women with early-stage breast cancer who undergo breast-conserving surgery and radiation live just as long as women who have a mastectomy, about 40% of women still choose mastectomy, says study leader Laura Kruper, MD, a breast cancer surgeon at City of Hope Medical Center in Duarte, Calif.

"Once they choose mastectomy, there are clear psychological benefits to reconstruction," she says.

So the researchers used California’s government-funded health care database for women treated for breast cancer in four counties from 2003 to 2007 to look into what factors influence their decisions to have implants.
Older Women, Non-Whites Less Likely to Have Breast Implants

Results showed that the number of mastectomies performed increased slightly between 2003 and 2007, and the reconstruction rate rose substantially, from 21% to 29%.

Further analysis showed:

• Women under age 40 had the highest rates of immediate reconstruction compared with any other age group. Compared with them, women 40 to 59 were 48% less likely, women 60 to 79 were 68% less likely, and women over age 80 were 93% less likely to have reconstruction.

• African-American women were less than half as likely as white women to undergo reconstruction, and Asian women had one-third the reconstruction rate of white women.

• Women with private insurance were nearly eight times more likely to have reconstruction than women with Medi-Cal insurance, California’s Medicaid program.

• Women treated at teaching hospitals were twice as likely to undergo reconstruction as women treated at other institutions.

Patient Perence Influences Breast Implants

ASBS spokeswoman Deanna J. Attai, MD, of the Center for Breast Care Inc., in Burbank, Calif., says that in some areas, particularly rural regions, it may be difficult to find plastic surgeons trained in reconstructive surgery.

But, she says, "sometimes its patient perence. I am continually surprised at the number of women, younger women, who feel it is just not important to them. It really is an individual issue," she tells WebMD.

John Corbitt Jr., MD, a private practitioner in Palm Beach County, Fla., was completely surprised at the studys findings.

"In my practice, closer to 90% or 95% of women opt for reconstruction," he says.

Nipple-Sparing Mastectomies Seem Safe

At the meeting, Corbitt presented a study of nipple-sparing mastectomies. The procedure is just what its name implies: intricate surgery to preserve the nipple and the areola after mastectomy.

"For years, the nipple was removed because there were worries the breast tissue it contained had breast cells with the potential to become cancerous," he says.

Once considered experimental, nipple-sparing mastectomy has become common enough that the ACSM is starting a registry to ensure women who have it fare as well as women who dont, Attai says.

In Corbitts small study, one of 228 procedures resulted in a recurrence of cancer in the nipple. "So we simply went in and removed it, and the patient had no cancer.

Treating infection-prone patients over a 12-month period with high doses of vitamin D reduces their risk of developing respiratory tract infection – and consequently their antibiotic requirement. This according to a new study by researchers at Karolinska Institutet and Karolinska University Hospital published in the online scientific journal BMJ Open.

"Our research can have important implications for patients with recurrent infections or a compromised immune defence, such as a lack of antibodies, and can also help to prevent the emerging resistance to antibiotics that come from overuse," says Peter Bergman, researcher at Karolinska Institutets Department of Laboratory Medicine and doctor at Karolinska University Hospitals Immunodeficiency Unit. "On the other hand, there doesnt seem to be anything to support the idea that vitamin D would help otherwise healthy people with normal, temporary respiratory tract infections."

Vitamin D is synthesised in the skin through exposure to sunlight and obtained through certain foods. In Sweden there is a seasonal variation in vitamin D in the blood, the trough coming during the darker half of the year. Studies have shown that low levels of vitamin D can increase the risk of infection, and it has long been known that the vitamin can also activate the immune defence.

For the present study now published in BMJ Open the researchers examined whether treatment with vitamin D can prevent and relieve respiratory tract infections in particularly infection-prone patients. All the 140 participants from the Immunodeficiency Unit had symptoms of disease in their respiratory tracts for at least 42 days prior to the study. The patients were randomly divided into two groups, one of which received vitamin D in relatively high doses, the other a placebo. They were also asked to keep a diary recording their state of health every day during the year-long study period.

The results show that symptoms of respiratory tract infection declined by almost a quarter and the use of antibiotics by almost half. Vitamin D treatment was also tolerated well by all patients and gave no serious side-effects.

The effect of vitamin D on respiratory tract infection is controversial, and a major study from New Zeeland published recently in the scientific journal JAMA found that it did not reduce the incidence or severity of viral respiratory tract infections. However, the present study differs from the JAMA study in several important respects, which could explain their different results. The JAMA study examined a group of healthy people with initially normal levels of vitamin D in the blood, and used bolus dose administration (i.e. large doses on fewer occasions), which is thought to be less effective that daily doses.

"However, the most important difference is probably due to the fact that our participants had much lower initial levels of vitamin D than those in the New Zealand study," says Dr Anna-Carin Norlin, doctoral student and co-lead author of the study along with Dr Bergman. "There is evidence from previous studies that vitamin D supplements are only effective in patients who fall well below the recommended level, which also suggests that it would be wise to check the vitamin D levels of patients with recurrent infections."

Publication: Vitamin D3 supplementation in patients with frequent respiratory tract infections - a randomized and double blind intervention study, Bergman P*, Norlin AC*, Hansen S, Rekha RS, Agerberth B, Björkhem-Bergman L, Ekström L, Lindh JD, Andersson J (*equal contribution), BMJ Open, online 13 December 2012.

AstraZeneca and Ardea Biosciences today presented results from a large study of allopurinol, a treatment commonly used to lower uric acid in patients with gout. The LASSO (Long-term Allopurinol Safety Study evaluating Outcomes in gout patients) study was a multinational, 6-month, open, prospective observational study involving 1,735 patients with gout and was designed to evaluate the safety and efficacy of medically appropriate doses of allopurinol. Results of the LASSO study showed no new safety signals with allopurinol doses of approximately 300mg/day. The study also revealed that at the time of last dose fewer than half (43%) of patients taking allopurinol achieved the target serum uric acid (sUA) level of <6.0 mg/dL, the level recommended by the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR). Results of the LASSO study were presented today at the ACR Annual Meeting in San Diego, CA.

Allopurinol, the most commonly used treatment to lower blood uric acid levels in gout, is a generic treatment that has been available for more than 50 years. It is a xanthine oxidase inhibitor, a class of drugs intended to reduce the bodys production of uric acid. Allopurinol is recommended at doses between 100mg and 900mg per day, depending upon disease severity. The LASSO study encouraged investigators to increase, or titrate, the dose of allopurinol over the six months of the study to a medically appropriate dose. There was a high rate of adherence to therapy (97% across doses) and the most commonly used dose was 300mg. Approximately 45% of patients finished on the same dose as their baseline dose. Results show that even among patients titrated to final doses above the most commonly used dose of 300mg/day, approximately 46% did not reach target sUA levels of <6.0 mg/dL.

"Gout is a painful form of arthritis that is often misunderstood and inadequately treated. The LASSO study demonstrates that many patients with gout fail to reach the recommended treatment goal," said study co-author Nicola Dalbeth, MD of the University of Auckland. "Failing to reach the recommended sUA target leaves patients with gout at risk for further disease progression and long-term consequences of gout."

The results of this large, multinational, prospective observational study of gout are consistent with published literature confirming many patients do not reach sUA targets with allopurinol therapy as currently used.

Specific findings from LASSO include:

- The study revealed no new safety signals with allopurinol (approximately 300mg/day).
- There were no cases of allopurinol hypersensitivity syndrome in this study.
At the time of last dose 43% of all patients in the study achieved target sUA levels of <6.0 mg/dL.
- Of patients in the study at final doses above 300mg/day, approximately 54% achieved target sUA levels of <6.0 mg/dL.
- Gout is the most common form of inflammatory arthritis with a prevalence of 8 million in the U.S. Gout is commonly misrepresented as a lifestyle disease. While diet can contribute to elevated levels of uric acid, the majority of uric acid is produced by the bodys naturally occurring processes, and gout is most often caused by the inefficient excretion of uric acid by the kidneys.
- In patients with gout, abnormally high levels of uric acid in the blood known as hyperuricemia lead to deposition of needle-like crystals in joints and soft tissues throughout the body, causing inflammation. Hyperuricemia results when the kidneys do not efficiently remove enough uric acid, or when the body produces too much. A persons genetics play a significant role in their risk of developing gout. The most common symptom of gout is extremely painful arthritis. Over time, the deposits of uric acid crystals may lead to joint damage, visible nodules called tophi, and impaired quality of life. Additionally, gout has been associated with serious health problems including cardiovascular disease, diabetes and kidney damage.

An echocardiogram of the heart

The shortness of breath just wasnt going away.

After years of being treated for persistent asthma, Dr. Smith (name changed) found his usual mix of inhalers and pills was no longer working.  Unable to comfortably sleep at night and finding he couldnt hustle as quickly up and down his clinics hallways, he decided it was time to see the Disease Management Care Blog.  After a quick look and a listen to his heart and lungs, the DMCB tapped its heuristics and made a shortcut bet that this wasnt asthma.  The echocardiogram that was obtained that afternoon proved that it was right: Dr. Smith had heart failure.

Heart failure is the leading cause of hospitalizations in the elderly and is a huge cost to the U.S. health care system.  Theore, if docs like the DMCB on an individual basis - or the U.S. on a health care policy basis - could prevent heart failure, that would be a big deal.

"Natriuretic Peptide–Based Screening and Collaborative Care for Heart Failure - The STOP-HF Randomized Trial" that was just reported in JAMA may be a step in that direction.

The DMCB explains.

First off, there is a hormone that is made by a stressed heart (yes, the human heart secretes hormones) called "naturetic peptide" (or NP) that signals the kidneys to excrete more salt and water. "BNP" is one type of naturetic peptide that can be detected using a simple blood test.

The STOP-HF trial set out to examine whether BNP levels could identify otherwise well-appearing persons with stressed hearts who were at future risk for the development of clinically evident heart failure.  By catching these persons early and getting them into treatment, the hope was that these patients wouldnt turn out like Dr. Smith.

39 practices in the catchment area of Dublin Irelands St Vincents Hospital erred patients who were older than 40 years and had one of the following cardiovascular risk factors: high blood pressure, high cholesterol, an obese body mass index, documented (by an angiogram or a known heart attack) coronary artery disease, history of stroke, peripheral vascular disease, diabetes, arrythmia or heart valve disease.  Persons with known heart failure were excluded from the study.

After entry into the study, patients had a BNP level drawn and were then erred to either a "control" (observation only) group or to an intervention group.

In the intervention group, patients with an elevated BNP level of 50 pg/ml or more were erred to a cardiology service and had a cardiac function study using echocardiography. In addition, any of the cardiovascular risk factors were aggressively managed with medications and a specialist nurse-coach.

In the control group, physicians and patient were not told about the BNP level and were cared for on a routine basis.  Patients were not erred for any cardiology care unless another reason supervened.

1374 patients were randomized, 697 in the intervention groups and 677 in the control group. High blood pressure was the most prevalent risk factor and most patients had two risk factors. 263 (38%) and 235 (35%), in the two groups respectively, had BNP levels greater than 50 pg/ml.  Average follow-up was 4.2 years and all patients eventually had an echocardiogram to assess their heart function

During follow-up, 8.9% of the control group patients and 5.3% of the intervention patients developed heart failure as determined by echocardiography.  That difference was statistically significant and was due to a higher level of treatment with drugs that help control risk factors and prevent heart failure. When the DMCB uses a number needed to treat analysis, the works out to 28 patients needing to be screened and treated for an elevated BNP to avoid one case of heart failure.  Thats not bad, even if you compare it to aspirin and heart attacks.  There were also fewer emergency room visits and hospitalizations in the intervention group.

The DMCBs take:

1. This is classic population health management: This study was not only about using BNP to find patients at risk for heart failure, it was about relying on nurse coaches to manage the underlying clinical drivers, such as high blood pressure or underlying coronary artery disease.  If the DMCB suggests a better title for this article would have been "Population Health Management to Screen and Treat Patients with Elevated BNP at Risk for Heart Failure."

2. An appealing value proposition with a return on investment: Given a NNT of 28 and the future costs of heart failure, combined with statistically significant reductions in emergency room use and hospitalizations, the DMCB expects population health management service providers as well as medical homes to use BNP and non-physicians to screen and treat patients to prevent heart failure.

3. Still imperfect: Despite aggressive management by a specialized team, 5% of patients in the intervention groups went on to develop disease.  We have a ways to go. 

Image from Wikipedia

People who take statins to reduce their risk of cardiovascular disease are less likely to be diagnosed with the most common form of glaucoma, according to a nationwide study of more than 300,000 patients. A University of Michigan School of Medicine research team, directed by Joshua Stein, MD, MS, found that the risk for glaucoma was reduced by eight percent in patients who took statins continuously for two years, compared with patients who did not take statins. The study, the largest to date on the topic, is published in the October issue of Ophthalmology, the journal of the American Academy of Ophthalmology.

Dr. Steins study was sparked by growing evidence that statin use may protect the optic nerve and retinal nerve fibers, structures that are essential to good vision and are damaged by glaucoma. His team used healthcare claims data for a diverse population of Americans aged 60 and older who took statins to control high blood levels of unhealthy fats, a condition known as hyperlipidemia, between 2001 and 2009, The researchers assessed patients risk for open-angle glaucoma (OAG). Unlike earlier studies, their analysis adjusted for patients who also had diabetes and/or hypertension to prevent distortion of the results.

Several of the studys findings suggest that statin use may be most important before glaucoma is diagnosed, or in the early stages of the disease. Dr. Steins research may lead to new preventive treatments that could especially benefit groups at increased risk, including African-Americans, Hispanics and those with a family history of glaucoma.

Glaucoma affects more than 2.7 million Americans age 40 and older . If untreated, glaucoma causes vision loss or blindness by damaging the eyes optic nerve. The optic nerve sends signals from the retina — a layer of light-sensitive tissue at the back of the eye — to the brain, where these signals are interpreted as the images we see. Only about half of the people who have glaucoma know it, since symptoms are rarely noticed in the early stages and vision loss is very gradual in most cases.

"Statins apparent ability to reduce glaucoma risk may be due to several factors, including improved blood flow to the optic nerve and retinal nerve cells and enhanced outflow of the aqueous fluid, which may reduce intraocular pressure," said Dr. Stein. "While more research is needed, we hope our results may contribute to saving the sight of thousands who are predisposed to glaucoma."

Dr. Stein cautioned that the study results apply only to patients with hyperlipidemia, and that further study is needed to determine whether statins also protect patients who dont have this diagnosis or have other characteristics that differ from the study population.

Infections are difficult to manage for a healthy person, let alone someone with diabetes. Illness can cause blood glucose levels to rise and makes managing those levels even more challenging.

Now a study set to appear in the August 1 issue of Clinical Infectious Diseases adds to the reservoir of clinical data supporting the notion that people with diabetes get sick more often than people without the disease.

The study found that people with either type 1 or type 2 diabetes had a greater risk for infection (specifically of the respiratory tract, urinary tract, and skin and mucous membranes) than people without diabetes.

The lead author of the study, Leonie Muller, advises physicians to "be aware of the fact that diabetes patients have an increased risk of common infections." She recommends that people with diabetes take preventative measures such as getting the flu vaccine, drinking plenty of fluids, and not hesitating to contact a physician at the earliest sign of an infection.

________
For a summary of the study:
Study Shows Increased Risk of Common Infections in Diabetic Patients

For the study itself (abstract only, subscription required for full article):
Increased Risk of Common Infections in Patients with Type 1 and Type 2 Diabetes Mellitus

Joanne Wu, writing in the Annals of Family Medicine, suggests that we dismantle the health insurers "pay for performance" ("P4P") programs in favor of "pay patients for performance" (PP4P).  As blood pressure control, cholesterol treatment, cancer screening rates or fitness rates increase, she proposes that patients receive "health care credits" in the form of lower co-pays, discounts or premium reductions.

Good idea, says the  Disease Management Care Blog, but:

1) Long standing regulations stand in the way. Health insurance regulators generally frown on programs that compromise community-rated risk pooling that gives everyone the same benefit for the same price.  ERISA-protected plans, on the other hand, have greater latitude in flexing their insurance benefits. 

2) Politics stand in the way. Opponents argue that persons less well off will be unfairly disadvantaged by wellness incentives.  You can read more about that here. 

3) Doctors stand in the way. Last but not least, insurers generally fund P4P by diverting the money from the providers inflation-adjusted or market-driven fee schedule increases.  In other words, taking P4P money from the docs and giving P4PP to the patients aint gonna easily happen.

That being said, the DMCB thinks Dr. Wu may be onto something.  She recommends a pilot be tried in a small community.  Given the downstream savings, wed be foolish to not take every advantage we can to achieve patient buy-in, and a pilot sounds like a grand idea.

Im baaaaack!

When persons are admitted to a hospital, insurers payment rates are based on the diagnosis, not the number of days in the hospital (known as a "length of stay").  As a result, once the admission is triggered, the hospital has important economic incentive to discharge the patient as quickly as possible.  The Disease Management Care Blogs physician colleagues used to refer to this as "treat, then street."

Unfortunately, discharging patients too soon can result in readmissions.  Thats why the DMCB has agreed with others that diagnosis-based payment systems and a policy of "no pay" for readmissions were working at cross purposes.  Unified bundled payment approaches like this seem to be a good start.

But thats all theoretical.  Whats the science have to say?

Peter Kaboli and colleagues looked at the push-pull relationship between diagnosis-based payment incentives  and the likelihood of readmissions in a scientific paper just published in the Annals of Internal Medicine. 

The authors used the U.S. Veterans Administration (VA) Hospitals "Patient Treatment Files" to examine length of stay versus readmissions in 129 VA hospitals.  The sample consisted of over 4 million admissions and readmissions (defined as within 30 days and not involving another institution) from 1997 to 2010. The mean age started out at 63.8 years and increased to 65.5 years, while the proportion of persons aged 85 years or older increased from 2.5% to 8.8%. Over the years, admissions also grew more complicated with a higher rate of co-morbid conditions, such as diseases of the kidney (from 5% to 16%).

As length of stay went down, readmissions should have gone up, right?

The answer was yes and no.

Yes, if the data were trended over time: Over the 14 year period of observation, the number of days in the hospital (length of stay or LOS) decreased from 6.0 days to 4.3 days.  Yet, as LOS decreased, readmissions also decreased from 16.6% to 15.2%. 

The decreases held up when the LOS was risk-adjusted for hospital and patient characteristics.  There was also no increase in mortality rates

No, if hospitals were compared to each other:  Hospitals with risk-adjusted low lengths of stay had higher readmission rates compared to their average peers.  In that group, each day of saved LOS was associated with a 6% increased rate of 30-day readmissions.

It gets even more complicated.  As the LOS increased beyond the average, each additional day in the hospital was associated with a 3% increased rate of 30-day readmissions.

What should the DMCB learn from these data?  Keeping in mind that the VA is not necessarily generalizable to the typical community medical center,

1. Over 14 years of worth of VA data for 129 hospitals suggest it is possible to have your cake (a lower LOS) and eat it too (lower readmissions).  Thats the good news.

2. While overall performance improved over the years, between hospital comparisons showed there is a "U" shaped relationship between days in the hospital and the likelihood of readmission.  The DMCB agrees with the authors: premature discharge before the patient is ready is associated with an 6% per day readmission rate, while patients who are very sick and have to stay a few extra days in the hospital are also at risk to the tune of 3% per day.  Thats the sobering news.

What are the implications?

Overzealous efforts to discharge patients can backfire with readmissions.  It appears theres an optimum length of stay that minimizes, but will never eliminate, readmissions.

Patients who do go home "too soon" or need extra days in the hospital appear to be at special risk.  Accountable care organizations and population health management service providers should use this information to target patients at special risk of "treat, street and... repeat."