Health for life

Researchers in Chicago found it is possible to induce a state of insulin resistance - with subsequent rises in blood glucose - in young, healthy, non-overweight subjects by simply disturbing their sleep.

When volunteers entered a stage of sleep called deep non-rapid eye movement (NREM), also known as slow-wave sleep (SWS), researchers made noise, but not enough to wake them. After three days, the participants ability to regulate blood glucose declined by 25%.

This impaired glucose tolerance occurred even though the participants slept for 8.5 consecutive hours. It was the quality of their sleep, not the length, that determined their ability to manage blood glucose.

The research appeared in an online edition of the Proceedings of the National Academy of Sciences (PNAS) this month:

Slow-Wave Sleep And The Risk Of Type 2 Diabetes In Humans
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Some news summaries:
Lack Of Deep Sleep May Increase Risk Of Type 2 Diabetes (Science Daily)
Sleep Disruptions May Up Diabetes Risk (Yahoo)

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.

People who reported dietary intake that was most consistent with the 2005 Dietary Guidelines for Americans had lower risk of pancreatic cancer, according to a new study published August 15 in the Journal of the National Cancer Institute.

Previous studies investigating the relationship between food and nutrient intake and pancreatic cancer have yielded inconsistent results. The U.S. Government issues evidence-based dietary guidelines that provide the basis for federal nutrition policy and education activities to promote overall health for Americans. The authors evaluated how closely study participants diets matched the 2005 Dietary Guidelines for Americans, as measured by the Healthy Eating Index (HEI-2005), and then compared their risk of pancreatic cancer.

Hannah Arem, Ph.D.,, from the Division of Cancer Epidemiology and Genetics at the National Institutes of Health in Bethesda, MD, and colleagues calculated HEI-2005 scores for 537,218 participants in the NIH-AARP Diet and Health Study (ages 50-71 years), based on responses to food frequency questionnaires. Pancreatic cancer risk was then compared between those with high and low HEI-2005 scores, accounting for the influence of other known pancreatic cancer risk factors.

Among the study participants there were 2,383 new cases of pancreatic cancer. Overall, the investigators observed a 15% lower risk of pancreatic cancer among participants with the highest HEI-2005 score compared to those with the lowest HEI-2005 score. This association was stronger among overweight or obese men compared to men of normal weight, but there was no difference for normal vs. overweight or obese women. While the authors adjusted for known risk factors such as smoking and diabetes status, they caution that other health factors not collected in the questionnaires may be associated with a more healthful diet and might explain some of the observed reduced risk. They also noted that diet is difficult to measure and the HEI-2005 was not designed specifically for the purpose of overall cancer prevention.

According to Arem and colleagues "the Dietary Guidelines for Americans are issued to promote overall health, including the maintenance of a healthy weight and disease prevention. Our findings support the hypothesis that a high-quality diet may also play a role in reducing pancreatic cancer risk." Future studies are needed to confirm these findings.

In an accompanying editorial, Rachel Ballard-Barbash, M.D., and Susan M. Krebs-Smith, Ph.D., from the Applied Research Program at the National Cancer Institute (Bethesda, MD), and Marian L. Neuhouser, Ph.D., from the Cancer Prevention Program in the Division of Public Health Sciences at the Fred Hutchinson Cancer Research Center (Seattle, WA) discuss that progress has been made in understanding associations between diet and cancer risk, but they have not resulted in noticeable changes in cancer incidence in the US. They conclude, "Practical and actionable dietary recommendations that are based on sound research should ultimately reduce patient suffering and treatment-related expenditures from preventable cancers."

Maybe theyll put up a plaque honoring Mr. Obama?

The health care newsie Disease Management Care Blog thought it had seen it all.  Now this.......

In a striking policy about-face, the Obama Administration has adopted a market-based approach to setting prices and controlling utilization. Everyone agrees that letting prices rise in response to demand disproportionately harms lower income Americans. We also know its another drag on an already fragile economy. Last but not least, its vexing the Presidents political base. 

Nonetheless, the Administration is being resolute. Putting political expediency aside, the White House has courageously put their faith in an unabashed conservative philosophy by arguing that long-term benefits of higher prices will ultimately pay dividends in wise consumerism, innovation and quality.

Wow.

As a result, the White will House forgo any "demand" or "supply" side interventions.  There will be no price regulation based on prevailing costs and projected outcomes. Theyll spurn the suggestions of myriad legal, economic and regulatory expert panels.  Theyll resist activist calls to expand the role of the Federal government. 

Politics?  Sure, but the machinery in West Wing knows how to manage that. They know a normally friendly news media will report some inflammatory anecdotes about how low income Americans are being forced chose among lifes other basic necessities. Theyll just ride out the news cycle and counter with populist attacks about "profits" and "fat cats" and "corporate jets."  While the messy politics sort themselves out, Mr. Obama has faith: supply, demand and the marketplace will take us where we need to be.

Is this about health care you ask?  Hardly.  Education?  Nope.  Housing? Negative. The Disease Management Care Blog points out that this is the Administration posture on an arguably equally important part of our collective national well-being: transportation and energy prices.  Mileage standards and Detroit bail-outs aside, The DMCB thinks this is quite a reversal.

A harbinger of things to come?  We can only hope. 

Image from Wikipedia

Sei Lee and Louise Walter, in this Commentary published in the Oct 5 issue of JAMA, argue that the current  approach to measuring health care quality often leads to unintended harm for many older adults.  Thats because the guidelines-driven and evidence-based measures are "unbalanced."

The Disease Management Care Blog agrees that the state-of-the-art is unbalanced, but its even worse than Drs. Lee and Walter describe. 

First, the Commentary.....

Right now, standard methods for assessing the degree of blood pressure control (typically defined as being less than 140/90) doesnt account for some elders being prone to getting low blood pressure and dizzy when theyre upright. Blood sugar control is a good idea among most persons with diabetes, but for many reasons, older persons are more prone to having dangerously low dips in their glucose levels.  Last but not least, theres also the questionable wisdom of screening for cancer when the likelihood of death from other causes is far greater.

Most nationally recognized clinical guidelines usually have a disclaimer that they are not intended to be used as an inflexible and one-size-fits-all standard of care (for example, read the 4th paragraph of the high blood pressure guideline here).  Yet, in contrast to the flexible guidelines, the all-or-none quality approach to measurement (for example) are inflexible and fail to give "credit" when testing or treating in individual patients are unwarranted. 

Drs. Lee and Walter propose to fix this by reconciling the measures with life expectancy.  If better blood pressure, diabetes or cancer screening can mathematically be expected to result in more years of life, then they should be implemented and only then should credit be given.  While this could get complicated (think life expectancy tables being used during a visit with your doctor or, egads, politically underhanded accusations of ageism and death panels), the authors point out that electronic health records decision support - despite its disappointing track record - could enable life expectancy awareness during physician office visits. Whats more, doctors wouldnt necessarily have to follow the decision support recommendations, but the fact that they were considered could be also be rolled into quality measurement.

What does the DMCB think?

It salutes the authors and JAMA for raising an important point. The idea of accounting for clinical benefit in quality measures is intriguing.  Yet, the DMCB doesnt think the authors go far enough in addressing the imbalance.  It would go one step further and make the measures depend on the on a rather radical patient-centered approach: if the patient was engaged and became aware of the risks, benefits and alternatives to the guidelines-based testing and treatment, was allowed to make an independent, educated and reasoned judgement and gave either active consent or refusal, only then is credit given.  Life expectancy can be part of that shared decision making, but its not the only ingredient.

Novel thought hm?  Its not up to any utilitarian calculation of life expectancy.  Its not up to some buggy computerized decision support algorithm.  Its not up to any expert guidelines.  Its not up to national quality setting organizations.  Heck, its not even up to the physician.  Thats all unbalanced.

Want true balance? Once all the above inputs are understood, its up to the patient.