Health for life

1. Using traditional research to detect a "statistically significant" decrease in insurance claims expense is notoriously difficult.

2. Theres scientific statistical proof and then there is a reasonable business assurance.  The latter may be enough for business-minded health insurers.

3. The conclusion is based on published research.  Unpublished "in house" data have convinced many insurers to include the medical home in their covered benefit.  They know something AHRQ doesnt.

4. While medical homes alone may be insufficient to save money, that doesnt mean that medical homes that are part of a package of interventions (value-based purchasing, P4P, vendor-based population health management or an ACO) are unnecessary.

5. While there is no evidence of savings, there is also no consistent evidence of increased cost. That means the quality associated with the medical home represents high value.

That being said, the U.S. Agency for Healthcare Research and Quality (AHRQ) Evidence Report Technology Assessment on the Patient Centered Medical Home says:

"Based on a combination of good- and fair-quality studies, there is a low strength of evidence that PCMH implementation may lead to lower utilization (inpatient and emergency department) for some subgroups of patients, but this effect was not uniform. Moreover, total costs were not lowered in the reviewed studies.

However, three observational studies specifically designed to test PCMH do report lower inpatient and emergency department utilization among patients in the PCMH program. However, total costs were not statistically different for PCMH and non-PCMH patients in the three studies. None of the clinical trials of functional PCMH interventions had statistically significant differences between intervention and control arms for inpatient or emergency department utilization.

No studies reported statistically significant cost savings among PCMH patients. In fact, when taking into account program costs, two studies, one good-quality trial and one fair-quality observational study, reported greater total costs among intervention patients."

 Image from Wikipedia

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.

There are several reasons to attend the Oct 21 Patient Centered Primary Care Collaboratives 5th Annual Summit.

Youll see the good work that the PCPCC is doing as the leading national organization advocating on behalf of the Patient Centered Medical Home (PCMH).

Along with an auditorium-full of like-minded learners, youll benefit from an agenda that is packed with clinicians from the real world of medical practice who have developed successful medical homes. 

Youll get to meet others who share your interest in an innovative and rapidly evolving approach to primary care.   

Youll be in Washington DC at the height of beautiful fall weather. 

And, last but not least, youll get your own copy of the PCPCC Report, Care value, community connections: Care coordination in the medical home.  According to this newswire press release, the report "includes the insights of thought leaders" on the theories and tactics behind the definition, role and function of care coordination.

The immodest Disease Management Care Blog couldnt have put it better itself, especially because its the author of the first second chapter.

An ovary almost completely replaced by cancer

As regular Disease Management Care Blog readers may have predicted, the controversial anti-cancer drug Avastin went bust again in two just-published studies (here and here).  This time it wasnt for the questionable treatment of breast cancer but ovarian cancer.  Yet, while the nations mainstream media has passed sentence on Avastins failure, the DMCB isnt quite ready to "short" the drug.

Very briefly, one randomized prospective trial involved women with high risk or disease that had spread.  Participants were randomly assigned to standard chemotherapy plus Avastin, while the other group got just the chemotherapy.  Women in the Avastin group went 24.1 months without progression of their disease versus 22.4 months in the non-Avastin group.  Death rates are still being analyzed.

The other trial involved women with cancer that had spread.  They were randomly assigned to one of three groups: just 1) chemotherapy or 2) chemo plus either Avastin in the earlier cycles of chemotherapy or 3) Avastin with all the cycles of chemotherapy.  The just chemo group went a median of 10.3 months before there was disease progression, while the Avastin groups went 11.2 and 14.1 months, respectively.

Even with the depressing results outlined above, the DMCB has several reasons for believing that weve not seen the last of Avastin for ovarian cancer.  Much of the DMCBs obstinacy has to do with the complexities of cancer treatment and how statistics are collected and interpreted:

1.  The trials involved patients with aggressive or advanced disease. Much like the logic of using a small extinguisher on a huge house fire, that doesnt mean that persons with limited or microscopic disease wouldnt be helped by Avastin.  The only way to find out is to perform the same sorts of randomized trials involving patients with less widespread or aggressive disease. 

2.  Its possible that some of the Avastin patients may have gotten much better, but their positive results were diluted by the majority of the patients who didnt benefit. In other words, the clinical trials report the average response rate.  That does little to answer the two questions that every individual cancer patient asks: 1) are there exceptions and 2) am I one of them?

3. Assuming exceptions exist, there may be a way to identify that small minority of patients who are more likely to derive a greater benefit from Avastin. Assuming ovarian cancer is a heterogeneous disease, there may be a blood test or an additional type of biopsy that can answer the two questions above.

4. "Disease progression" is just one of several cancer outcomes.  While its important, there are others that may have more meaning for patients and could simultaneously put Avastin in a better light.  As a reminder, death rates in one of the trials described above are still being compiled and have yet to be reported.  Stay tuned.

5. Last but not least, the most selectively generous interpretation of the data above is that Avastin helped patients go an additional 4 months before their disease started spreading again.  While that may not seem worth it, the DMCB has taken care of plenty of patients who would think its plenty worth it.  While commercial insurers will have every reason to question payment for a horrendously expensive drug with only 4 months of benefit, patients and their doctors will argue that hope is "medically necessary."

Image from Wikipedia

What do I want for dinner... lamb or anemia?

Let me first say this.  I have nothing against vegans or vegetarians; I respect everyones dietary choices.  I have a lot of friends who are vegan/vegetarian, and, aside from the occasional accusation that I murder animals (kidding), we get along just fine.  They eat their veggie burgers, I eat my grass-fed beef burgers; they run their marathons, I do my Crossfit; they poke fun at Dr. Oz, and I, well, poke fun at Dr. Oz.  See... were not so different after all.  Having said that though, based on my research I cant imagine a situation where I would recommend a vegan diet to anyone.  Thats vegan, not vegetarian.  Vegetarians typically eat dairy and eggs, vegans dont eat any animal products.  Its the vegans Im talking about here (although some of this applies to both) .  So without further ado, here are 5 reasons why I dont like veganism.


1.  Humans are not herbivores.
This myth just wont go away.  Every once in a while I get this argument from some fool trying to justify a vegan diet as the best diet on the planet.  It typically sounds like this... "You know some people think humans are carnivores, but theyre not.  Theyre herbivores."  Theres so much wrong with this, I dont even know where to begin.  Okay first of all, nobody thinks humans are carnivores.  Were clearly not.  But were not herbivores either.  This argument completely neglects the fact there is another option:  an omnivore, which eats both plants and animal foods.  Humans are most definitely biological omnivores.  Just look at our teeth... mostly flat like herbivores (think about a cows teeth) but with a few canines like carnivores (think of a cat).  Then theres our digestive system... its definitely nothing like that of an herbivore.  Heres a picture of a cows digestive tract:



You can see here that a cow, designed to eat grass, has four stomachs (not to mention the spacious interior and giant cecum).  If youre counting, thats three more than we humans have, and those extra stomachs serve to ferment fibrous plant material for digestion and absorption.  Humans dont have this ability, which is why insoluble fiber goes through our guts undigested.  What humans do have, however, is the ability to produce HCl, aka stomach acid, to break down protein from animal products.  Cows and other herbivores do not.  I wont go into detail about any carnivorous digestive systems, like that of a cat, but I will just say this:  I had to dissect cats many times in Anatomy lab.  I can tell you first hand that their digestive system looks very similar to ours.  Heres some evidence, courtesy of catlas.


Point made, humans are most definitely not herbivores.  We have the teeth of both herbivores and carnivores, and our digestive machinery is closer to carnivorous than herbivorous.  We are fully equipped to digest and assimilate animal foods.  Theres more to this argument of course, and if youre interested I recommend this article, written BY A VEGETARIAN, explaining the fact that humans are indeed omnivores.  So seriously, cut the herbivore shit.  It just makes you look uneducated.


2.  Avoiding animal products will not save the environment.
Another common argument to support a vegan diet is the environmental impact.  Vegans argue that producing meat is a highly wasteful and environmentally damaging process, and theyre sort of on to something.  Conventionally farmed meat is indeed a disaster for the environment.  Now Ill admit Im no expert on the topic, but it doesnt take a genius to see why.  We have to grow all of this corn and grain (in and of itself an environmentally damaging process), just to feed the cattle to make them fat, just to eventually feed ourselves.  So its not difficult to see a solution in there... just feed the corn and grains to ourselves, dont waste it on the cattle. 

But again, this argument has holes... it says nothing about naturally raised livestock, like grass-fed beef.  The production of grass-fed beef is exponentially less input-intensive; all you really need is cows and an open field, and a place for shelter.  In addition, cattle grazing can actually have a positive impact on the land and can help rejuvenate the nutrients within the soil.  Not to mention the vastly improved quality of life for the cows, compared to a factory-farmed life.  As I hinted at before, growing corn, wheat, and other grains isnt exactly environmentally friendly either.  Clearing land to grow annual crops like grains destroys entire ecosystems.  That means animals die because youve destroyed their natural habitat.  So dont think youre saving animal lives by going vegan; thats just not the case.  Then theres also the extensive use of pesticides, insecticides, and herbicides on these mass-produced grains and the impact that has on the environment.  And the depletion of nutrients in the soil over years and years of intensive grain agriculture.  Its not exactly a pretty picture.  Not pretty like the one vegans will try to sell you.  Producing grains does more to destroy the environment than to save it.


3.  Avoiding animal foods doesnt save animal lives.
I may have jumped the gun with this one in the previous section, but heres a more in depth explanation.  As Ive been told a million times...  "If I dont eat meat, I wont be contributing to the death of innocent animal lives."  Well I admire your compassion, but I think we need a biology lesson here.  Death is what makes the world go round.  There is no life without death, and there is no death without life.  Rabbits eat grass and vegetation, wolves eat rabbits, bears eat wolves, hawks scavenge these animal remains, and bugs in the soil recycle the nutrients from said remains.  Its just how biology works.  You cannot separate the ecology of plants and animals; they work together to balance an ecosystem.  When you clear land to grow massive amounts of corn, youre destroying the former ecosystem, which was likely full of all kinds of cute squirrels and mice.  Its a mass homicide!  When you spray these massive fields of corn with herbicides and insecticides, killing EVERYTHING but the corn itself and polluting the air... mass homicide!  No matter how you slice it, whatever you choose to eat, something is dying to feed you.  This is just one of those times when the human capacity for emotion gets in the way of the realities of biology.  I know death is sad.  But without it, you wouldnt have life, so thank those that died to provide you life and get on with it.  And no Im not talking about Jesus.  But thank him too if you want, although hes probably sick of being thanked at this point.

Oh and one more important point... we use animals for much more than just food.  Heres a quote from a Weston A. Price Foundation article that sums it up quite nicely:  "Cows are slaughtered not only to put steak on the table, but to obtain components used in soaps, shampoos, cosmetics, plastics, pharmaceuticals, waxes (as in candles and crayons), modern building materials and hydraulic brake fluid for airplanes. The membrane that vibrates in your telephone contains beef gelatin. So to avoid hypocrisy, vegetarians need to also rain from using anything made of plastic, talking on the telephone, flying in airplanes, letting their kids use crayons, and living or working in modern buildings."  Good luck.


4.  The people most likely to adopt a vegan diet are the same people who need animal products the most.
This is perhaps the most unfortunate part of this issue.  To me its obvious that the people most attracted to veganism are young females.  Probably due to socialization and this new age "everybodys a winner" mentality were teaching our kids these days, girls seem more likely to have compassion for these cute, poor little animals that were all killing and eating.  But we need to grow up.  Ethical issues aside, we humans have nutritional requirements that simply cannot be ignored.  And one of the most important nutrients for maintaining health, especially in young women, is iron.

Iron is the backbone of hemoglobin, which is responsible for transporting oxygen in blood.  Without sufficient iron, oxygen transport is impaired, and we develop iron-deficiency anemia.  Symptoms include chronic fatigue, muscle weakness, shortness of breath... exactly what you would expect when your body is having trouble transporting oxygen.  And since women bleed every month (hence, they lose iron), they have a significantly higher requirement for the stuff.  Women ages 19-50 need 18 mg/day.  For comparison, men ages 19-50 only need 8 mg/day.  According to this paper, women are 6-10 times more likely to develop iron deficiency anemia than men!


The problem with vegan diets is that they almost assuredly are deficient in iron.  All of the best sources of iron are from animal products:  clams, oysters, organ meats, red meat, etc.  Youll find some in plant foods as well, like beans and leafy green vegetables, but the type found in plant foods is poorly absorbed.  Sure, its possible to get enough iron from plants.  Just not easy, especially if youre bleeding some out every month.  In addition to iron, there are some other things like vitamin B12 (completely absent from plant foods) and long-chain omega-3 fatty acids (youll have to eat algae) that will be nearly impossible to get enough of on a vegan diet.  A little grass-fed meat would take care of all three... easy solution right?


5.  Veganism is a very recent phonomenon.
Enter the evolutionary perspective.  Humans have been around on this planet for at least 2.5 million years at this point.  For the vast majority of that time period, we have been eating like the omnivores that we are, consuming both plant and animal foods.  Now think about that... 2.5 million years eating animals and plants... theres no question that we as a species are designed to be omnivores. Now, according to Wikipedia, the first recorded individual eating a vegan diet was Dr. William Lambe in 1806.  Thats 200 years ago.  In other words, vegan diets have been around for 0.008% of our human history.  Thats only 10 generations or so, and with only a tiny proportion of us choosing to eat this way.  So looking at this from an evolutionary biology perspective, how in holy hell is an herbivorous diet the best way to go for an omnivorous animal??  Its not.  Its just not.

Heres an example of the importance of animal foods, based on the wisdom of traditional cultures.  Since we cant go back in time and study past hunter-gatherers, these modern societies still living as foragers offer us some insight into what it was like.  In the 1920s when Weston A. Price traveled the world to study these indigenous cultures, he fully expected to find a vegan or vegetarian society out there.  He even expected those societies to be the healthiest on earth.  To his surprise though, such a society did not exist; every tribe he found consumed both animal and plant foods.  The closest to vegan was in the South Sea Islands of southeast Asia.  He found that when the people on the interior of the islands faced the possibility of losing access to animal foods and going vegan, they instead opted for cannibalism. According to Price, "the livers and other organs of their enemies from the coast provided the much needed chemicals which were requisite to supplement the plant foods."  Gross?  Yes.  But also very telling of the nutritional shortcomings of a vegan diet.  I just hope this doesnt start a new diet fad...



Alrighty, there it is, 5 reasons I dont like veganism.  Actually I can think of a few more, but this post is too long as it is.  I guess that means Ill have to do a volume 2 at some point!  If I offended anyone, Im sorry Im not sorry.  Im not trying to put anybody down... just laying out the facts as I see them.  Oh, and in all seriousness, dont go eating other peoples livers.  Dont do anything to others you wouldnt want done to you, thats what my mama says.

Hugging a health insurer

Its an old conservative joke, but what is the one key difference between health insurers and terrorists? 

Answer: liberals only occasionally attack terrorists.

For the latest example of the continuing disdain for health insurers, check out this rather typical July 5 Washington Post article "Is this the end of health insurers?" After extolling one enlightened companys decision to self-insure its workers*, writer Sarah Kliff points out that hospitals can cut out the insurer middle man and offer the same service. The result, says the article, will be the wiser use of the premium dollars, lower costs and fewer coverage denials.

While the physician Disease Management Care Blog agrees that the health insurers have only themselves to blame for their bad reputation, it doesnt think that these companies are going to go away anytime soon.  Its not because, under Obamacare, U.S. citizens are now required to buy their product at any price.  Its not because they control hundreds of billions of dollars.  And its not because theyve had the ear of the political class for years.

The contrarian DMCB thinks theyll continue to stick around because they perform a two useful public services:

1. Keeping Providers From Going Belly Up: There have been too many examples of hospitals and physician organizations being unable to collect todays premium dollars and hold them as a promise to pay for tomorrows sickness.  Whether its not charging enough or being unable to say no, providers are vulnerable to running out of cash and being unable to cover their insureds health care bills.  The DMCB says its better to insulate hospitals and doctors from the perils of the underwriting cycle.  Insurers do that.

2. Keeping Providers From Going to the Dark Side: Assuming a hospital or physician organization can hold the dollars, pay for all that health care and end the year in the black, theres a good chance that theyll do it by ultimately employing the same tactics used by many mainstream insurers: denials of services based on determinations of "medical necessity."

*As an aside, self-insured companies dont always act in the their employees best interest.  Look at this infamous example and note that Cigna only "administered" the insurance plan on behalf of a self insured organization.

The Disease Management Care Blog really likes Twitter. Its scrolling 140-character tableau of news nuggets fit perfectly on the DMCBs hand held device, lap top and home personal computer.  Its easy to glance at between tasks and the advertising is blessedly minimal. The DMCB controls the content by following and unfollowing other Twitter accounts with a simple click or a touch.

But why, physician-skeptics may ask, is Twitter any better than traditional web browsing, email, list-servs and handheld apps?  Your DMCB thought about that and is pleased to offer its Top Twelve reasons why every doc should include Twitter in their informatics medical bag.

1. Lit Headlines: The major medical journals use Twitter to efficiently describe their latest content with links. For example.

2. Fame: Traditional print authors are publishing more and more about less and less. Getting peers to follow your original and insightful tweets is the new route to attaining status as an expert.  The DMCB has more than 500 daily followers vs. how many actually read the average peer-reviewed article?

3. News Junkies: Some of your like-minded peers are freely aggregating and retweeting relevant headlines with links for your perusing efficiency. They can be indefatigable.

4. Kool-Aid Immunity: Did you know your Chief, Chair, VP, lead administrator or Dean wants to control all your communication?  Twitter is an easy way to step out of the information bubble and monitor contrary news about that EHR, medical device, performance standards, your institutions business partners, the competition and more. For example.

5. Efficiency: Twitter trains you to be both brainy and brief. If you cant fit it into 140 characters or less, youre wasting your readers time.

6. Messaging: The "@" allows you to interact with established and potential colleagues outside of your institutions email system. Thanks to this function, DMCB has met some wonderful colleagues.

7. Medical Conference Tweets: View formal and informal updates and insights about that conference youre attending from not only the meeting organizers but other attendees.

8. Community: Like-minded colleagues are not only clustering in listservs but in Twitter.

9. Room for Diversions: Efficiency makes it guilt-free to include non-medical content.

10. Speed: Its astonishing how quickly Twitter users spot and link just-released reports that take days to appear on the web and weeks to appear on print.

11. Searches: Yes, traditional literature searches and Google have their advantages, but the "#" function can find links to information resources that you might otherwise miss.

12. The Disease Management Care Blog is on Twitter.