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.

Just a quick rant today. Ive been thinking a lot lately about the concept of "voting with your food dollar". Voting with your food dollar is just what it sounds like... when you buy a particular food, youre essentially "voting" for it. Youre telling producers that you like it and you want more of it. But beyond that, youre supporting the entire process that made that food available to you at your local grocery store. This is obviously true of anything you buy in a free market system. You have the opportunity to vote every time you buy anything. Anything at all. Whether its fitness equipment, a new leather purse, or the new Justin Timberlake album, your dollar essentially votes for what you buy. Just think of the consequences if nobody bought JTs new album (which I know isnt true since I already bought it)... Justin would end up a complete failure. Hed likely enter a downward spiral involving drugs, Taylor Swift, and his first emo album, until hes finally relegated to neighborhood bar gigs opening for Good Charlotte.  But worst of all, nobody would adopt his new hairstyle.

Okay a little off topic there.  Where was I?  Oh yes, when you buy a food at the store, you support everything that went into putting that food on your grocery store shelf.  In addition to supporting the food itself, you support the production methods, the processing, and the transportation costs.  Id like to take this opportunity to go through a few different food options and talk about what it means when you choose to buy them.

1) Doritos
One of my favorite childhood foods.  I could eat an entire bag of this stuff as a teen.  Of course theyre yummy, but lets talk about where Doritos come from.  Heres an ingredients list...


Now I dont have time to go through all of these or else Id be here all day.  The corn is genetically modified, along with the corn oil and soybean oil.  Theres partially hydrogenated oil in there (trans fat), theres MSG (monosodium glutamate), and therere artificial colors (yellow 6, yellow 5, and red 40).  I know you buy Doritos because they taste good, and that is the ONLY reason the food manufacturers want you to buy them, because looking any deeper at the product would scare you off. Thats why they hide all of the scary information in the ingredients list; and youd need some training in nutrition to even interpret it.  Thats why Im here.

So unfortunately, when you buy Doritos because they taste good, youre also supporting GMOs, trans fat, MSG, and artificial colors, many of which are banned in Europe because, unlike Americans, they actually care about the quality of their food and the health of their children.  See example here. There are more natural options available, you just have to look for them, and yes they DO taste good. And when youre cocky-ass friend makes fun of you for buying organic chips, just tell him to fuck off.

2) A Grocery Store Chicken
On to some real food.  To the lay person, a roaster chicken may seem harmless.  At least its a real food, not some packaged, processed corn chip like Doritos.  But nevertheless, when you spend your food dollar on a grocery store chicken, there are some unsavory consequences. Factory farmed chickens typically spend all of their lives indoors.  Theyre genetically bred to have oversized breasts because consumers, like men, per breasts.  As a result of these large breasts and the fact that they may never leave their cage, they often cant even stand up.  Not to mention the fact that nearly their entire diet is made up of genetically modified corn and soy.

Not to freak everyone out, but I think its important to know what youre dollar is supporting.  When you buy chicken at a grocery store, you vote for this system, whether you mean to or not.  Free range chicken is just a little better, and organic may be a little better on top of that.  Unfortunately, though, your best option is to find a local farmer producing chicken the right way.  I know its time-consuming and inconvenient, but the option is there.  But hey, if we vote for this kind of chicken more often, we might start seeing it in our grocery stores!

3) Blueberries in the Winter
Or oranges in the summer.  Same difference.  Blueberries are in-season in July.  Oranges are in-season in December.  Yet we still see both available year-round.  Why?  Because in the winter, blueberries are shipped in from Chile; same with oranges in the summer.  And it costs a lot of money, and wastes a lot of gas, to fly those blueberries from Chile to the United States.  The distance from Santiago, Chile to New York City is about 5,125 miles.  Thats far.


This blogger here did some calculations to figure out how much energy it takes to transport one package of blueberries... ONE PACKAGE... and I quote, "You would have to run your blender for 11 hours, continuously, to use the same amount of energy."  Thats just insane, and completely unsustainable.

Sad but true, even our healthiest, seemingly most natural of options can put our money in the wrong place.  Its nice to have the option of fresh blueberries in the winter, but the implications on the environment are pretty strong.  Local, in-season fruits and vegetables are always a more sustainable choice.


And another quick rant turns into a long-winded one!  Sorry if I just ruined your life with education. But this is important to me.  Most Americans are ignorant of what their money is truly supporting, and the food industry would love to keep it that way.  But we have the power to change things, if only we all understood where our food comes from.  I know the barriers to this stuff go far beyond education; its often much more expensive to put your food dollar in the right place.  But even a little bit helps.  You dont have to go all out and buy 100% of your food from a farmers market... Maybe start by leaving the name-brand snacks on the shelf and opting for a more natural, organic option with fewer ingredients.  See where that takes you.

If you take away nothing else from this post, I hope youll at least now take the time to think about what youre buying.  Every time you put something in your grocery cart youre taking a vote; I think its important you know what youre voting for.

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