By Jaan Sidorov, MD

We’re all aware of the past criticisms of “disease management.” According to the critics, these for-profit vendors were in collusion with commercial insurers, relying robo-calls to blanket unsuspecting patients with dubious advice. Their claims of “outcomes” were based on flawed research that was never intended to be science; it was really intended to market their wares.

But suppose this correspondent alerted you to:

1. A company that had developed a patient registry to identify at-risk patients who had not received an evidence-based care recommendation? Software created mailings to those patients that not only informed them of the recommendation but offered them a toll-free number to call if there were questions. Patients who remained non-compliant were then called by coordinators, who made three attempts to contact the patient and assist in any scheduling needs. If necessary, a nurse was available to telephonically engage patients and develop alternative care options.

If you think that sounds like typical vendor-driven telephonic disease management, you’d be right.  You’d also be describing an approach to care that was studied by Group Health Cooperative using their electronic record, medical assistants and nurses.  When it was applied to colon cancer screening, a randomized study revealed each additional level of support progressively resulted in statistically significant screening rates.

Continue reading “Why Disease Management Won’t Be Going Away Any Time Soon”

By MIKE MIESEN

You’d be forgiven if, after reading last month’s Health Affairs, you came to the conclusion that all manner of wellness programs simply will not work; in it, a spate of articles documented myriad failures to make patients healthier, save money, or both.

Which is a shame, because – let’s face it – we need wellness programs to work and, in theory, they should. So I’d rather we figure out how to make wellness work. It seems that a combination of behavioral economics, technology, and networking theory provide a framework for creating, implementing, and sustaining programs to do just that.

Let’s define what we’re talking about. “Wellness program” is an umbrella term for a wide variety of initiatives – from paying for smoking cessation, to smartphone apps to track how much you walk or how well you comply with your plan of care, and everything in between. The term is almost too broad to be useful, but let’s go with it for now.

When we say “Wellness programs don’t work,” the word work does a lot of, well, work. If a wellness program makes people healthier but doesn’t save lives, is it “working”? What if it saves money but doesn’t make people healthier?

Continue reading “Wellness Programs Aren’t Working. Three Ideas That Could Help.”

By Alan Payer

Increasingly, the health care community is experimenting to see if managing the health of a defined population – say diabetics – improves their health and also reduces the cost of health care or its rise over time. In other words, the healthcare profession seeks to determine if value can displace volume (our fee-for-service tradition) in delivering medical services. Humana’s first-of-its-kind, two-year pilot health-and-wellness program may provide some welcome answers.

A unique factor of the Team Up 4 Health program reflects its participants – hundreds of residents in Bell County, Kentucky (population: 28,750). Statistics show that its population bears a high incidence of preventable chronic illnesses. One-third of the county’s adults are obese and one-in-eight has Type 2 diabetes.

Continue reading “Gauging if Chronic Diseases can be Tamed By Enlisting Residents of an Entire County”

By Nilofer Merchant

I find myself, probably like many of you, spending way too much time in front of my computer.

When I do face-to-face meetings, my colleagues and I typically met around some conference table, sometimes at an airport lounge (nothing like getting the most out of a long layover), and quite often at coffee shops (hello Starbucks!). But that means that the most common denominator across all these locations wasn’t the desk, or, the keyboard, or even the coffee. The common denominator in the modern workday is our, um, tush.

As we work, we sit more than we do anything else. We’re averaging 9.3 hours a day, compared to 7.7 hours of sleeping. Sitting is so prevalent and so pervasive that we don’t even question how much we’re doing it. And, everyone else is doing it also, so it doesn’t even occur to us that it’s not okay. In that way, I’ve come to see that sitting is the smoking of our generation.

Continue reading “Sitting Is the Smoking of Our Generation”

By David Katz, MD

According to a widely circulated op-ed in the New York Times by Paul Campos, a law professor at the University of Colorado with whom I don’t believe I have ever managed to agree on anything, our “fear” of fat — namely, epidemic obesity — is, in a word, absurd. Prof. Campos is the author of a book entitled The Obesity Myth, and has established something of a cottage industry for some time contending that the fuss we make about epidemic obesity is all some government-manufactured conspiracy theory, or a confabulation serving the interests of the weight-loss-pharmaceutical complex.

In this instance, the op-ed was reacting to a meta-analysis, published last week in JAMA, and itself the subject of extensive media attention, indicating that mortality rates go up as obesity gets severe, but that mild obesity and overweight are actually associated with lower overall mortality than so-called “healthy” weight. This study — debunked for important deficiencies by many leading scientists around the country, and with important limitations acknowledged by its own authors — was treated by Prof. Campos as if a third tablet on the summit of Mount Sinai.

We’ll get into the details of the meta-anlysis shortly, but first I’d like to say: Treating science like a ping-pong ball is what’s absurd, and what scares the hell out of me. Treating any one study as if its findings annihilate the gradual, hard-earned accumulation of evidence over decades is absurd, and scares the hell out of me. Iconoclasts who get lots of attention just by refuting the conventional wisdom, and who are occasionally and importantly right, but far more often wrong — are often rather absurd, and scare the hell out of me.

And so does the obesity epidemic.

Continue reading “Unscience”

By DAVID SHAYWITZ, MD

As we anticipate a new year characterized by unprecedented interest in healthcare innovation, pay particular attention to the following three emerging tensions in the space.

Tension 1: Preventive Health vs Excessive Medicalization

A core tenet of medicine is that it’s better to prevent a disease (or at least catch it early) than to treat it after it has firmly taken hold.   This is the rationale for both our interest in screening exams (such as mammography) as well as the focus on risk factor reduction (e.g. treating high blood pressure and high cholesterol to prevent heart attacks).

The problem, however, is that intervention itself carries a risk, which is sometimes well-characterized (e.g. in the case of a low-dose aspirin for some patients with a history of heart disease) but more often incompletely understood.

As both Eric Topol and Nassim Taleb have argued, there’s a powerful tendency to underestimate the risk associated with interventions.  Topol, for example, has highlighted the potential risk of using statins to treat patients who have never had heart disease (i.e. primary prevention), a danger he worries may exceed the “relatively small benefit that can be derived.”  (Other cardiologists disagree – see this piece by colleague Matt Herper).

In his new book Antifragile, Taleb focuses extensively on iatrogenics, arguing “we should not take risks with near-healthy people” though he adds “we should take a lot, a lot more, with those deemed in danger.”

Both Topol and Taleb are right that we tend to underestimate iatrogenicity in general, and often fail to factor in the small but real possibility of potential harm.

At the same time, I also worry about external experts deciding categorically what sort of risk is or isn’t “worth it” for an individual patient – a particular problem in oncology, where it now seems  fashionable to declare the possibility of a few more months of life a marginal or insignificant benefit.

Even less dramatically, a treatment benefit that some might view as trivial (for hemorrhoids, say) might be life-altering for others.  For these sufferers, a theoretical risk that some (like Taleb) find prohibitive might be worth the likelihood of symptom relief.  Ideally, this decision would ultimately belong to patients, not experts asserting to act on patients’ behalf.

Continue reading “Through a Scanner Darkly: Three Health Care Trends for 2013″

By PETER UBEL, MD

Gun rights advocates are correct: a well armed principal might have reduced the death toll from the tragic elementary school shootings in Connecticut last week.

Gun carrying citizens might also have been able to take down the shooters in Aurora and Virginia Tech. To most people, after all, guns are about self-defense, not about committing crimes. As the old saying goes: “There has never been a mass shooting at a gun show.”

On the other hand, gun control advocates are correct to point out that mentally disturbed people like Adam Lanza would not be able to commit massacres if they were prevented from getting their hands on high-powered, semiautomatic weapons. They are also correct to point out that Americans have staggeringly easy access to weapons that far exceed what any sportsmanlike hunter would use during deer season.

In other words, figuring out what to do in the wake of the Connecticut massacre means recognizing the truth in both of these views. It means considering the possibility that the answer to reducing gun violence is a matter of both having more guns and less.

To understand what I mean by “both more and less,” I offer two analogies: a straightforward one about airport security, and a more unexpected one about breast cancer screening.

Continue reading “A Well-Armed and Regulated Citizenry, Led by Heavily-Armed Teachers in Body Armor …”

By E. Loren Buhle

Few diseases invoke more fear in patients and families than dementia (e.g., Alzheimer’s Disease (AD), progressive multiple sclerosis, Pick’s Disease). Surveys have shown the fear of dementia—especially AD—far outweighs concerns of a diagnosis of cancer, stroke, or cardiovascular disease.

Perhaps this fear arises from two concerns: (1) dementia robs us of what makes us human—memory, reasoning, emotions, language—and (2) in most cases there are no effective treatments to cure or palliate the disease. While diagnostics for certain forms of dementia are progressing—allowing us to sort out the reversible causes of dementia, such as hydrocephalus, electrolyte or blood sugar imbalances, brain tumors, and brain injuries—once the diagnosis of AD or Pick’s disease is made, there is little we can do aside from manage the comfort and safety of the patient and family.

What if we could prevent or delay dementia?

In the mid-1960s, the incidence of heart attacks and stroke were increasing at an alarming rate. Great strides were made in treating existing cardiovascular disease, followed by programs at preventing the disease in the first place. These prevention methods included exercise, diet, and the tracking of key incidence indicators such as blood pressure, body mass index, and cholesterol levels to maintain a quantifiable physical health.

Could we use similar prevention methods for preventing or delaying dementia?

Continue reading “Can We Stop Dementia Before It Starts?”

By David Katz, MD

Yesterday was.

There are two reasons not to talk about gun control in the immediate aftermath of the Newtown atrocity, and opposition by the NRA and its adherents is neither of them.

The first is that addressing gun control right after innocents are shot might in some way seem exploitative. The second is that no imaginable degree of stringent gun control could fully exclude the possibility of an unhinged adult shooting a kindergartener.

But both of these objections are as porous as the sands of our shores battered by Hurricane Sandy. And a consideration of those shores readily reveals why.

With regard to exploitation, there was no thought of it as post-Sandy ruminations turned to how we might best prevent or at least mitigate the next such catastrophe. It was not exploitative to look around the world at strategies used to interrupt storm surges, divert floodwaters, or defend infrastructure. Those reflections continue.

Similarly, it’s not exploitative when my clinical colleagues and I speak to our patients in the aftermath of a heart attack or stroke about what it will take to prevent another one. In fact, these exchanges have a well-established designation in preventive medicine: the teachable moment.

It is opportunistic, but in a positive way: There is an opportunity to do what needs to be done. Admittedly, it’s better to talk about preventing heart disease, or the drowning of Staten Island, or of New Orleans, or the shooting of children, before ever these things happen. But the trouble tends to be: Nobody is listening then.

We are constitutionally better at crisis response than crisis prevention.

We’ll get back to the Constitution shortly.

Continue reading “Now Is Not the Time to Talk About Gun Control”

By William Bestermann, MD

The landmark 2001 document from the Institute of Medicine’s (IOM), Crossing the Quality Chasm, should have guided us out of the healthcare cost-quality crisis. It argued that the root cause of our difficulties has been a failure to meet the needs of patients with chronic disease. We have not solved this crisis because we have almost entirely ignored the recommendations for reform found in that document.

The claim that we have the best healthcare in the world is correct only if you have an acute condition. If you are having an event, such as a heart attack, our system can provide an emergency stent — for as much as $50,000 — that will open the blocked artery, immediately relieving the pain and saving your life. We are really good at rescue medicine-crisis medicine.

But acute conditions generate enormous costs only because we have not addressed the chronic condition earlier, interrupting the disease progression that produces the acute events. Since most healthcare cost growth over the past 2 decades has been related to patients with 4 or more chronic conditions, this should be recognized as the foremost issue in healthcare reform.

In fact, the IOM charged that, despite the central role of chronic disease in most pain, disability, death, and cost, care continues to be designed around the needs of providers and institutions, and most patients with chronic conditions do not receive the care they need. A 17-year lag in implementing new scientific findings results in highly variable care.

That cardiologists favor coronary stenting over optimal medical therapy — that is, managing vascular disease using $4 drugs and recommended lifestyle changes — provides a powerful case in point.

Continue reading “The Only Way Out of the Health Care Wilderness”