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Tag: Hypertension

The Great American Hypertension Epidemic of 2017

On November 15, 2017, an epidemic of hypertension broke out and could rapidly affect tens of millions of Americans.  The epicenter of the outbreak was traced back to the meeting of the American Heart Association in Anaheim, CA.

The pathogen was released in a special 488-page document labeled “Hypertension Guidelines.”  The document’s suspicious content was apparently noted by meeting personnel, but initial attempts to contain it with an embargo failed and the virus was leaked to the press.  Within minutes, the entire healthcare ecosystem was contaminated.

At this point, strong measures are necessary to stem the epidemic.  Everyone is advised not to click on any document or any link connected to this virus.  Instead, we are offering the following code that will serve both as a decoy and as an antidote for the virulent trojan horse.

Only a strong dose of common sense packed in a few lines of text can possibly save us from an otherwise lethal epidemic of nonsense.  Please save the following text on your EHR cloud or hard-drive, commit it to memory or to a dot phrase, and copy and paste it on all relevant quality and pay-for-performance reports you are asked to submit.

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Keas Poll on Workplace Stress and Disease Burden Provides an Education

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Al’s son once complained to Al’s Aunt Tillie about an overbearing supervisor.  Aunt Tillie suggested that he try to work under a different supervisor.  Tillie was one of those people – and we all know them – who could be counted on to inadvertently provide punchlines when needed.  Conversely, Al is one of those people – and we all know them – who can’t resist setting up those punchlines.  So I lamented that this suggestion may not work because, “Aunt Tillie, it’s a sobering fact that 50% of all supervisors are below average.”

Tillie replied, “I blame our educational system for that.”

Likewise, we may need to blame our educational system for Keas’ new poll on workplace stress.  To begin with, the lead paragraph from Keas — which like many other companies is “the market leader” in wellness – “reveals” that “4 in 10 employees experience above-average stress.”

SAN FRANCISCO, CA – (Apr 2, 2014) – Keas (www.keas.com), the market leader in employer health and engagement programs, today released new survey data, revealing four in ten employees experience above average levels of job-related stress. Keas is bringing attention to these findings to kick off Stress Awareness Month, and is also providing additional insight and tips to bring greater awareness to the role of stress in the workplace and its impact on employee health.

Wouldn’t that mean some other employees – mathematically, also 6 in 10 – must be experiencing average or below-average levels of stress?   It would seem like mathematically that would have to be the case.   However, the Keas poll also “reveals” that while some employees are average in stress, no employee is below-average – a true paradox.  Hence Keas’ selfless reasons for publishing this poll:  All employees being either average or above average in the stress department means we have a major stress epidemic on our hands.  This perhaps explains why Keas is “bringing attention to these findings.”

In a further paradox, Keas also uses the words “average” and “normal” as synonyms, even though they are often antonyms:  All of us want our children to be normal but who amongst us wants their children to be average?

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Will the Uninsured Become Healthier Once They Receive Health Care Coverage?

David OrentlicherThe Affordable Care Act might not bend the cost curve or improve the quality of health care, but it will save thousands of lives, as millions of uninsured persons receive the health care they need.

At least that’s the conventional wisdom.

But while observers assume that ACA will improve the health of the uninsured, the link between health insurance and health is not as clear as one may think. Partly because other factors have a bigger impact on health than does health care and partly because the uninsured can rely on the health care safety net, ACA’s impact on the health of the previously uninsured may be less than expected.

To be sure, the insured are healthier than the uninsured. According to one study, the uninsured have a mortality rate 40% higher than that of the insured. However, there are other differences between the insured and the uninsured besides their insurance status, including education, wealth, and other measures of socioeconomic status.

How much does health insurance improve the health of the uninsured? The empirical literature sends a mixed message. On one hand is an important Medicaid study. Researchers compared three states that had expanded their Medicaid programs to include childless adults with neighboring states that were similar demographically but had not undertaken similar expansions of their Medicaid programs.

In the aggregate, the states with the expansions saw significant reductions in mortality rates compared to the neighboring states.

On the other hand is another important Medicaid study. After Oregon added a limited number of slots to its Medicaid program and assigned the new slots by lottery, it effectively created a randomized controlled study of the benefits of Medicaid coverage. When researchers analyzed data from the first two years of the expansion, they found that the coverage resulted in greater utilization of the health care system.

However, coverage did not lead to a reduction in levels of hypertension, high cholesterol or diabetes.

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Sense and Sensibility on Hypertension

Every now and then even blind squirrels find acorns.  The medical care industry, which long ago abandoned sensible fiscal and therapeutic restraint in the quest for new patients, finally treats us to a revised hypertension guideline that thoughtful people can conclude makes a great deal of sense.  It is even based on evidence, or actually the lack of it, which is itself a startling admission of reality from an industry that dances around truth with a nimble sophistry envied by even the most mendacious politicians.

The hypertension guidelines are a sharp departure from last month’s cholesterol guidelines, produced by a supposedly equally august panel of “thought leaders” who gave us guidelines that seemed to channel the The Talking Heads quite literally.  John P. Ioannidis, along with Nortin Hadler, easily one of the two or three most important physician thinkers of this or any generation, wrote that the cholesterol guideline will be either…”one of the greatest achievements or one of the worst disasters of medical history.”

If you haven’t read the hypertension guidelines, here is a useful summary:

  1. we treat too many people today;
  2. we rely too much on drugs for things that drugs cannot fix;
  3. treatment frequently does not produce health because therapy aims at a point, while the pursuit of health is a matrix; and
  4. if we are really going to improve cardiovascular health, which is strongly implicated not just in stroke, heart disease, and kidney disease, but also cognitive health, people are going to have to change behaviors because there aren’t enough pills on the planet to fix what ails us.

Cognitive health is an especially useful guidepost, because contrary to popular myth, it isn’t something that mysteriously disappears in nonagenarians.  The seemingly age-related decline is more likely the manifestation of damage done by a lifetime of incremental harms.  Isn’t it edifying to have scientists catch up to our moms?

The new guidelines leave us a redefinition of high blood pressure: greater than 150/90, except in cases where a comorbidity compels pursuit of 140/90 or lower to prevent end-organ damage.  This has implications not just for medical care but for workplace wellness, which obsesses with hypertension when it is not obsessing with cholesterol and glucose.

The hypertension guidelines yank away from workplace wellness vendors yet another reason to fine or otherwise antagonize employees who don’t show up at health fairs.  The progression of hypertension is strongly related to aging, and healthy aging is the most reliable bulwark against premature stroke, heart attack, kidney failure, or dementia.  Unless workplace wellness vendors plan to follow people into retirement, which is when the overwhelming majority of heart attack, stroke, and dementia occurs, there is no logical reason to ask any employee what his or her blood pressure or deign to tell them how to address it.

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Blood Pressure Monitoring, Telemedicine, and Automated Hovering: A Future Model for Disease Management?

Use of an at-home telemonitoring blood pressure device significantly reduced out-of-control high blood pressure, according to a recent study in the Journal of the American Medical Association. It’s another data point showing the potential of telemedicine to have a profound effect on American medicine, by positively modifying health behaviors, providing real-time data to clinicians through “automated hovering,” and helping Americans get and stay healthy – all of which holds the promise of bending the cost curve.

Led by Karen Margolis, MD, MPH, a Senior Investigator at Health Partners Institute for Education and Research, the cluster-randomized study investigated whether using a cloud-connected, at-home blood pressure monitor paired with pharmacist and case manager support would lead to controlled blood pressure more than typical care, which involved check-ups with a physician.

Those using the telemonitoring device were 90% more likely to have controlled blood pressure at both the six and twelve-month checkups than the control group (57.2% and 30%, respectively), and had, on average, statistically significant lower systolic and diastolic readings.
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The Art of Measuring Blood Pressure

Edna Lavoie has had horrendous blood pressure readings for several decades, but she has never had a stroke or heart attack. Her eye doctor swears her retinae are healthy. Whenever she takes a pill that even begins to normalize her blood pressure, she complains of severe dizziness.

Dwayne Lieber’s home blood pressure cuff never reads anywhere close to our manual office sphygmomanometers, even though it is a good brand that usually seems quite accurate for our other patients who own the same model.

Donald Dickinson and Jane Green seem to be a pair of Jekyll and Hyde characters as far as their blood pressures are concerned; every other visit they seem to have a normal blood pressure in the 125/80 range and the rest of the time their systolic pressures are between 180 and 200.

Blood pressure measurements are routinely done every time a patient visits the doctor and hypertension is one of the most common diagnoses in primary care. A patient’s blood pressure is sometimes done with an automatic cuff, sometimes by the nurse or medical assistant and sometimes by the doctor. It is actually a complicated matter, fraught with problems and potential pitfalls.

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