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The Global Cardiovascular Risk Score: A New Performance Measure for Prevention

Everyone loves prevention. It may seem strange then, to learn that one of the biggest barriers keeping prevention from reaching its full potential is the current set of performance measures that, ironically, were created to promote them. The reason is that current measures are promoting activities that are inaccurate and inefficient. It is as though explorers who are trying to reach the North Pole have been given a compass that is sending them to Greenland.

This problem is being addressed by a new project conducted by NCQA and funded by the Robert Wood Johnson Foundation. The objective is to evaluate a new type of measure of healthcare quality called GCVR (Global Cardiovascular Risk). The new measure will have an important effect on the prevention of cardiovascular conditions.

To understand how, we need first to understand the limitations of current measures. For reasons that were appropriate when they were initially introduced – about 20 years ago — current performance measures were designed to be simple: simple to implement (e.g. collect the necessary data, do the calculations), and simple to remember and explain. This was accomplished in three main ways. One was to create separate performance measures for different risk factors. Thus there are separate measures for blood pressure control, cholesterol control, glucose control, tobacco use, and so forth.

While a performance measure for any one risk factor might take into account a few other risk factors to some extent, none of them incorporate all the relevant risk factors in a physiologically accurate way. A second simplification is that current measures are based on care processes and treatment goals for biomarkers, rather than on health outcomes. Thus a blood pressure measure asks if a patient with hypertension is controlled to a systolic pressure below 140 mmHG. A third simplification is the use of sharp cut points to determine the need for and success of treatment. For example, patients with hypertension are counted as properly treated if their systolic pressures are below 140 mmHG, otherwise not.

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Twitter Study of Vaccine Messages: Opinions Are Contagious, But In Unexpected Ways

Remember 2009? The H1N1 pandemic we were all waiting for? I do. I was pregnant; H1N1 was particularly risky for pregnant women. The vaccine wasn’t available until after I had my baby, but when they held a clinic an hour north of where I live, I brought my husband there so we could both get our shots. My infant son was too young to be vaccinated, so I wanted to protect him through herd immunity.

study came out recently on twitter messages from that time. How did pro-vaccine sentiments spread, versus anti-vaccine ones? Which messages were more contagious?

I talked to one of the authors, Marcel Salathe, today. He’s an infectious disease researcher studying the spread and transmission, not (just) of disease, but of information. “We assume people infect each other with opinions about vaccinations,” he said, and the H1N1 scare was a good opportunity to put some of his group’s theories to the test.

They collected nearly half a million tweets about the H1N1 flu vaccine. In 2009, H1N1 wasn’t included in the regular flu shot, and became available partway through flu season as a separate dose. With a possible pandemic looming, people had plenty of motivation to get the vaccine and encourage others to get it—butanti-vaccine sentiments were in circulation too.

The result, striking but perhaps not surprising: negative opinions were more contagious than positive ones. (Specifically, someone who read a lot of anti-vaccine messages was more likely to follow up by tweeting or retweeting negative messages of their own.)

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The Great Influenza of 2013?


The CDC has noted an early and nasty start to the flu season. Perhaps their own website has caught it, because as I’m writing this, the whole thing is down. Assuming it recovers, I will insert relevant links per routine. Otherwise, I wish it well, and leave you to find your way there on your own.

It’s a bit soon to say, but the virus and the outbreak pattern at this point seem to resemble those of the 2003-2004 flu season, in which nearly 50,000 Americans died. At least two children have already died of flu complications this fall.

This is not the sort of stuff a public health physician can ignore.

So, I recently noted on LinkedIn andTwitter that I’ve been vaccinated — as I am every year — and recommend this year’s vaccine, which appears to match the prevailing viral strain quite well, to everyone else. I promptly got comments back from naysayers, including at least one self-identified microbiologist, who noted he never got vaccinated, and had “never gotten the flu.”

I believe him. But this is like that proverbial “Uncle Joe” everyone knows, who smoked three packs a day and lived to be 119. It could happen — but I wouldn’t bet the farm on it. Uncle Joe is that rare character who somehow comes away from a train crash with a minor flesh wound. The rest of us are mortal.

But there is something more fundamentally wrong with the “I’ve never gotten the flu, and therefore don’t need to be vaccinated” stance than the Uncle Joe fallacy. Let’s face it — those who were ultimately beneficiaries of smallpox or polio immunization never had smallpox or polio, either. If they ever had, it would have been too late for those vaccines to do them any good.

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The Health of Nations

If all of us were simply to make better use of our feet, our forks, and our fingers — if we were to be physically active every day, eat a nearly optimal diet, and avoid tobacco — fully 80 percent of the chronic disease burden that plagues modern society could be eliminated. Really.

Better use of feet, forks, and fingers — and just that — could reduce our personal lifetime risk for heart disease, cancer, stroke, serious respiratory disease, or diabetes by roughly 80 percent. The same behaviors could slash both the human and financial costs of chronic disease, which are putting our children’s futures and the fate of our nation in jeopardy. Feet, forks, and fingers don’t just represent behaviors we have the means to control; they represent control we have the means to exert over the behavior of our genes themselves.

Feet, forks, and fingers could reshape our personal medical destinies, and modern public health, dramatically, for the better. We have known this for decades. So why doesn’t it happen?

Because a lot stands in the way. For starters, there’s 6 million years of evolutionary biology. Throughout all of human history and before, calories were relatively scarce and hard to get, and physical activity — in the form of survival — was unavoidable. Only in the modern era have we devised a world in which physical activity is scarce and hard to get and calories are unavoidable. We are adapted to the former, and have no native defenses against the latter.

Then, there’s roughly 12,000 years of human civilization. Since the dawn of agriculture, we have been applying our large Homo sapien brains and ingenuity to the challenges of making our food supply ever more bountiful, stable, and palatable; and the demands on our muscles ever less. With the advent of modern agricultural methods and labor-saving technologies of every conception, we have succeeded beyond our wildest imaginings.

So now, we are victims of our own success. Obesity and related chronic diseases might well be called “SExS” — the “syndrome of excessive successes.”

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Obesity: Global Public Health Challenge or Investment Opportunity?

Worried about the potential personal and economic costs of obesity?  Never mind.  It’s time to view obesity as a business opportunity.

As the press release for a new research report from Bank of America Merrill Lynch, Globesity—The Global Fight Against Obesity, points out:

“Increasing efforts to tackle obesity over the coming decades will form an important new investment theme for fund managers…Global obesity is a mega-investment theme for the next 25 years and beyond…The report…identifies that efforts to reduce obesity is a “megatrend” with a shelf-life of 25 to 50 years…BofA Merrill Lynch analysts across several sectors have collaborated to identify the sectors and companies developing long-term solutions.”

Given the worldwide increase in obesity, its high prospective costs, and the ever-present threat of government regulation, the report identifies more than 50 global stocks that provide investment opportunities for fighting “globesity.”  These fall into four categories:

  • Pharmaceuticals and Health Care: companies taking advantage of the FDA’s increased support for obesity drug development; tackling related medical conditions and needs including diabetes, kidney failure, hip and knee implants; making equipment such as patient lifts, bigger beds and wider ambulance doors.
  • Food: companies accessing the $663 billion “health and wellness” market and reformulating portfolios to respond to increasing pressure such as “fat taxes” to reduce sugar and fat levels.

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Mayor Bloomberg’s Soda Ban Proposal Hits the Wall

Yesterday, New York City Mayor Michael Bloomberg announced a ban on sales of sugary drinks larger than 16 ounces in restaurants, delis, sports arenas, and movie theaters.

The reactions have been ferocious, and not only from the soda industry, which placed an ad in the Times (see below).

The New York Times also weighed in with an editorial arguing that the mayor has now gone too far and should be sticking to educational strategies.

Alas.  If only educational strategies worked.  But they do not.

We know this from what it took to discourage people from smoking cigarettes.  We also know this from research on eating behavior.  This shows that it doesn’t take much to get people to eat too much.

Just barrage us with advertising, put food within arm’s reach, make food available 24/7, make it cheap, and serve it in enormous portions.

Faced with this kind of food environment, education doesn’t stand a chance.

That’s the point the Mayor’s proposal is trying to address, however clumsily.  After all, a 16-ounce soda is two servings.

Sugary drinks—especially large ones—make sense as a target for a portion size intervention.

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Save the Country with Preventive Care

We are entering the season of presidential politics, of bunting and cries of “What about the children?” and star-spangled appeals to full-throated patriotism.

So here’s mine: Do you count yourself a patriot? Do you care about the future of this country? (And while we are at it, the future of your hospital.) If so, bend your efforts to find ways to care for the least cared for, the most difficult, the chronically complex poor and uninsured.

“But we can’t afford compassion!” Wrong, brothers and sisters, we cannot afford to do without compassion. “But why should we pay to take care of people who can’t take care of themselves?” Because we are (you are) already paying for them — so let’s find the way we can pay the least.

The problem of the overwhelming cost of the “frequent fliers,” people with multiple poorly tracked chronic conditions, has always been that the cost was an SEP — “somebody else’s problem.” Now, increasingly, hospitals and health systems are finding that they are unable to avoid the crushing costs of pretending it’s not their problem, are not being paid for re-admits, and are finding themselves in one way or another at risk for the health of whole populations. They’re also facing more stringent IRS 990 demands that they demonstrate a clear, accountable public benefit.

At the same time, employers and payers are realizing that they end up paying the costs of the uninsured as well as those of the insured who are over-using the system because they are not being tracked. These costs become part of the costs of the system, and the costs are (and must be) shifted to those who do pay. There is no magic money well under the hospital.

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Conference Highlights Rapid Growth of Health Impact Assessments in the United States

According to a recent poll in Washington State, 71 percent of voters supported a bill that would require the state to consider impacts on people’s health when planning new transportation projects. This poll speaks to the growing recognition that illnesses like asthma, obesity, and diabetes, as well as injuries are shaped by the conditions in the places where we live and work. To address this, we need to factor health into decisions in fields like transportation, energy, housing, and agriculture.

The level of interest in the inaugural National Health Impact Assessment (HIA) Meeting held April 3 and 4 in Washington, D.C., highlights that this approach has become a centerpiece of community, state, and national efforts to improve Americans’ wellness. An HIA is a type of study that allows decision makers to factor health into projects like planning roads, passing agriculture policy, and siting schools. I have been using HIAs for over eight years, and until recently, I knew most of the people in the field. In organizing the National HIA Meeting, I worried that we might not find 200 people to attend. Instead, we had to close registration six weeks early: more than 430 leaders in public health, urban planning, housing, transportation, agriculture, and environmental regulation participated, and many more were on the waiting list.

The Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts, sponsored the two-day meeting, along with The California Endowment, the Centers for Disease Control and Prevention, and the National Network of Public Health Institutes.

Keynote speaker Jonathan Fielding, the director of the Los Angeles County Department of Public Health who also chairs the U.S. Community Preventive Services Task Force, gave an overview of the fast-growing approach. “The first HIAs were done roughly 12 years ago in the United States,” he said. “There has been huge progress in this field.”

At the Health Impact Project, we are tracking this growth. Today, nearly 200 HIAs have been completed or are ongoing. In 2007, there were only 27 such studies on the books.

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Is mHealth Just Another Gimmick?

The use of cell phones by community health workers and other medical practitioners in low-income countries has been promoted as a potential revolution for health systems development. This “mHealth” revolution has been seen as an opportunity to develop diagnostic, treatment and surveillance networks wirelessly, to build mobile apps allowing remote nurses and doctors to provide higher-quality care to rural patients even in places without a hospital or well-functioning health clinic. Several foundations are now offering grants to build and distribute phone applications that will offer everything from prescription drug advice to epidemic surveillance tools. But is mHealth really going to improve health outcomes? Or is it just another technological bomb thrown at poverty and poor infrastructure?

The theory

Globally, about 3.1 billion people used mobile phones in 2007; that’s nearly half the planet. The greatest growth during the last decade has occurred in Asia, the Middle East, and Africa. In many of these continents, mobile phone subscribers outnumber fixed-line telephone subscribers, particularly as countries leap-frog over the traditional development step of planting land-lines and rely instead on building wireless communication towers and Internet-based businesses.

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