Monday, November 21, 2011

We Are Ruining Our Children’s Future Health

Our children (and grandchildren) are the future and we are responsible for their growth and development. As responsible parties, we are clearly failing.

That is my interpretation of the report issued a few days ago by the Centers for Disease Control (CDC) on seven criteria known to the associate with ideal cardiovascular health as part of the National Health and Nutrition Examinination Survey. They are defined, briefly, as 1) a diet with 4 ½ servings of fruits and vegetables per day, 3 servings of whole grains per day, fish twice per week, no more than 1500 mg of sodium (salt) per day, and less than 36 oz of sweetened drinks per week. Also 2) a normal body mass index (BMI) which roughly means not being overweight, 3) not smoking, 4) having at least one hour of physical activity per day, 5) a normal level of cholesterol, 6) normal blood pressure and 7) normal blood glucose (blood sugar.)

Infants start out life with a normal risk for heart disease but risk increases rapidly from preteens and into adolescence. We have known for some time that kids are getting less and less exercise, even less as they progress into the teenage years.

But this new report is striking. Not one child out of 4157 aged 12 to 17 in the study group monitored between 2003 and 2008 was in the “ideal” category for diet. And only 16% of the boys and 11% of the girls were in the ideal range for all of the remaining six categories.

Looked at differently, 20% were obese (not just overweight); about 20% smoked; about 50% had too little physical activity; cholesterol was elevated in about 30%; and glucose was somewhat high in about 40%. One bright spot – blood pressure was elevated in less than 10%.

This report is important for at least two reasons. We know that atherosclerosis begins to build up in childhood and young adults even though angina and heart attacks are not common until a few decades later. It is essential to maintain a healthy lifestyle and this needs to begin in childhood. Second, we know that the 7 criteria are each associated with a lessening of heart disease risk when kept to the normal or ideal level (diet, weight, not smoking, etc) and that each, when not meeting the standards, add together to increase the risk of cardiovascular disease in later life.

These are not impossible standards to meet. Diet might be most difficult, especially for kids in urban or rural poor areas who have less access to fresh fruits and veggies but there is little excuse for over indulging in salt and sodas. One big problem is the ready availability of processed foods – foods high in salt, fat and sugars including high fructose corn syrup – along with ubiquitous sodas, often in very large containers.

Parents – they are your children. They need good food, they need lots of activity, and they need parental support to avoid tobacco and processed foods. They are your (and all of our) future.

Friday, November 18, 2011

Frailty – Common In Older Ages But Is It Preventable?

Americans are aging – fast. And that means more chronic illnesses like arthritis, heart failure and cancer. It also means more falls, more osteoporotic fractures, poorer hearing and vision and myriad other problems we equate with aging. It also means some older folks become “frail,” irrespective of chronologic age.

You know a person is frail when you see him or her – instinctively you will think a person is “frail” if they are “skinny,” weak, tired, inactive and slow. But frailty can actually be measured. Among the systems is one developed by the Cardiovascular Health Study, a longitudinal program that evaluated cardiovascular risk factors with annual examinations from 1989 to 1999 for individuals over age 65. This was followed through to the present with annual telephone follow-ups. Their “frailty indicator variables” include unintentional weight loss of more than ten pounds (as some measure of loss of muscle mass), grip strength,(as a measure of weakness) , fatigue score on a standardized test (as a measure of tired), physical activity (measure of inactivity), and walking speed (“slowness.”)

Using this approach, and if we define “frail” as having three or more of these five characteristics, about 7% of adults over age 65 living in the community will be regarded as frail. Importantly, frailty is not the result of co-morbidities but co-morbidity is a risk factor for frailty and disability is a frequent outcome of frailty.

With this definition of 3 or more characteristics, frail individuals will be found to have more falls, more hospitalizations, more fractures, increased sleep disordered breathing and more difficulty with the activities of daily living. They also, on average, demonstrate certain biological differences such as elevated C-reactive protein.

One person – otherwise healthy – might become frail in his 70’s whereas someone else might not until his 90’s or even after 100. That would suggest a possible genetic component and some preliminary studies as consistent with this theory.

We know that our bodies begin to “decline” with aging beginning in middle age. Bone mineral density for example declines about 1% per year. So too does cardiac function, muscle mass, lung capacity, etc. These processes are “normal” but can be slowed. Regular aerobic and weight bearing exercise will help maintain all of these functions. The decline will continue but at a slower rate.

What can we each do now? After checking in with your health care provider, a reasonable regimen might include:

Daily aerobic exercise for about 30 minutes
Resistance exercises (weights, Nautilus, etc)
Balance training

A personal trainer or physical therapist might be useful to give guidance and check out if the exercises are being done correctly and with enough intensity.

Then it might be good to add in a

Nutrition consultation to be sure your diet is appropriate for your age and lifestyle. For example, do you get enough protein in your diet?

And you might want to include some mental exercises to complement your physical ones. Studying a foreign language, playing chess or bridge, or Sudoku challenges your brain – but not TV watching or mindless books (even if they are interesting.)

This approach will slow the normal aging process and it may even help prevent the onset of frailty and is sequela. And for certain you will feel better, have fewer falls and other problems common with older age.

Monday, November 7, 2011

Reasonable Goals for Health Insurance Coverage and Defining Medical Necessity

Health care should be a right but it needs to be paired with some responsibility – some share of the cost, especially for routine care, and some attention to maintaining a reasonably healthy life style. To do so will not only lead to better health but reduced expenses overall – positive outcomes for all.
One of the major goals of the Affordable Care Act is to reduce the number of uninsured from the current about 50 million people (or 16+% of the US population) by both offering Medicaid to many more individuals and creating state-based insurance exchanges for individuals who cannot obtain insurance at their worksite. Medicaid will be available for those at <133% of the federal poverty rate (currently $22,050). The insurance exchanges will be available to everyone but those with income below 400% of the poverty level ($88,200 for a family of four) will be eligible for tax credits based on actual income. Unlike Medicaid which has essentially no cost sharing by the individual, insurance from the exchanges will be purchased at one of four levels – 60, 70, 80 or 90% of the approved covered expenses will be paid by the insurance; the remainder will be the individuals’ responsibility. Higher deductibles will likely correspond to lower premiums.

The Institute of Medicine (IOM), at the request of the Department of Health and Human Services, formed a committee to consider the process for defining “essential health benefits” which ultimately will translate into what is covered or not by the insurance from the exchanges. The IOM, wisely in my opinion, emphasized he need for affordability rather than just comprehensiveness. They argued that coverage should be “evidence-based, specific and value promoting over time.” They proposed that medical necessity should be based upon clinical appropriateness, best scientific evidence and a likelihood of providing an “increased health benefit…that justifies an added cost.” [For a fuller discussion of the IOM recommendations, see John Iglehart’s article in the New England Journal of Medicine, Oct 20, 2011]

These seem like wise and sensible proposals. Too often there has been a “push” to insist on very comprehensive coverage, little attention to evidence-based criteria and little or not cost sharing by the patient.

My own hope is to see insurance that carries high deductibles to encourage each of us to personally monitor our health expenditures. When we have our own money at stake, we are more likely to ask our physician if that MRI, procedure or specialist visit is really needed of if it is “just to be complete.” That high deductible may also encourage us to maintain a better life style and maintain our health. That is good for us and reduces the overall costs further.

My new book discusses these topics in detail – “The Future of Health Care Delivery, Why It Must Change and How It Will Affect You” will be published in Feb, 2012 by Potomac Books

Tuesday, November 1, 2011

Kudos for Electronic Medication Ordering But Problems with Electronic Physician Documentation

I toured a major medical center recently to get a look at the robots in the pharmacy and to understand how the electronic medical record worked there. I was particularly interested in the new robot that made up “injectables,” the fluid bags filled with medications to be given intravenously, such as antibiotics. There was also a robot that selects pills and tablets based on bar code technology. A third robot actually delivers the medication to the individual nursing units, a little “R2D2.” The robots depend on the electronic medical record (in this case purchased from a major vendor oriented toward large hospitals and academic medical centers) for input. It begins with the physician placing an order that includes the drug name, dose, route and frequency of administration. The pharmacist reviews the order and then sends it to the appropriate robot for production. It is a terrific system that reduces errors, coaches the physician during the ordering process, and allows the pharmacist to spend more time using his or her knowledge rather than in preparation activities.

I then asked to see a physician using the electronic medical record to enter an order. The doctor showed me how it was done and how it helped her to avoid mistakes. Basically she was very complimentary of the new system.

So I then asked if she also found it effective for writing her medical documentation such as history and progress notes. Medical documentation is the essential communication tool providers use to collaborate on patient treatment. “No way,” was the immediate response. “It [Electronic Physician Documentation] is too cumbersome, takes much too much time, does not allow me to enter information in a logical manner – basically it wants me to use [the computer’s] logic, not mine. So I just hand-write my notes.” Not a good recommendation, so I asked a few more physicians at different locations and got the same response. I checked with the hospital CIO and learned that few physicians actually used the “physician documentation” part of the system although they gave high marks to the other elements such as ordering tests and reviewing results and images. Since then I have asked similar questions at multiple hospitals, using different major vendor systems, always with about the same response. Clearly, there is a problem here.

The long standing written methodology for physician documentation works sort of like this: the doctor writes an “Admission Note” which includes the patient’s history of the present illness, social and medical history, examination findings, diagnostic test findings, a presumed diagnosis, further testing to be done and a treatment plan. Concurrently, the doctor writes “Orders” such as bed rest, frequency of vital signs to be collected, type of diet and drug orders. Thereafter, the doctor enters “Progress Notes” on a daily or greater basis that summarizes the patient’s status since the last physician visit, new information, supplemental orders for additional testing and new treatment approaches. With an electronic medical record many commercial systems try to adjust this process to use “Check offs” and to eliminate or markedly reduce typing which cannot be readily manipulated for later analysis. Some details are readily done by “check offs” such as age, race, gender and even much of the examination. But the “history,” especially that of a person with one or more chronic illnesses, is by nature a narrative not readily amenable to check offs. A second issue is that the physician deals with the patient and therefore with the chart in a discontinuous manner. For example, he or she might visit each patient early in the morning, then go to radiology to review the films with the radiologist, then to pathology to look at slides with the pathologist, etc. Meanwhile the nurse calls with a problem to be resolved with a verbal order or an electronic order urgently. Each of these encounters may need an update to the medical record and so it needs to be adaptable to that requirement. In teaching hospitals, the intern and residents need a simple manner to sign out to each other with a list of problems for each patient – absent that it means taking notes at a sign out conference. Each of these are issues that most of the current commercial vendors have not resolved which is why the doctor I queried responded “No way.” This problem needs to be resolved promptly if electronic medical records are to gain their full potential.

There is hope, however, with innovative niche companies and new technologies to solve these problems where the vendor market has traditionally been unable to do so. Companies such as Salar, Inc., which have carefully observed how physicians work, have found ways to extend hospital EMR’s to deliver a more flexible templating solution. [Disclosure: I was a Salar board member for five years.] Furthermore, advances in voice recognition and natural language processing give promise of allowing physicians to continue to document in their own methods (allowing for narrative and flexible workflow) while coding the information and delivering the information to the EMR.

I believe that once good systems are in place for physician documentation, the electronic medical record will be rapidly adapted with the attendant advantages for patient, doctor, hospital and insurer. This will be especially important as we increasingly need to care for patients with multiple chronic illnesses with the multi-disciplinary team-based approach. The question at hand is why have the major vendors not corrected/improved their systems to make physician documentation easy and thorough for the doc? I suspect that it is because they have large bureaucracies with software written by those who have not actually observed how physicians work. Hopefully this will change.

My new book “The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You,” from which this post is adapted, will be published Feb 28, 2012 by Potomac Books

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).