Category Archives: Chronic Disease

Getting your teeth into health care

Posted by on October 27, 2013 Comments Off on Getting your teeth into health care

We all know the reasons for going to the dentist regularly:

  1. Early detection (cavities, gum disease, oral cancer, bruxism)
  2. Checking existing fillings for structural weakness or peripheral decay
  3. Review of oral health practices

These are dental reasons, but there are other reasons as well.

The relationship between dental health and other medical health is not a new concept, with studies going back to the 1980’s. For example, the statistical relationship between heart attacks and poor dental health was noted in a 1989 Finnish study.

Managed care organizations have a strong financial incentive to lower health care costs. Healthier members have lower medical costs, so improving the health of members is an attractive alternative to cutting benefits in order to lower costs.

Aetna has been a leader in “Dental-Medical Integration” (DMI) as an approach to that end.

A study in 2006 found significant relationships between treatment for gum disease ( a proxy for having gum disease) and higher medical costs for cardiovascular, cerebrovascular, and diabetic conditions, heart, stroke, and diabetes, respectively.

In 2009, Aetna reported considerable success in getting dental care for at risk members:

In 2008, nearly 67,000 medically at-risk members sought dental care after being enrolled in Aetna’s Dental Medical Integration program. At-risk members are identified as those with diabetes, heart disease and pregnant women who have not seen a dentist in 12 months or more.

A 2011 University of Pennsylvania study in collaboration with Cigna Dental established lower medical costs two years after periodontal (gum) treatment:

2011_UPa_Dental

Earlier this month Aetna reported:

  • Lowered their medical claim costs by an average of 17 percent
  • Improved diabetes control by 45 percent
  • Used 42 percent less major and basic dental services
  • Required 3.5 percent fewer hospital admissions year-over-year compared to a 5.4 percent increase for non-members

With the caveat that the Aetna programmed targeted individuals with particular diagnoses who had not seen a dentist in a year, we are nonetheless facing an important question:

Is it time to end the division between dental and medical insurance, treating health care for the mouth as a medical specialty like others, and dentists as medical specialists like others?

What we almost know

Posted by on September 25, 2013 Comments Off on What we almost know

The impact of intestinal flora on health conditions is known, thus fecal transplants for numerous conditions. Last week I wrote about an experiment with mice verifying the impact on obesity.

As a consequence, there are numerous products being marketed as “probiotic.” We have no idea whether those products are helpful, harmful, or simply benign.Bacterial flora are an instance where we know some bacteria are essential, and we know some can be added beneficially, but we do not know which ones to add. There are promising studies with lactobacillus acidophilus shown: lactobacillus We almost know about GI flora, but not quite enough yet.

There are other topics where we are at a similar place. We know a lot about what mental illness is and isn’t. We know that increasing serotonin in the interstitial spaces of the brain helps with depression and that too much serotonin is associated with schizophrenia. As of this point, however, we don’t have imaging or blood tests or biopsies that will tell us who is mentally ill–we use written testing and observation not laboratory tests to diagnosis it. When physicians attempt to treat it, it is largely a matter of trial and error. We do not know beforehand whether a particular selective serotonin re-uptake inhibitor (SSRI), such as fluoxetine or venlafaxine will work with an individual, or if any SSRI will work. Some people will do better with buproprion, which uses a different mechanism. Others will do better with a serotonin–norepinephrine reuptake inhibitor (SNRI) such as duloxetine. Others will experience no clinical effect at all. We almost know about mental illness, but not quite enough yet.

These examples lead to a more general question about what we know and do not know. It is usually phrased as “nature vs. nurture,” but it is really genetics vs. environment. I am not sure if the the “versus” between them is appropriate–something else I do not know–as it is the relative interaction of the two rather than a false choice between them that is a more likely source of the truth about who we really are.

Researchers often conduct identical twin studies, controlling for genetic variation by comparing the environmental impact of twins with nearly identical DNA. Molecular computer graphic of DNA double helix However, the studies are limited: it is intriguing if they both smoke the same brand of cigarettes or like the same foods despite very different upbringings, but it does not neatly tell us which behaviors are genetic and which are environmental.

Similarly, we know that 3/4 of children of two bi-polar parents are likely to have bi-polar disorder, which seems to indicate a Mendelian genetic inheritance, but we only almost know about the inheritability of mental illness, not quite enough.

Even where we know that a trait is inherited, we often do not know what genes or constellation of genes are associated with a given, visible trait. We almost know about the human genome, but not quite enough yet.

As scientists or those of a scientific bent, we are obligated to say what we know and what we don’t know, being able to distinguish the difference. It is not always an easy distinction to make, but is central to our effort to know more, and eventually know enough.

Disease and National Defense

Posted by on July 29, 2013 Comments Off on Disease and National Defense

In Biblical times, where historical accounts and historical myth sometimes mingle, there are accounts of great armies being destroyed by disease. Conflicting accounts of the siege of Jerusalem circa 701 BCE by the Assyrian king Sennacherib are of that nature.

Fast forward two thousand years. Evans, Kleinman, and Pagano write:

In 1334 an epidemic struck the northeastern Chinese province of Hopei. This “Black Death” claimed up to 90% of the population, nearly five million people. The epidemic eventually reached and decimated Tartar forces that had been attacking Kaffa, a Genoese colony on the Crimean Peninsula. In 1347, the departing Tartars catapulted plagueinfested bodies into Kaffa. The Genoese quickly dumped these bodies into the sea, however it was too late. Four ships escaped back to Italy carrying the plague that in just two years killed one-third of the European population.

The relationship between disease and national defense is not a new one in the US. Just a simple web search revealed this 72-year-old article from the American Journal of Public Health on the dangers of venereal disease to military preparedness. Another article in the Journal of the American Medical Association (JAMA) of the same year reports that venereal disease has been a concern of the US Army and Navy since 1778.

There is continued concern about the impact of infectious disease on national defense, for example, the emergence of antibiotic-resistant pathogens and the threat from tick-borne diseases, and from influenza.

Indeed, with anthrax and ricin scares, preventing and managing bio-terrorism is a major part of contemporary national preparedness.

In addition, the Department of Defense is participating in prevention initiatives. As Dr. Jonathan Woodson, Assistant Secretary of Defense for Health Affairs in the Department of Defense, put it:

At the Department of Defense, we’ve moved from a concept of health care to health, meaning that we understand health really is a much more involved concept other than just freedom from disease. It relates to healthy communities and healthy and active lifestyles and also addresses mental wellness and spiritual wellness as well. For us to create a fit and ready force, we need to make sure that we’re paying attention to all these dimensions of health and wellness.

All of these efforts center upon a single premise: national defense depends upon maintaining the health of the civilian and military populations.

That raises an important question: does it matter whether the threat to our health is a foreign enemy, a small band of domestic terrorists, or what we do to ourselves?

As we eat too much, as we eat too much of the wrong foods, as those foods provide biological encouragement to continue those habits, as we exercise too little, and as we create our own national health epidemic, is that not more than what any adversary could do to us?

Or as Walt Kelly’s cartoon Pogo once famously stated: We is met the enemy, and he is us.

Obesity confusion

Posted by on June 10, 2013 Comments Off on Obesity confusion

We are agreed that obesity is a problem, for individuals and for society.

We are agreed that dieting alone will not help. The latest popular diet approach is part of the background noise not part of the solution. Here is some noise from my Facebook feed as I was writing this posting.

Obesity diet noise

Exercise and dieting combined would work, but is probably beyond the ability of many if not most people facing obesity. Indeed, starting any exercise program may be a challenge to both will and health of someone morbidly obese.

We know that bariatric surgery can work; however, it is invasive, expensive, and there are debates among specialists about what works sufficiently.

Indeed, after Governor Chris Christie of New Jersey announced that he had had a gastric band implanted, there was considerable debate about whether that was sufficient compared to gastric bypass surgery, particularly given the failure rate of the laparascopic gastric band or “lap band.”

There is open debate about whether obesity prevention measures are cost-effective.

As if the problem were not challenging enough, a study has shown that physicians fail to demonstrate to obese patients the empathy necessary to effect change.

Al Lewis argues that many of our workplace wellness programs are ill-conceived and ineffective.

The seriousness of the problem is underscored by a Metlife study showing that obesity contributes $1,723 per person per year to the Medicare budget, or 8.5 percent of the total.

We are not left with a solid place to make a stand against obesity. My plan is to walk a bit more and eat a bit less as I contemplate next steps. What are your thoughts?

How Do We Implement What Works?

Posted by on April 29, 2013 Comments Off on How Do We Implement What Works?

Medicare is abandoning the one experimental program that works. So claims Ezra Klein of the Washington Post in “If this was a pill, you’d do anything to get it.”

Klein describes a program by Healthy Quality Partners (HQP) where nurses make home visits to geriatric patients with chronic illnesses. It has been subsidized by Medicare as an experiment, in which some randomly chosen patients receive the intervention while some do not. The results have been better outcomes at lower cost to Medicare per the article as well as a study published last July.

Let’s assume that the claims are true: better outcomes and lower costs. How do we take an experiment, and by definition experiments have a beginning and an end, and generalize it into practice?

There are numerous possibilities:

First, we could do what the article implies: provide more government funds to Healthy Quality Partners, instructing them to expand the experiment operationally beyond the 1,736 members in Pennsylvania. I am assuming that maintaining indefinitely a small-scale experiment that works makes no sense–onward and upward.

Second, we could change the reimbursement scheme at Medicare to provide reimbursement for such services so that anyone in the country could create a similar program with the financial incentive of knowing that Medicare would reimburse the services.

Here is how that second possibility has developed:

The Clinical Procedure Terminology (CPT) codes were created and are owned by the American Medical Association. Recently Medicare adopted additional CPTs for coding reimbursement for coordination of care services.

Care Coordination CPTs

A statement by the American Nurses Association (ANA) is enthusiastic about the addition of the codes. Note: the ANA participates on the AMA CPT and RVU Update Committee.

ANA Care Coordination

Eileen Shannon Carlson RN, JD of the ANA points out that it is rare for CPTs to be adopted that only apply to nurses, as do two of chronic care coordination additions.

To be fair, the new codes only reimburse care coordination after a hospitalization and for a short period of time, why the HQP initiative addressed the needs of the elderly with chronic conditions. Nonetheless, I can imagine the next step being a protocol to target care coordination for the elderly independent of a hospitalization. Contrary to much in the popular press, government programs are very aware of spending dollars and getting value in return, so they limit risk by taking baby steps in developing programs.

Ezra Klein may well be correct, or he might be underestimating the challenge of turning a large ship, particularly when the upfront costs of such a turn may be prohibitive. What do you think?

Sugar and spice, and salt is not very nice Part II

Posted by on February 21, 2013 Comments Off on Sugar and spice, and salt is not very nice Part II

Last time we looked at the danger of dietary sodium, likely to shorten the lives of a million Americans. If knowledge is power, then here is some power for you:

Let’s start simple, with the major sources of dietary sodium from the CDC.
CDC Sources of Sodium

Unless we make our own bread (a fun thing to do with a bread maker, not as much fun by hand), we have little control over the amount of salt in bread. We can look for low-sodium alternatives or we can wait for government action. By the way, the government has been regulating bread for a long time, in Europe before the founding of this country and since the 17th century by colonies/states such as Massachusetts. Since 1941 the US government has been mandating nutritional additives to bread, including folic acid, iron, and other nutrients. Regulating sodium content is not even a stretch.

Take a look at this graphic from the CDC–sodium can be reduced by half in nearly identical sandwiches with a bit of care in choosing ingredients:

Low Sodium Sandwich

Reducing sodium in our diets is one of those simple things we can do to improve our health. Doing the easy thing is sometimes better than the difficult. 2 Kings 5:13

Here is some further reading on dietary sodium:

UCSF Low Sodium Guidelines
CDC Sodium Tip Sheet
Medline Plus: Dietary Sodium

Sugar and spice, and salt is not very nice Part I

Posted by on February 19, 2013 Comments Off on Sugar and spice, and salt is not very nice Part I

“No matter how we look at it, the story is the same – there will be huge benefits in reducing sodium,” said Pam Coxson, PhD, a UCSF mathematician and the lead author on the paper who performed one of the three analyses published in Hypertension.

The quotation is an understatement–the studies claim that hundreds of thousands of lives can be saved by less salt. What are the facts?

Let’s start with the Centers for Disease Control and Prevention (CDC):

About 90% of Americans eat more sodium than is recommended for a healthy diet. Too much sodium increases a person’s risk for high blood pressure. High blood pressure often leads to heart disease and stroke. More than 800,000 people die each year from heart disease, stroke and other vascular diseases, costing the nation $273 billion health care dollars in 2010.

The key point is the relationship of sodium to hypertension and cardiovascular events:

About 45 percent of these cardiovascular deaths are attributable to high blood pressure, and numerous medical studies have already demonstrated how reducing dietary salt – the primary source of sodium – can lower blood pressure and reduce the risk of a heart attack or stroke.

The study’s three analyses came up with varying numbers of saved lives, ranging from 250,000 to 1,200,000 over the next decade by reduced sodium intake–they averaged 280,000 to 500,000. We have long known that certain populations are more salt-sensitive and should radically reduce intake. The CDC list below tells that story, but we all should reduce sodium, not merely by not picking up the salt shaker, but by eating more fresh foods and looking at the labels on the processed foods we eat. Salt-sensitive populations

We can all benefit by a reduction in sodium, long before we become part of a vulnerable population. Next time, let’s look at some strategies we can use while waiting for food companies to offer lower sodium alternatives and government action in this domain.

Helpful links for more information about dietary sodium