moments of joy

I have a cherished memory. I was in my early twenties and working in New Brunswick at a summer English language program for adults. Students came from all over the world (but mostly from Quebec) and lived in residence on a university campus.

The staff, most of whom were young, lived in residence with the students and were (in addition to teaching all day and coordinating recreational activities) in charge of patrolling the halls at night to ensure that only English was being spoken (every student signed a contract to that effect and agreed that if they were caught in violation of this rule three times, then they would be sent home. I have never heard of a university based program to be as tough as this one. But it worked). Most of us loved the work but it was intense, exhausting (the hours were very long) and, at times, very stressful. And it was exactly the environment that fostered strong bonds between staff members.

One evening, most of the staff were told that we could have an unexpected day off. At eleven o'clock that night, a bunch of us piled into two cars and drove all night to a friend's cottage (stopping only for gas and to take pictures at the world's longest covered bridge). We arrived at dawn (I couldn't tell you where exactly, but it was beautiful), and a few of us immediately went to put on our suits and go play in the rapids. I remember laughing and playing in the cool water as the sun came up, then crashing for a couple of hours on the cottage floor. Later that morning, we all went for a paddle and I remember drifting lazily in the sun (I am still a very lazy paddler).

We left after dinner that night, to be back in time for work the next morning.

I have lost touch with all of my friends from that day but the memory remains a special one, as a time that I was joyfully living right in the moment.

I was feeling a bit sad the other day as I reflected that I am unlikely to ever have that kind of experience again, what with responsibility, health and (let's face it) age all working against me.

But then I realized that such joyful moments occur routinely, I just need to remember to be open to them. And my kids help a lot with that.

A couple of weeks ago, S. had his birthday party. This was the first such party he wanted in years, so we agreed to go all out and have it at the movie theatre. They were such a nice group of kids and had a great time being silly together! And as I looked down the aisle and took in nine enraptured faces (we saw the new Indiana Jones movie. Good fun), each kid balancing popcorn on skinny knees, I realized that I was having one of those moments. Pure joy.

Cross-posted to Mommybloggers.

USPSTF: Blood Pressure Trumps Blood Glucose & the Implications for Diabetes and Hypertension Disease Management

Persons with blood pressure readings consistently greater than 135/80 should be screened for diabetes mellitus every three years, or so says the U.S. Preventive Services Task Force. When this headline first crossed the Disease Management Care Blog’s twin flat screen monitors, it thought the rationale was simple.

A high prevalence of undiagnosed diabetes among persons with hypertension should be the cause for alarm. Diabetes mellitus is present in about 9% of the U.S. population, its prevalence increases to more than 20% among persons aged greater than 65 years and is also associated with a high body mass index. Since these risk factors tend to cluster together, it makes sense to look for the condition, right? Earlier diagnosis would lead to earlier treatment and prevention of the complications of diabetes, right?

That’s not the case. Instead, the USPSTF logic is reversed and twofold. The first is that the presence of diabetes alters the preferred blood pressure to less 135/80, even if it means starting a lifetime of daily pills. The second is that it makes a difference as to which medicines are used. So it’s not a matter of diagnosing and then treating diabetes, it’s a matter of managing the blood pressure differently.

Don’t be surprised. Several studies including the U.K. Prospective Diabetes Study (UKPDS) and the Hypertension Optimal Treatment (HOT) Study demonstrated a strong link between blood pressure control and macrovascular complications, such as heart attack and stroke, among persons with diabetes. Up to 80% of persons with diabetes will die of macrovascular disease, so blood pressure control is a priority. In fact, it is probably more important than blood glucose control. To give you a sense of this, the very valuable “Number Needed to Treat” (NNT) blood pressure calculation, provided in this excellent Annals article, is an impressive 23 or less for all cause mortality, stroke or heart attack over ten years. Thiazide diuretics or ACE inhibitors (and frequently both, combined with other medications if necessary) should be used initially, versus other first line agents.

Note that there are no prospective studies that show control of the blood glucose level in diabetes changes the incidence of heart attack or stroke. Rather, blood sugar control is correlated with fewer “microvascular” complications, such as damage to the sensory nerves in the feet or kidney disease.

The DMCB wonders how this new recommendation would work for physicians in primary care settings:

Scenario 1: During the course of every one-on-one visit with patients, the physician tries to remember that a blood pressure reading that normally isn’t considered “high” should prompt a check of those past blood tests in the back of the chart and to order a screening test for diabetes, in addition to all the other things that need to fit into a 15 minute office visit. If really well organized, have a flow sheet in the front of the chart. Anyone without an appointment loses out.

Scenario 2: Have a standing order for the office nurse to review the charts’ labs and arrange for a screening test for diabetes if, during the course of the intake, the blood pressure is more than 135/80. Anyone without an appointment loses out.

Scenario 3: During the course of every one-on-one visit with patients, the physician gets annoying prompts from that new EHR that a blood pressure reading that normally isn’t considered “high” is high and a lack of any labs under the 'results' tab should prompt an order for a screening test for diabetes click here, in addition to all the other aspirin, cholesterol screening, mammogram and immunizations prompts – click heres that clutter the screen during the 15 minute office visit. Anyone without an appointment loses out.

Scenario 4: Physician fires up that new and improved EHR registry and uses some if-then branching programming logic to extract everyone with a mean of > 135 OR >80 over three visits in the two BP fields AND absent diagnosis of diabetes (look up the ICD 9) codes AND absent qualifying blood test over the last 365 days x2. Generate form letter to all patients meeting criteria and “blow in” the name and address from the demographic data fields. Blow in a screening lab order on hundreds of patients. The physician and the office staff deal with each one at a time when patients start calling with questions and when the physician needs to actually see the folks with evidence of diabetes.

Scenario 5: Physician tells the office manager or nurse to deal with Scenario 4. They tell the physician (s)he needs to contact the EHR vendor and find out how much it will cost to have this ad-hoc programming done.

Scenario 6: Physician awaits the arrival of a newly developed HEDIS measure for the number of persons with blood pressure > 130/85 (denominator) who have a screening blood glucose level (numerator). (S)he resists the flaky letter from the managed care organization listing patients, many of whom are not recognized, that the MCO believes meet criteria for measurement or intervention so that they can get NCQA accreditation. There is a change of mind when the flaky letter Ver. 2 outlines the terms of a new P4P initiative linked to this measure.

Scenario 7: The physician discusses this with the Medical Home trained staff and instructs them to work with the disease management vendor, who has the mojo to contact everyone meeting criteria after they’ve remotely accessed the electronic patient files in a HIPAA compliant way. Patients meeting criteria are contacted with letters, IVR and eventually live nurses who remotely arrange testing. Patients who have the labs done have been coached, and those with a fasting blood glucose > 126 (have diabetes) and a blood pressure > 135/80 are seen by your Medical Home staff and medications are started and adjusted using a standing order protocol that is safe and effective. Physician is in the meantime seeing sick people, but available if the protocol isn’t working.

i love the internet

Found this recipe, which became dinner (we had a 'cross rib roast' thawing. I had never heard of such a thing).

When I realized I didn't have rosemary, I asked the internet what to do and found out I could substitute savory.

It was delicious.

I am off to bed very soon (I am as tired as when my kids were babies) and will offer up a more coherent post tomorrow.

Good night.

Comprehensive Health Care Reform and Massachusetts--Are We On Our Way To a Very Different Debate?

The Massachusetts health care reform law appears on its way to:Covering two-thirds of those who did not have health insurance on the day it was enacted--about 400,000 people by the end of 2009.Covering most of those who were uninsured in households with incomes below 300% of the federal poverty level--below which the plan pays all or most health insurance premiums.Offering health insurance plans

my little leap of faith

Meet Lucy (she's the furrier one, on the right).

She's a Tibetan Terrier and she has just joined my family.

TTs can live for as long as seventeen years.

How ambitious am I?

We really wanted to get a dog from a shelter or a rescue organization (J-Dog is a rescue and possibly the best dog in the history of dog-dom). But we needed a dog that is healthy, good with kids, other dogs and cats (we almost adopted a wheaten terrier from a rescue group during winter but when the dog met a cat, he tried to eat it. Literally).

And hypoallergenic (D. is mildly allergic to both dogs and cats and we couldn't in good conscious bring another dog into the house who would irritate his allergies).

We also needed a dog who would happily come on long walks or runs with me when I am well and take it easier on the weeks I have treatment. After a year of cruising the internet and working the phones (I reached out to rescue groups across Canada and into the US), I reluctantly admitted defeat.

So we chose a dog from a very responsible breeder and a relatively rare breed with few genetic health problems.

And she's really sweet and cute, too.

I am almost as exhausted as right after my kids were born.

And very nearly as blissed out.

And, for the record, if something does happen and I am unable to take care of this sweet puppy (who we are all working very hard to train), T. and the boys will take good care of her. And of J-Dog. And even of our belligerent cat.

Because when this family adopts an animal, it's for life.

Do You Deserve an Award for Disease Management? Here's Your Chance

Do you work hard on behalf of populations afflicted with chronic illness? Would you and your co-workers appreciate some recognition for once? Have your company's ideas gone unnoticed by too many for too long? Is there a professional colleague that deserves better ?

Or alternatively, do you have a boss that could use some serious sucking up?

Here's your chance. You can nominate yourself or a coworker or your boss or your company for one of eleven awards from the the Organization Formerly Known As D.M.A.A., now simply DMAA the Care Continuum Alliance. You don't even have to be a DMAA member (though, let's face it, you ought to be if you aren't) to be considered. Note that submitting more than one application is not only verboten, but in poor taste.

The Disease Management Care Blog has participated in past evaluations of nominees. While there have been some rather fabulous, famous, expert and star-studded winners, the Committee has always carefully considered all the merits of each nominee and has not been prone to being swayed by the usual rock stars. The small, meek and the mild with meaningful track records of success have actually won some important recognition.

Think the awards don't have much gravitas? Think again. The DMCB has participated in site visits and program evaluations for payers and purchasers where the DMAA trophy has been prominently displayed (we're talking in the middle of the table with a small spotlight) and mentioned on the first page of the response to an RFP. The reason they do that is to take business away from you.

Deadline is June 13, 8 PM EST. Time to get crackin' - this is less than two weeks away.

The DMCB's advice for next year: Create a 12th Award: Best Blog.

Humbly speaking of which, the DMCB's position in the blogmos has now reached being in the top 500 blogs in the Healthcare100 ranking (there are a cornucopia of health care blogs out there and many are big business) and two hundred and something in the Wikio Health Blog ranking. Impressed? Well the spouse isn't. The DMCB wonders if a recent conversation on the difference between the outcomes and process of using a vacuum cleaner is playing any role. Husbands, be forewarned, this is not an area you want to tread in.

A Type 1 Diabetic's Insights About Insurance, Quality and Cost (& an erratum re Lifemasters)

While DiabetesMine is a famous must-read blog for all things diabetic, the Disease Management Care Blog discovered this morsel at Finding Our Way. Ms. Erika also has type 1 diabetes and her latest blog is a telling essay that gives the patient's points of view on all these high falutin concepts about insurance, quality and cost. When I read this, I thought about:

Risk vs. retail: Can we be confident that the Material Girl's efforts are reasonably destined to save her and her insurance company money in excess of the $14,000 per year? Suppose a cheaper pump were used and testing was limited to 4 times a day? Cost would go down and the risk of increased claims expense might go up, but by not as much. Maybe the retail dimensions are more important: her insurer can use its purchasing power to gain discounts on the cost of supplies and share the expense outside notions of insurance risk. Reconciling both functions is difficult but it's the right thing to do.

Benefit design and silos: it's not clear if the yearly cap of $3500 applies to all costs or some; it's possible that "durable medical equipment" like pumps have a different cap. The point is that from the patients' point of view, it doesn't really make that big a difference. Money is money. Health is health. Maybe there is a role for 1st dollar coverage of 'no-brainer' health care like pumps.

Consumer Directed Health Plans or variants thereof: it's pretty obvious that Running Mama is going to blow right through her out of pocket cap in just a few months. If interpreted correctly, this new insurance could possibly represent a simple cost transfer from the insurer to the enrollee. On the other hand, it's clear the 'consumer' is now carefully weighing the pros and cons of high frequency testing and making rational economic decisions based on her values and life style.

The Doctors: Think docs cost a lot of money? Think again. Depressing isn't it? Of the 14 grand, her physician occupies only $500. Yet, that doc presides over a whopping amount of money. It seems to the DMCB that the doc deserves better compensation in general and should also be rewarded for making sure the $14,000 is spent in the best interest of the patient with dimensions that include quality and value.

Disease management: This patient is obviously doing such a good job with DM, if I were a vendor, I'd stay away and move onto the next patient. However, perhaps there is a future role for DM companies is to help persons navigate the insurance benefit design. This will be examined in a future post.

Thanks Erika, for sharing.

++++++++++++++

Postscript: the DMCB has issued its first ever erratum (and hopefully last) on a prior post, mistaking Lifemasters for Healthways. The DMCB has made the necessary corrections & regrets the error.