"Practice At Top Of License" - The Newest Phrase in Dog Whistle Politics

The Disease Management Care Blog remains fascinated - if irritated - by the lingering pestilence of "dog whistle" politics. Readers may recall that this is the use of otherwise innocent sounding rhetoric that conveys deeper meaning that is only "audible" to a tuned-in constituency. So, when the DMCB announces that it supports cinematic art that explores the impermanence of life, the clued-in DMCB spouse quickly discerns this is really all about watching vulgar zombie movies.

One juicy health care dog whistle that's emerging is the phrase "practice at the top of license" as applied to non-physician professionals. To most people, this is interpreted to mean that nurses, pharmacists, optometrists, podiatrists and other health professionals should be able to care for patients at a level commensurate with their training and local State law. Ask an attuned and politically savvy nurse, pharmacist, optometrist or podiatrist what that really means, and you'll get a different answer: this means that they should be able to independently take care of and prescribe treatments for patients without doctor oversight.

Not much seems to be actually written about this (for example), which leads the DMCB to think that only makes it more deniable. It has certainly heard that phrase from many speakers at many conferences on the topic of primary care, access, manpower, patient centered medical homes and accountable care organizations.

This isn't going to be a small issue. Other than the eternally irksome topic of the Medicare sustainable growth rate, there is probably no other issue that is more likely to vex the organized physician groups. For the latest example of this, contrast the Institute of Medicine Report Brief on The Future of Nursing (the phrase here is a similar dog whistle "practice to the full extent of their education and training") with the response of the American College of Physicians: "Physicians and nurses complete training with different levels of knowledge, skills, and abilities that are complementary but not equivalent."

The DMCB appreciates both sides of the issue, which may be suitable for a future post. The important issue here, however, is that the same dog whistle contagion that infected reform ("cover all Americans" really being interpreted as the government option, "provider efficiency" meaning economic credentialing of doctors and the "Patient Bill of Rights" meaning "please forgive us for passing this ugly bill") continues to cheapen what should be an ongoing, open and civil health care debate that brings credit to our Republic.

The next time the DMCB hears the term, it's going to call the speaker out. The topic deserves to be examined in the light of day.

Image from Wikipedia

The Latest Cavalcade of Risk Is Up!

The (in)famous Cavalcade of Risk rating system of the anonymous Ironman's Political Calculations Blog is at it again, and the DMCB has a healthy Ab2 rating. If it were a bond, you'd be on topic and informed: definitely investment grade! There's a lot of other good and bad products out there, all assembled for your reading pleasure. Enjoy!

this is kind of nice

TopOnlineColleges.com as included Not Just About Cancer in their list of "15 Inspiring Breast Cancer Blogs."

Get inspired by this breast cancer survivor, who turned her unfortunate situation into a book about defying the odds and beating cancer.

Pretty cool, no? It's nice to know that someone's reading and finding resonance in my words. As for the "beating cancer" part - I know it lurks there somewhere and that we who have gone to Stage 4 are never, ever out of the woods but I do like to think I'm beating it.

The Republican Health Care Anthem (with apologies....)

The Disease Management Care Blog asked a very shrewd connoisseur of all things political if the midterm electoral conservative shift might prompt the survivors to play nice with each other. To the DMCB's chagrin, he said he doubted it, noting that it was the practical-minded centrists who were going to get clobbered. He predicted that the survivors left standing at the extremes of the political spectrum are destined for extremism, vituperation and gridlock.

What's a despondent blogger to do, then, than break out into song. The DMCB tried to capture the resurgent Republican mojo in the lyrics below. They're adapted (with apologies) to a deliciously deprecating anthem composed by The Magnetic Fields. The original lyrics may be within reach of that ultimate put-down song of all time, Bob Dylan's Like A Rollin' Stone.



You think we’ll work, not screw with you
Why compromise health care with you?
We want that Reid to go away
Block all the funding... yeah!
Like an ugly Tea Party
With Sara Palin!

Chorus:
If he thinks we'll leave the past behind
Obama's out of his mind
If he thinks we'll simply press rewind
Prez must be out of his mind... yeah
He must be out of his mind!

Dems want what was turned off turned on
You said reform, but it’s a bomb
You can't go 'round just saying “hope”
Because it Twitters
Jon Stewart can’t say enough
To get supporters!

Chorus

We want to kill the ACA
Our opponents will have to pay
The budget is beyond all control
We’re printing money!
Medicare is in a hole
Our mood is crummy!

Chorus

mind body spirit

Thanks to Andrea for the photo.

I just spent an inspiring (and I don't use that word lightly) week end at Body, Mind, Spirit, 2010: National Conference for Young Women Living with Breast Cancer.

My best parts:

A Friday afternoon workshop: "Take charge of Your Treatment for Women with Metastatic Breast Cancer" with Dr. Maureen Trudeau. Engaging, accessible, interesting, informative and hopeful.

A Saturday afternoon workshop: "Intimacy after Cancer: Rekindling the Flame" with Dr. Sally Kydd. Amusing, motivating, reassuring, helpful and just plain fun.

A Sunday morning workshop: "Living with Metastatic Breast Cancer. Support that Works" with Dr. Tzeporah Cohen. Emotional,moving, cathartic, uniting, strengthening.

Speakers who resonated: Deborah Dubenofsky (Ontario Region Board Chair, Canadian Breast Cancer Foundation) and Carol Ann Cole.

My takeaway message (from Dr. Natasha Zajmalowski, Dr. Rob Rutledge, Dr. Roanne Segal and others)-

When it comes to breast cancer recurrence, it appears that insulin is the root of all evil. Lowering insulin levels improves the odds for a long and healthy life. How to do this:

1. Get at least thirty-five minutes of moderate exercise every day. Hooray! Something I'm already doing right!

2. Maintain a healthy body weight. This has provided the kick in the pants to re-commit to dropping 44lbs by my 44th birthday. Weighing too little isn't good either but that's never been my problem.

3. Eliminate or reduce alcohol and sugar. The insulin explanation is the first one I've understood and accepted re the link between these yummy things and cancer recurrence. To be truthful, not being an "all or nothing" kind of person, I don't see myself promising to never consume booze or sweets again. I can't even say that I haven't partaken since the conference, this being the season of Hallowe'en and pumpkin ale. I can say that I will make a greater effort to hold out for the good stuff and not give in to cravings.

I'm happy to say that although this message was consistent, the speakers seemed to be devoid of judgment. No one was blaming the victim or telling cancer patients that they brought the cancer on themselves.

I still feel that there are greater environmental and medical issues that need to be addressed. But there are just so few things we can control as cancer patients that I appreciate straightforward advice and simple things I can do to increase my odds of being around to see my children grow up.

Thank you so much to the staff (especially Jenn McNeill of the CBCN) and volunteers (especially Andrew, a volunteer from Humber college who helped with my books, kept me company and was enormously supportive during and after my book signing) at the Canadian Breast Cancer Network and the Canadian Breast Cancer Foundation for helping me to promote Not Done Yet, and especially for organizing an amazing conference.

Can we do it again next year, please?

Osteoarthitis Disease Management: One of the "Big Six?"

The Disease Management Care Blog has always wondered why there aren't more disease management programs for osteoarthritis (OA). Sure, some population health vendors offer them (for example) but OA never achieved status as one of the "Big Five" (mentioned on page 5 here). That's curious, because the condition is quite prevalent, self-care has a role in limiting disability and big pricey surgery awaits at the end of the line. There is no shortage of rigorous peer-reviewed studies that show that patient education programs can reduce pain, increase mobility and reduce physician visits (for example, here and here).

By the way, osteoarthritis shouldn't be confused with other types of joint inflammation, such as "rheumatoid" arthritis. The former is primarily a disease of middle aged and older individuals involving the cartilage of the major joints (back, hip, knees and hands) typically accompanied by bony thickening. It is often a diagnosis of exclusion, made after other causes of joint inflammation are ruled out. Criteria on making the diagnosis can be found here.

Thanks to a randomized prospective study appearing in the latest Annals of Internal Medicine, it may be time to reconsider whether OA should become one of the "Big Six."Researchers at Durham VA scoured their electronic health record for patients with the diagnosis of OA, mailed them letters about the study and then telephoned them. Out of 3477 persons with an EHR diagnosis, 523 were successfully recruited for participation while 461 completed the study.

The patients were randomly allocated to one of three treatment arms:

1) the intervention OA self-management group (N=172) which received "grounded in social cognitive theory," education, goals setting, action plans with monthly phone calls from an educator,

2) the control health education group (N=172), which received generic education on a host of health issues plus phone monthly calls from an educator, and

3) usual care (N=171).

At the end of 12 months, measures using standardized self-assessment scales showed the intervention group was experiencing less pain and also had better mobility and flexibility. The intervention itself was estimated to cost a total of about $118 per participant versus $63 in the health education control group. 172 patients times $118 is just over $20,000. While avoided surgeries were not measured in this study, the figure of $20,000 contrasts with the cost of a single total knee replacement.

The DMCB was also struck by the similarity of the research protocol to standard disease management vendor approaches to covered populations. Instead of using an EHR to find patients, vendors use insurance claims. Just like the Durham Va researchers, they also send letters and then telephone patients with a less than 100% success rate. In addition, the economic game of cost "savings" or "ROI" success or failure can hinge on one or two patients. The only difference is that the authors never used the terms "disease management" or "population health management."

These study results, combined with more than a decade of other research, make the DMCB suspect that an $118 per member per year (PMPY) program like this would ultimately yield significant savings for a managed care health insurance or self insured sponsor. While it could benefit all patients with OA, the DMCB wonders if it couldn't be targeted at patients that have been referred by primary care physicians for specialty care, since those patients are probably at the greatest risk for having an elective total knee replacement.

Last but not least, note that evidence-based guidelines on the treatment of OA strongly emphasize the role of patient education. It may be time to update them so that they emphasize the role of cognitive psychology, goal setting, action plans and remote coaching. Of course, the guidelines could sum up all that and more with two simple words: "disease management."

Image from Wikipedia. Because the translucent cartilage that lines the joint is diseased, the bones that make up the knee are not separated and have begun to touch and rub on each other. There is also lipping and a knobby appearance, thought to occur as a result of the joint inflammation leading to attempts to heal.

sugar hangover

Lots to tell about the conference I just attended but I'm exhausted and it's not just the result of all the sugar that was consumed in our house last night.

Instead of words, I give you some of the coolest kids in the world:



How often does one see a lady bug hanging out with Captain Kirk and the Grim Reaper? Death himself is my adorable offspring. The little trekkie and the bug are his very brave friends.




12 year old S. opted not to go trick or treating for the first time this year. Instead, he and his dad went to an early viewing off a movie that's usually shown at midnight. He's a character from that movie. Can you guess who he is? Those who've been privy to the discussion on Facebook are not allowed to vote!