0 More On The Death Of Disease Management

At the email prodding of several colleagues, the Disease Management Care Blog next turns its attention to a blog posting by Archell Georgiou MD provocatively titled "The Death Of Disease Management (Finally!).  The Archelle on Health Blog contrasts the industrys early promises of evidence-based medicine plus patient self-care with the bitter fruits of non-existent savings, the disappointing Medicare Health Support (MHS) demo and a just-published anti-disease management New England Journal article. 

Using that last Journal article as the final word, Dr. Georgiou provides her readers with a graveside eulogy of what went wrong:

1. The NCQA promoted an "enroll and counsel all patients at risk" approach, when what was really needed was a focus on the patients at greatest risk.

2. The disease management industry relied on gimmicky marketing instead of reducing costs, and

3. Inflexible adherence to evidence-based medicine failed to account for individual patient circumstances.

Enter Al Lewis of the Disease Management Purchasing Consortium with a rebuttal, but, um, sort of.  Al points out that the DM industry still clings to life and, even worse, uses spurious financials.  Yet, thanks to ICD-10, inclusion of labs in predictive modeling, lower program costs, physician involvement and the marvelous insights of his soon-to-be-published book, he confidently predicts that the DM vendors will emerge from what is better described as a near-death experience.

Where to start?

Medicare Health Supports Lessons

That New England Journal article used by Dr. Georgiou to  nail DMs coffin was a really retread of Medicare Health Supports (MSH) failings.  Look deeper and what MHS really demonstrates is CMS ineptness in demo design, program support and data interpretation.  Toss in this CBO Report and its clear that the issue isnt whether DM "works" in in FFS Medicare, but that the administrators running FFS Medicare dont know how to implement DM. 

Disease Management Is In Use In Most Commercial Settings

CMS bumbling stands in contrast the long term and continued reliance by commercial insurers on disease management in the commercial and self-insured sectors.  While nattering nabobs may suggest that the commercial sector isnt paying attention to the "evidence" of studies like MHS, a cursory search of the published literature can find studies like this, this, this, this and this that suggest that the commercial sector knows what its doing and that patients and their premiums are better off for it.

Disease Management Ver. 1.0 Deserved To Die, But Didnt.  It Changed

Archelle On Health has it only partially right. When industrys own studies proved that a) an all-patient approach didnt work, b) it had to get serious about documenting outcomes and c) patients had to be "engaged" on their own terms, it didnt crawl into a hole and die.  It changed to what the DMCB has characterized in past postings as "disease management Ver. 2.0," otherwise known as "population health."

And What About Al Lewis Insights?

The DMCB agrees with four out of five.  If his new book is anything like his last one (by the way, it included the DMCB as an author), make that five out of five.

But Wait, Theres More!

In the original "Death" post, Dr. Georgiou points to six innovations that promise to further shake up the landscape of population health: social networking, gaming, remote biometric monitoring, wireless health management apps and "passive" environmental changes that lead denizens to lead more healthy lives.  The DMCB says shes right and finds the topic endlessly fascinating.  While the population health and disease management industry is using monitoring and social media, it remains to be seen how it will embrace the other innovations. 

That being said, the DMCB hopes that Medicare doesnt run any demos on any innovations like gaming, apps or environmental changes, lest future bloggers end up pronouncing their death too.

Image from Wikipedia

0 Being overweight associated with lower risk of death

In an analysis of nearly 100 studies that included approximately 3 million adults, relative to normal weight, overall obesity (combining all grades) and higher levels of obesity were both associated with a significantly higher all-cause risk of death, while overweight was associated with significantly lower all-cause mortality, according to a study in the January 2, 2013 issue of JAMA.

"Estimates of the relative mortality risks associated with normal weight, overweight, and obesity may help to inform decision making in the clinical setting," according to background information in the article.

Katherine M. Flegal, Ph.D., of the National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Md., and colleagues conducted a study to compile and summarize published analyses of body mass index (BMI) and all-cause mortality that provide hazard ratios (HRs) for standard BMI categories. For the review and meta-analysis, the researchers identified 97 studies that met inclusion criteria, which provided a combined sample size of more than 2.88 million individuals and more than 270,000 deaths. Regions of origin of participants included the United States or Canada (n = 41 studies), Europe (n = 37), Australia (n = 7), China or Taiwan (n = 4), Japan (n = 2), Brazil (n = 2), Israel (n = 2), India (n = l), and Mexico (n = l).

All-cause mortality HRs for overweight (BMI of 25-<30), obesity (BMI of ≥30), grade 1 obesity (BMI of 30-<35), and grades 2 and 3 obesity (BMI of ≥35) were calculated relative to normal weight (BMI of 18.5-<25).

The researchers found that the summary HRs indicated a 6 percent lower risk of death for overweight; a 18 percent higher risk of death for obesity (all grades); a 5 percent lower risk of death for grade 1 obesity; and a 29 percent increased risk of death for grades 2 and 3 obesity.

The authors note that the finding that grade 1 obesity was not associated with higher mortality suggests that that the excess mortality in obesity may predominantly be due to elevated mortality at higher BMI levels.

The researchers add that their findings are consistent with observations of lower mortality among overweight and moderately obese patients. "Possible explanations have included earlier presentation of heavier patients, greater likelihood of receiving optimal medical treatment, cardioprotective metabolic effects of increased body fat, and benefits of higher metabolic reserves."

The use of predefined standard BMI groupings can facilitate between-study comparisons, the authors conclude.

0 Excess Calcium Doubles the Risk of Cardiovascular Death in Women

Cardiovascular disease continues to rank as the leading cause of death among men and women in western cultures. Many lifestyle factors, including processed food diet, lack of physical activity and daily stress contribute to this largely preventable disease and cause of early death. While there are many natural compounds and nutrients that help to help lower the risk of developing heart disease, taking supplemental calcium to prevent bone loss and osteoarthritis is now shown to be a significant factor that promotes the development of cardiovascular disease and advancing mortality, especially in women.

Excess Calcium Intake Disrupts Homeostatic Balance to Double Heart Disease Risk in Women

A research team from Uppsala University in Sweden has published the results of a study in the British Medical Journal that explains how high intakes of calcium (corresponding to diet and supplements) in women are associated with a higher risk of death from all causes, but cardiovascular disease in particular, compared with women with lower calcium intake. For decades, women have been advised to supplement with a daily course of calcium ranging from 1,000 to 1,500 mg to prevent bone loss. This study demonstrates how that advice may be a leading cause for the development of heart disease and early death.

Researchers studied 61,443 Swedish women over an average period of 19 years to test the association between heart disease risk and calcium intake. Data was gathered on total calcium received from both dietary and supplemental sources. The team grouped the women from the lowest mean calcium intake of 572 mg/day to the highest (2,137 mg/day). The scientist factored in lifestyle data including menopausal status, postmenopausal estrogen therapy, weight and height, smoking habits, leisure-time physical activity and educational level to help parse the results.

Women Need to Closely Monitor Calcium Intake from Food and Supplements to Lower Heart Disease Risk

Over the course of the study, 11,944 women, or 17 percent died. The team determined that 3,862 died from cardiovascular disease, 1,932 from heart disease and 1,100 from stroke. The study did not further differentiate specific diagnoses between cardiovascular disease and heart disease. The highest rates of death from all heart disease related causes were associated with a daily calcium intake higher than 1,400 mg/day or lower than 600 mg/day. Women in the top quartile that took a daily calcium supplement were found to be twice as likely to die when compared to those in the ideal range of 600 to 999 mg/day.

The researchers concluded that either high or low calcium intake can override normal homeostatic control causing changes in blood levels of calcium. Although not mentioned in this study, past work has also found that vitamin K is necessary to move excess calcium from the blood into the bones and teeth. Without this critical nutrient, calcium remains in circulation where it is easily bound with oxidized LDL cholesterol to form deadly arterial plaque. Individuals consuming a healthy diet rich in vegetables, nuts seeds and fruits should receive sufficient calcium from diet and naturally benefit from a reduced risk of cardiovascular disease, without the need for supplementation.

0 Dietary Fiber May Reduce Risk Of Death From Heart Disease

Research from Japan this month finds that dietary fiber from fruit and cereals/grains, but not from vegetables, reduced the risk of death from cardiovascular disease:

Dietary Fiber Intake Is Associated with Reduced Risk of Mortality from Cardiovascular Disease among Japanese Men and Women, The Journal of Nutrition, August 2010

The study which involved over 58,000 men and women was prospective with a 14-year follow-up.

Both soluble and insoluble fiber provided benefit, but insoluble reduced risk more than soluble. Fruit fiber reduced risk more than cereal/grain fiber.

The findings are in good company:

"The inverse associations of fruit and cereal fiber intakes, but not vegetable fiber intake, with mortality from [coronary heart disease] in the present study were consistent with findings from previous studies: the Womens Health study, Nurse Health study, Cardiovascular Health Study, and the pooled analysis of 10 American and European cohort studies."

Possible mechanisms:

• Fiber, especially soluble, may improve lipid profile via cholesterol lowering.
  
• Fiber may lower blood pressure
  
• Fiber may reduce abdominal obesity
  
• Fiber may improve insulin sensitivity
  
• Fiber may inhibit a postprandial rise in glucose and triglycerides
  
• Fiber, especially insoluble, may improve fibrinolytic activity (reduce blood clotting)

Those in the highest fiber intake group consumed about 14 grams/day, about double what those in the lowest intake group consumed. The authors state this may have been underestimated and that the actual mean (not maximum) fiber intake was about 15 grams/day.

The hazard ratio, in the highest vs. lowest quintile, for insoluble fiber:

• For men: 0.48
  
• For women: 0.49

Insoluble fiber cut their risk of death from coronary heart disease in half.

The American Heart Association recommends adults consume about 25 grams of fiber a day from foods rather than supplements.

These finding dont bode well for low-carb, low-cereal-fiber Atkins-like diets.
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0 Physical Inactivity Can Cause Death

Physical Inactivity Can Cause Death - Most of us life and work in busy area, so many people choose to rest and relaxing in-front of TV or just change the activity in sleeping. this lifestyle can trigger the people, if this rarely move lifestyle happen and taken for along time.

Physical inactivity is the term that identified to the people in low of physical activity level or none at all. As a result of combustion energy is not more than 1.5 times the burning energy while resting.

For knowledge, now 48,2 the people on ages more of 10 years is on less of physical activity. Accord to WHO, 60-80% adult population not active in physically.

Physical inactivity is a long time may cause overweight or obese. In the world, obesity ranks fourth leading cause of death or contributed to 30 percent of world mortality.

"From our time 24 hours a day, mostly allocated to inactive. The portion of the most sleep, then work all day sitting in front of the computer. The trip home was also a lot of sitting, at home coupled with watching television and playing video games on weekends,"

said Urip Nuratno, fitness training manager of Fitness First Indonesia.

In fact, to keep in shape, WHO recommends that we exercise at least 30 minutes every day. Sport is meant is that regular physical activity. May we can keep our shape by exercise for 30 minutes a day. Good Luck