0 Why Everybody Should Read Why Nobody Believes the Numbers

Music of the Spheres

Back in the early 1900s, Albert Einstein had a problem. Sophisticated instruments were unexpectedly showing that the measured speed of light was the same if the source or the observer were moving or stationary.  In other words, if one were moving away from a bullet, it should look (to the observer) that the bullet had slowed down. Lights usal to conform to the prevailing common sense about how the universe should work ultimately forced Einstein in 1905 to conclude that, in order for the speed of light to be constant, time and mass had to be elastic. This ushered in a new field of relativity mathematics that is still being used to plumb the known universes Music of the Spheres.

While the controversies surrounding the effectiveness of "population health management" (PHM) are quite minor compared to Einsteins Theory of Relativity, the comparison is still instructive. The similar mismatch between what is assumed, what is observed and how to mathematically describe the ultimate truth also underlies Al Lewis book, Why Nobody Believes the Numbers.  In other words, we assume care management-based patient coaching always yields savings, increasingly sophisticated observations often fail to show it and, as a result, we need new mathematics to reconcile what we assume and what we observe.

Interestingly, author Al Lewis of the Disease Management Purchasing Consortium never doubts the speed of light or that high quality PHM ultimately can save money. While PHM vendors may interpret his long history of skepticism as some sort of shakedown, Als passion is clearly evident: Why Nobody Believes the Numbers is ultimately driven by a search for the truth. For that he deserves a lot of credit.

The good news is that Mr. Lewis does a masterful job of examining the prevailing assumptions underlying the PHM universe by relying on laymans logic, simple examples, real world anecdotes and clever insights. As a result, even the mathematically challenged can come away with a better grasp of the pitfalls that surround selection bias, regression to the mean, invalid comparators and calculation of trend. As a result, the first chapter on "Actuaries Behaving Badly" is arguably "must reading" for human resources managers, sales personnel or C-suite types that are contemplating the "return on investment" from a company wellness or a disease management program.

That bad news is that Al Lewis is no Einstein. He suggests that a solution is at hand thanks to a simplistic "dummy year adjustment" methodology that is based on serial observations over a long period of time that includes all patients with the index condition.  When this is combined with a series of common-sense based "plausibility" tests, Al proclaims his mix of common sense and fundamental mathematics will yield a single, yes or no, black or white, it did or did not reduce insurance-claims expense-truth.

Unfortunately that aint necessarily so. Even Einsteins insights couldnt explain all of the sublime harmonics that make up the Spheres. Therell be a future Disease Management Care Blog posting with more on how Why Nobody Believes the Numbers falls short.  That will address the unavoidable impreciseness that surrounds measures of central tendency, the challenges of measuring subgroups and the moving-target realities of an insurance industry that continue flummox those of us who are trying to explaining the health care universe.

In the meantime, if youre a buyer or a vendor, the DMCB recommends Why Nobody Believes the Numbers for your bookshelf.  DMCB readers will come away with a better grasp of the good, the bad and the ugly of outcomes measurement, understand what it can and cannot tell us and appreciate the underlying and still evolving debate over the ultimate value of the PHM industry.

0 Should Health Insurer Coverage Be Conditional On Participation In Disease Management

Standing between patients
and outcomes?

The unsophisticated Disease Management Care Blog used to think the answer was a simple yes. 

Its rationale was twofold:

1. The patient impact of the medical and pharmacy benefit, i.e., medications and other treatments, will be greater if theres a link to concurrent care management services that promote self care and increase doctor-patient engagement, and

2. The gateway to accessing the medications and treatments could be used to incent enrollment in care management programs which, depending on the circumstances, increase quality and lower costs.

Both factors undoubtedly underlie the decision of many insurers to combine disease management and coverage of certain services.  For example:

Many Medicaid programs wont cover tobacco cessation medications unless the patient is participating in "counseling services."  Thats because much of the original research on the drugs showed they work if they are linked to concurrent behavioral support.  By the way, the same is true when it comes to drugs for the treatment of obesity (page 53), which showed up in this coverage document.

In addition, consider the example of "external insulin pumps."  These are battery powered, small and discreetly wearable devices that provide a highly tailored course of insulin to persons with diabetes.  They are are also complex and expensive, which is why many commercial health insurers rely on guidelines that require participation in a diabetes program before theyll be approved.

There are exceptions to the rule.  For example, while asthma treatment guidelines (page 60) recommend instruction, demonstrations and frequent reviews along with the prescription of peak flow meters, coverage of these devices is not conditional on participation in an education program.

Upon further lection, however, it occurred to the DMCB that having to enroll in disease management - whatever its merits - could be viewed by patients as a barrier which could, in turn, paradoxically reduce medication possession ratios, participation in tobacco cessation programs or use of insulin pumps.

In mulling this over, the DMCB turned to the topic of Value Based Insurance Designs. While VBID can be defined as the explicit setting of patient out-of-pocket-cost (such as co-pays or co-insurance) to the underlying value of any medical service,the DMCB thinks it can be broadened to include the removal of any barriers that stand between the patient and high value services.  The highly regarded University of Michigans Center for Value-Based Insurance Design, in this excellent review, doesnt think of disease management as a barrier but as an incentive.

Incentive or not, the good news is that its possible to combine VBID and disease management that together achieve outcomes that are better than either one alone.  Unfortunately, the DMCB fears those outcomes are limited to patients willing to enter the programs in the first place: there may be a larger unseen population outside the disease management intervention who arent included because they dont want the hassle.  In other words, good outcomes for a few known participants doesnt make up for the potentially bad outcomes for the many non-participants.

If any readers have an answer, the DMCB would appreciate hearing from you.  In the meantime, the DMCB cautions that the population health management suppliers need to be aware of the downsides of linking insurance coverage to their services.  They also need to do everything they can to avoid being viewed by patients as a barrier.

Image from Wikipedia

0 What Should We Eat to Lose Weight

Hi,

Brad Pilon has revised his book "Eat Stop Eat" and since I am on his mailing list from having purchased his last version I have been given the opportunity to read his revision and provide feed back to him, if I have any, before he publishes it. What a great idea. In my former life I was a proof reader and typesetter so this is "old hat" to me and I enjoy doing it. So I am again reading his book and thinking about some of his statements.

I am again struck by this one: ...research was trying to uncover the completely backwards idea, "What should we eat to lose weight?"

Sometimes it is so simple we do not see the forest for the trees. When a person wants to lose weight they immediately look for a "diet plan," or "way to eat," which nearly always has a "diet guru" to go along with it. The guru can be a person, like a celebrity, or an organization, like Weight Watchers, etc.

In reality the only thing that is needed is an actual calorie reduction. It is not completely about that, but the main thing of impact is the reduction in calories. Some people, like me, also need to pay attention to how many carbs are eaten, but, for the most part, if you simply eat less you will lose weight.

By far the easiest way that I have found to reduce calories is with intermittent fasting. You give up a few meals a couple of times a week and voila! you have reduced your calorie intact while not really changing how or what you eat the rest of the time.

The only pit fall is if you suddenly start eating more in between fasts. That is the formula for gaining weight. Remember the Sumo Wrestler exercises, fasts every morning, and eats two 10,000 calorie meals -- every day. (http://blogspot.com/2012/06/same-dedication-different-goal.html)

Is it not eating excessive amounts of food that makes us fat? So does it not follow that not eating food for a period of time would help you to lose weight? And guess what.... weight loss is not the only result. During a 24-hour fast blood sugars improve, cholesterol improves, fat is actually used rather than stored, and you feel alert, alive, and peppy, too.

Think about animals in the wild. They hunt down some food, kill and eat. Then they go without, until they find something more to eat. The ancient human hunter/gatherer did the same thing. Find a rabbit and some berries. Have a feast. The food is gone so now they fast until they find some more food to eat which could be on the same day, but was very likely, the next day.... or even the next. Water, in this scenario, becomes really important.

In between eating, they drank water.... as they fasted. Did they not per to live near water? Did not civilizations grow up right next to a body of water?

So now. Looking at my own life, when I fast for two 24-hour periods each week, I either maintain my weight or lose a little -- I dont usually gain. If I eat veggies and protein in between fasts, my body likes it better.

I started my fast today at 11:30 after eating a breakfast of steamed broccoli and lemon slices with two eggs over easy. It is always easier to start a fast after eating a nice healthy meal.

Ill go swimming in a little while, and then tomorrow at 11:30, Ill eat again.

If I do that a couple of times a week. I am in like flint.

The hard part for me is sometimes I just dont want to. I get lazy and want to do things my way (which is the way that got me into trouble in the first place). Reading Brads book always gets me motivated again because it reminds me of all the benefits of fasting.

Seeking the Lord is the same, in that if I remember the benefits, it is so much easier, and becomes more constant in my life. It is the constancy that I want.

Psalm 103:2 Bless the LORD, O my soul, and forget not all his benefits:

Read the rest of Psalm 103 and you will be blessed.

Be back soon,

Marcia

0 How Much Protein Should A Person With Diabetes Eat

The American Diabetes Association (ADA) recently published their new Position Statement on nutrition therapy for people with diabetes:

Nutrition Therapy Recommendations for the Management of Adults With Diabetes, Diabetes Care, Published online ahead of print, 9 October 2013.

This post focuses on protein. (A previous post focused on carbohydrate. That post summarized the grading system they used to rate their evidence.)

The panel did not designate a particular amount of protein to consume, either in grams or percentage of calories, other than noting that people with diabetes eat about 45% of their calories from carbohydrate, 36-40% from fat, and 16-18% from protein:

Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes. Grade B

Macronutrient distribution should be based on individualized assessment of current eating patterns, perences, and metabolic goals. Grade E

Diabetes is the most common cause of kidney failure in the US. Even when a persons diabetes is controlled, they can still develop chronic kidney disease.

One job of the kidney is the removal of excess nitrogen or nitrogenous waste. Protein is the primary source of nitrogen in our diet. (The other macronutrients - fat, carbohydrate, and fiber - do not, by themselves, contain nitrogen. However, natural foods usually contain a combination of macronutrients.)

About protein consumption, the National Institutes of Health, NIDDK, say:

"In people with diabetes, excessive consumption of protein may be harmful. Experts recommend that people with kidney disease of diabetes consume the recommended dietary allowance for protein, but avoid high-protein diets. For people with greatly reduced kidney function, a diet containing reduced amounts of protein may help delay the onset of kidney failure."

The ADA panel said:

For people with diabetes and no evidence of diabetic kidney disease, evidence is inconclusive to recommend an ideal amount of protein intake for optimizing glycemic control or improving one or more [cardiovascular disease] risk measures; theore, goals should be individualized. Grade C

For people with diabetes and diabetic kidney disease (either micro- or macroalbuminuria), reducing the amount of dietary protein below usual intake is not recommended because it does not alter glycemic measures, cardiovascular risk measures, or the course of GFR* decline. Grade A

There appears to be some disagreement in these recommendations. Do people with diabetes and kidney disease reduce their protein intake or not? The best course of action may be to have kidney function checked regularly and individualize protein intake based on those measurements.

The term "protein" conjures meat and other animal-based foods. However, plant-based foods also provide protein. Here is what the ADA panel said about soy:

"For individuals with diabetic kidney disease and microalbuminuria, changing the source of protein to be more soy-based may improve [cardiovascular disease] risk factors but does not appear to alter proteinuria."

They cited the following 2 studies as a basis for that statement, both of which found that intake of soy protein improved serum cholesterol levels and markers of kidney function, including proteinuria, "and may be beneficial for type 2 diabetic patients with nephropathy [kidney disease]":

Isolated Soy Protein Consumption Reduces Urinary Albumin Excretion and Improves the Serum Lipid Profile in Men with Type 2 Diabetes Mellitus and Nephropathy, Journal of Nutrition, August 2004

Soy Protein Intake, Cardiorenal Indices, and C-Reactive Protein in Type 2 Diabetes With Nephropathy, A longitudinal randomized clinical trial, Diabetes Care, April 2008

Lastly, the following recommendation by the ADA stands out:

In individuals with type 2 diabetes, ingested protein appears to increase insulin response without increasing plasma glucose concentrations. Theore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia. Grade B

* GFR is Glomerular Filtration Rate, a measure of kidney function. Higher numbers are better. A normal, healthy kidney has a GFR above 90 (the unit is mL/min/1.73m2) with no protein, such as albumin, found in urine.
________

0 7 Things you should know about wrinkles

7 Things you should know about wrinkles - Wrinkles are one of the biggest fears women. This is because the wrinkles will ruin the appearance of wrinkles mereka.Padahal is the aging process that can not be avoided.

However, with diligent skin care done, then one can avoid wrinkles.

Here are 7 reasons behind the appearance of wrinkles you should know as quoted magforwomen.com.

1. Wrinkles are derivatives

Wrinkles can be caused by pollution, sunlight, and stress interfere. But in addition to these factors, it turns out wrinkles can also be caused by genetic derivatives. You will tend to have the same wrinkles parents or your grandparents.

2. Food can cause wrinkles

Eating too much or too little can cause wrinkles. When you decide to go on a diet then your weight will drop that causes saggy skin. On the other hand, people who eat too little wrinkles will also be affected because they are not getting enough nutrients to meet their skin health.

3. People who often drive more vulnerable wrinkles

They are too often drive will easily stressed and too much exposure to sunlight. If this continues, it will cause wrinkles to appear.

4. Eating habits cause wrinkles

Eating too much junk food will cause the skin to certain nutritional deficiencies that can cause wrinkles. Theore, change your diet to be more healthy by eating vegetables and fruits and drink plenty of water.

5. Natural vitamins good for preventing wrinkles

In addition to moisturizing the skin as well as sunscreen, vitamin A and vitamin C is also good for preventing wrinkles in the skin.

6. Sleeping position can cause wrinkles

Although it may sound a little strange, the position you sleep can also cause wrinkles in the skin. If you tend to like sleeping position tilted to one side, then you will easily wrinkled skin.

7. Stress can cause wrinkles

Stress that you experience can cause skin wrinkled and ends with skin wrinkles. Theore, when you approach stressful, try to resolve it in order not to affect the firmness of the skin.

Wrinkles can interfere with your performance. Theore avoid wrinkles with various ways of preventing both from within and from outside the body.

0 This reason should not drink while eating

This reason should not drink while eating - Sipping water during dining amid seemingly harmless, it was helpful when there is food in my throat choked up. But do you know that the drinking water in the middle of a meal can be bad for digestion and health?

Macrobiotic counselor Shonali Sabherwal explains that drinking while eating can inhibit digestion and increase insulin levels quickly. This of course can be dangerous, especially if you are diabetic or have digestive diseases.

"Some people do not know how wrong this practice and what could have on their digestion. When the body begins to receive food, the digestive system to release digestive juices. If you drink water at the same time, you will be diluting the digestive juices and hinder its performance," said Sabherwal, as reported by the Times of India.

Research shows that drinking a little water during meals may not be a problem, but drinking a glass or two glasses of water can inhibit digestion. It is better to drink water two hours before or after a meal. This will help the digestive process and the body to absorb nutrients from food.

Incoming water during meals will be absorbed by the stomach wall. This continues until the water runs out. After that, re-issuing the digestive system to digest food liquids, but is thinner so it will inhibit digestion.

In addition, it can also lead to increased acid and heartburn. Not only that, drinking water during meals also increase insulin levels in the blood and causes the body to accumulate fat faster.

To prevent drinking water while eating, Shaberwal recommend that you do not eat foods that are too salty. Salty foods will make you faster thirsty and want to drink water. Also, do not eat in haste so that your food is stuck in my throat. In addition, many are chewing over. This will make the job easier when the stomach to digest food.

0 Should Patients in Population Health Management Programs Have Access to Lay Care Coaches

Based on prior posts like this, the Disease Management Care Blog thinks the answer is yes. 

That being said, this hot-off-the-presses research paper shows just much we need to learn about this emerging approach to the care of persons with chronic conditions like diabetes, high blood pressure and chronic heart failure.

Lay Persons Educating Persons With Chronic Conditions in Primary Care Clinics

The paper was just published in the Annals of Internal Medicine. It was a one year randomized study involving the patients at six Allina Health primary care clinics. 

Twelve lay "care guides" had at least 2 years of college education and "strong interpersonal skills." They received two weeks of education that included setting goals, identifying and overcoming care barriers, behavior change techniques, the limits of scope of practice and how to use the electronic records to message physicians.  It was up to the care guides and the patients to decide on how often they needed to meet in face or by telephone. The guides were supervised by two RNs.

Active (i.e. seen in the clinics within 6 months) patients who agreed to be in the study with high blood pressure, diabetes or heart failure were allocated in a 2:1 ratio to either a "care guide" or usual care. Goals were proscribed and were the usual HEDIS-style outcomes, such as achieving blood pressure control, reaching an A1c level, getting an echocardiogram, being on beta-blocker medications or getting a pneumovax immunization.
 
The study was not "blinded," in that they and their providers were aware of the assignment. Recruitment began in July of 2010 and the study was completed in April of 2012. 6168 patients were screened, 2135 patients agreed to participate and 1423 and 702 completed the study from the care guide and usual care study arms.

Results?

One year later, 82.6% of the care guide patients achieved their selected care goals vs. 79.1% of the usual care patients. That 3.5% increase was statistically significant.

Most of that improvement was accounted by a higher rates of tobacco cessation, pneumovax immunization, getting persons with diabetes to get an eye exam as well as urine protein testing, and getting persons with heart failure to go through an echocardiogram.  There were no statistically significant impacts on blood pressure control, diabetes control, cholesterol control or medication prescribing.

The care guides interacted with their patients on average 7 times (2 face-to-face and 5 by telephone).  They messaged physicians an average of 4 times.  There was no difference between the two groups in primary care office visits. Estimated cost was $286 per patient per year.

The Disease Management Care Blogs take:

There is increasing interest in incorporating lay-persons in the outpatient care of persons with chronic conditions.  That makes sense, because much of the educational "payload" may be deliverable using far cheaper and more engaging "peer" members of the community who - literally - speak the patients language.  This is a nicely done randomized clinical trial done in a real world setting that adds to our understanding of this care option. The bottom line is that this study showed that the care guides had a real impact.

When the DMCB looks at the actual numbers, it is also clear that the study had an uphill climb.  Many of the baseline measures of blood pressure, diabetes and heart failure quality relatively high to begin with. The impact of the care guides may have been much greater in a population with a lower baseline (such as in this study) with more "room" to move.

Problems to think about for the next study.....

Not all outcomes are created equally: Unfortunately, this study was something of a disappointment because the improvements were spotty, relatively small and limited to lightweight "testing" outcomes vs. more -hard-to-achieve disease control outcomes.  It may one thing for a peer patient to talk a patient into a urine test or a heart scan, its another getting a patient to take more pills.  That may take a professional educator, a pharmacist or nurse.

What do the patients want: In addition, the goals were based on a one-size-fits-all HEDIS approach.  They were not adaptable, negotiable or subject to shared decision-making.  If that had been in the mix, patient engagement may have been an additional ingredient that could have pushed other outcome measures toward statistical significance.

What do the docs think: The DMCB notes that provider office visits did not go down among the care guide patients compared to the usual care patients. This makes the DMCB wonder if there wasnt enough physician buy-in: if there had been higher trust in the care guides ability to manage these patients, it would have been reflected in less need to see the patients for a separate appointment.

Predictive modeling to the rescue: Finally, there is the problem of treating all chronic illness patients the same. Not all patients with high blood pressure, diabetes or heart failure are as susceptible to behavior change, and not all patients who engage in behavior change achieve better outcomes.  The trick is to use risk stratification to find the patients with the greatest chance at benefit.  This study may have benefited from a more focused approach.

0 Why Should You Use Anti Cellulite Cream

There are many among us who are suffering from fat accumulation in key parts of the body. Cellulite is one such problem which develops around the breasts, upper arms, thighs, buttocks and lower abdomen.
Several surgical and non-surgical treatments are available to treat this problem. However, anti cellulite cream is one of the effective ways to treat this condition. It contains several plant extracts which is primarily focused in removing fats in a constant and steady rate.

One of the main advantages of using anti cellulite cream is its effectiveness in burning fats and restricting the deposit of fats in specific areas. The ingredients are pure and do not contain harmful chemicals. Thus, they are quite harmless for skin and yield positive results too.

Presence of essential nutrients in cream gives a smooth and quick boost to the treatment. These nutrients get absorbed after application to prevent further build up of fats around the affected areas. It also helps boosting the metabolic system and digestive system effectively.

For example, the ingredients contained Vitamin A which helps repair connective tissues under the skin. As the tissues start gaining strength, the cellulite starts showing signs of failure. With the strong support of these tissues, there is less chance for the situation to show up.

Presence of caffeine along with vitamins improves blood circulation underneath the skin. When the blood starts flowing smoothly, the calories get burnt and there is a control exercised over emergence of cellulite.
There is another ingredient which helps improve the metabolic system by cutting down fats. L-Carnitine is effective in improving metabolism which in turn allows reduction in storage of fat. In fact, it is helpful in reducing the amount of fat storage cells in the body.

Despite the presence of effective ingredients in anti cellulite cream, it is important to improve your routine. There is an immediate need to improve your daily diet. A healthy and nutritious diet will improve the effect of cream after application. Adopting regular exercises as a part of life is also helpful.

It might take a week or days for anti cellulite cream to achieve the desired result. The cellulite strength and deposit of fats play a crucial factor in addressing the issue. It is also important to quit smoking and drinking while the treatment is in progress.Using the cream at night after shower can produce maximum results.

Your body needs your attention. If you adopt a healthy lifestyle while using anti cellulite cream, you would certainly see your body shaped up as per expectations. At this moment, you will need a lot of patience and dedication to make yourself look better.

Haresh Rane is the owner of HealthPrima and a busy entrepreneur. He is passionate about helping people with Cellulite issues with their skin and has introduced an Anti Cellulite Cream to the UK market which is highly effective in treating Cellulite caused skin conditions. You can read more about how to treat Cellulite skin condition at:

Article by : Haresh_Rane, Source: http://EzineArticles.com/?expert=Haresh_Rane

0 Food Should be Avoided by Arthritis Patients

Food Should be Avoided by Arthritis Patients | your patients with rheumatoid arthritis? careful with your diet, there are many foods that can make your illness can be severe. In this article we will discuss about the foods that should be avoided for patients with rheumatoid arthritis.

Food Should be Avoided by Arthritis Patients

Avoid Foods for People with Arthritis. There are some foods that should be avoided by patients with rheumatic diseases. These foods are as follows.

• Offal
• Pinhead
• Preserved fish, such as sardines
• Salted fish
• Smoked fish
• Cured meats (ham, sausage)
• Alcohol, preserved foods
• Nuts
• Asparagus
• kale
• Bamboo sprout
• Meat
• Goat
• Emping melinjo

The above list is important for you to note, because sometimes we forget to consume foods that are to be avoided for people with rheumatic.