Notes & Links: August 18, 2013

Drug or Snake Oil?

Dan Munro of iPatient contributing to Forbes takes a look at the new black in healthcare ‘patient engagement’. His article gives us a chance to pause and consider what it should mean and how it should be measured. I am an advocate of outcomes and how to measure if what we are doing is working and improving patient care. 

Dan quotes Leonard Kish Principle and Founder of VivaPhi

Actually, it’s surprising that it has taken us this long to focus on patient engagement because the results we have thus far are nothing short of astounding. If patient engagement were a drug, it would be the blockbuster drug of the century and malpractice not to use it.

Dan provides the reader with some metrics (outcomes) from patient engagement

Kaiser Permanente HealthConnect™ / Collaborative Cardiac Care Case Study (here):
1) Prevented 135 deaths and 260 costly emergencies

2) Patients meeting cholesterol goals went from 26% to 73%

3) Patients screened for cholesterol went from 55% to 97%

4) “Clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent”

Dan’s advice, patient engagement is in place and is working while we all need is to be careful we are not being fed BS by believing what is passing for engagement is actually a way for systems to lower utilization cost at our expense. It is a short but excellent read. 

From my view patient engagement is key and should be build around an understanding of the problems patients and caregivers want to solve. Hereherehere and here are my thoughts on how to achieve patient engagement and what it does to drive improved patient care. 

Follow-Up: Google Scholar vs. PubMed

I post a summary of an article from the JMIR this week examining the relative strength of Google Scholar vs. PubMed for medical searches. What struck me on the article (here) was the authors contention that GS provided more free citations. Well today I had the chance to try GS out and was gobsmacked that many many of the citations that came back were behind a pay wall. So I wrote to the lead author. He quickly got back to me very quickly with the following:

In our study, we found that on average only ~25% of the relevant articles (understanding this was a strict definition of relevance – usually RCTs) per search were available for free from Google Scholar and ~16% from PubMed. Unfortunately free access is more an artifact of the journal that published the article than the search engine. However, Google Scholar almost always provides a link to the publisher’s site, while PubMed is hit or miss. Unlike PubMed, Google Scholar also links to non-Journal websites where a full-text article may be posted (may not always be legal).  

One trick I use is to maximize the chance of finding the full text of an article is to always click on the “All X Versions” (X representing a number) link at the bottom of the citation beside “Related Articles” in Google Scholar and trying all the links. Additionally, sometimes searching for an  article’s title surrounded by quotes in Google proper and limiting to pdf documents can help.

I hope this helps any of you using GS. 

Notes & Links: August 16, 2013

The Adopt One! Challenge

Changing how physicians are being motivated to improve their communications skills look at Adopt One! It’s a simple challenge to physicians to adopt techniques and tools to engage and satisfy their patients. The program offers participating physicians a baseline assessment of their communications skills with patients and benchmarks it against best practices and their peers. It will then offer online access to assessment, recommendations, and tools to develop and improves patient-centic communications skills.

Here are the benefits:

  • More productive visits
  • More engaged and activated patients
  • Higher level of patient trust, information sharing, and adherence
  • Fewer patient request ion for unnecessary tests
  • Fewer medical errors and malpractice claims
  • Exceptional patient experiences

I buy each benefit but do busy stressed and hard pressed HCP have the time to do this? If these benefits are accomplished even in a few practices it will support and expand the changes we are seeing with online patient learning and the desire for more and better engagement. Take look and let me know what you think?

Metaphor in Video: Simple Ways to Improve Patient Education and Boost ROI

 Now that is a promise. I mean a whopper of a promise. 

Andrew Angus writing on HealthWorks offers pharmaceutical marketers a way to eliminate the use of jargon to help patients become better involved in their healthcare. Already the hair on my neck is standing up thinking about pharma improving communications to patients. 

The way to do this is to replace jargon with metaphor. Let’s take a look at the example:

“Insulin is a hormone that treats diabetes by controlling the amount of sugar (glucose) in the blood…It’s important to space your insulin doses throughout the day to keep your blood sugar levels within the normal range despite eating habits and activity patterns.”
Prepare to watch as your patient’s eyes glaze over as first confusion, then boredom, set in. Or you could put it in terms he already understands:

“Okay, Jimmy. Think of your pancreas as a refrigerator. Refrigerators keep food cool so it doesn’t spoil, right? A chemical called Freon is what helps fridges stay cool. Think of that Freon as insulin. If a fridge runs out of Freon, the food will go bad. Your body needs a consistent stream of Humalog so its food doesn’t go bad.”

What you need to realize is that your story has to solve someone else’s problem, so you need a way to express it concisely. The trick is to know what your consumers will understand. Everyone has used a fridge, but there are as many metaphors as there are drugs, so don’t be afraid to get creative.

I think I get the Freon metaphor but the money shot is that last paragraph. I agree in learning if you speak about someone else that the learner can relate to they will improve their uptake of knowledge. “Know what you consumers will understand’ is the issue to learn what they know what they don’t is a Herculean task for a busy HCP. 

Now how do you put this in practice. Well of course with a 60 second video. Find a metaphor that covers all your patients and do a video for everything from hemorrhoids to hematoma is no mean feat. Let me know if I’m being mean. 

Staging Dementia From Symptoms Profiles on a Care Partner Website

Rockwood, Richard, et. al from Dalhousie University published a paper in JMIR looking at how symptoms of dementia tracked on by a partner/caregiver online relate to dementia stage. They used the Artificial Neural Network to find relationships between the dementia stages and individualized profiles of people.

The results were:

The ANN model was trained in 66% of the 320 Memory Clinic patients, with the remaining 34% used to test its accuracy in classification. Training and testing staging distributions were not significantly different. In the 1930 Web-based profiles, 309 people (16%) were classified as having mild cognitive impairment, 36% as mild dementia, 29% as moderate, and 19% as severe. In both the clinical and Web-based symptom profiles, most symptoms became more common as the stage of dementia worsened (eg, mean 5.6 SD 5.9 symptoms in the MCI group versus 11.9 SD 11.3 in the severe). Overall, Web profiles recorded more symptoms (mean 7.1 SD 8.0) than did clinic ones (mean 5.5 SD 1.8). Even so, symptom profiles were relatively similar between the Web-based and clinical datasets.

This is where the authors end and it speaks to the need and benefit of using the Internet to drive healthcare knowledge and improve patient care. 

Finally, especially as disease-modifying drugs are developed that modify the course of dementia (and thereby its stages), it could lead to the creation of a more robust clinical staging methodology that considers symptom profile composition as important to understanding dementia severity and potential treatment effects.

Efficacy of a Text Message-Based Smoking Cessation Intervention for Young People: A Cluster Randomized Controlled Trial

Haug, Schaub, et. al from the Swiss Research Institute Public Health and Addiction publishing in JMIR show how texting can do more then take down a politician it can impact smoking in adolescents. 

A 2-arm cluster randomized controlled trial, using school class as the randomization unit, was conducted to test the efficacy of the SMS text messaging intervention compared to an assessment-only control group. Students who smoked were proactively recruited via online screening in vocational school classes. Text messages, tailored to demographic and smoking-related variables, were sent to the participants of the intervention group at least 3 times per week over a period of 3 months. A follow-up assessment was performed 6 months after study inclusion. The primary outcome measure was 7-day smoking abstinence. Secondary outcomes were 4-week smoking abstinence, cigarette consumption, stage of change, and attempts to quit smoking. We used regression models controlling for baseline differences between the study groups to test the efficacy of the intervention. Both complete-case analyses (CCA) and intention-to-treat analyses (ITT) were performed. Subgroup analyses were conducted for occasional and daily smokers.

This study demonstrated the potential of an SMS text message–based intervention to reach a high proportion of young smokers with low education levels. The intervention did not have statistically significant short-term effects on smoking cessation; however, it resulted in statistically significant lower cigarette consumption. Additionally, it resulted in statistically significant more attempts to quit smoking in occasional smokers.

Text messaging reaches adolescents very well it speaks directly to where they participate but more importantly it speaks to lower socioeconomic groups more effectively. And remember the more one trys to quit the greater the chance of success.

Teaching Medicine Requires Teaching Thinking

I couldn’t resist this one just for the doh factor. But with due respect this is a well considered piece that looks at how do we assess diagnosis accuracy but db looks at how to teach a thought process. What can be done to help medical students learn how to critically appraise learn how to approach a medical problem 

This works for me:

Great medicine does not come from following scripts.  Great medicine occurs when the clinician knows enough to either proceed or know that they need another physician to help.  Algorithms are not the answer.  Excellent thought processes are the answer.

Notes & Links: August15, 2013

Retrieving Clinical Evidence: A Comparison of PubMed and Google Scholar for Quick Clinical Searches

Shariff, Math, et. al. publishing in JMIR compares the performance of PubMed vs. Google Scholar. It was a well designed study and the data was interesting to the point that Google Scholar may be my go to search, well quick search. To bad it has the word Google in it with all the associated tracking and saving of your personal data. It’s good know another search tool works well in healthcare. 

Compared with PubMed, the average search in Google Scholar retrieved twice as many relevant articles (PubMed: 11%; Google Scholar: 22%;P<.001). Precision was similar in both databases (PubMed: 6%; Google Scholar: 8%; P=.07). Google Scholar provided significantly greater access to free full-text publications (PubMed: 5%; Google Scholar: 14%; P<.001).

Our findings are consistent with those of previous studies [12,14,15,20,21]. In preliminary testing within targeted areas of respiratory care, sarcoma, pharmacotherapy, and family medicine, Google Scholar provided better comprehensiveness (recall) but worse efficiency (precision) compared with PubMed. Similar results were seen in our study when we considered all records that were retrieved and not just the first 40. However, previous studies tested only a small number of searches (range: 1-22), compared with the 100 searches in the current study. In addition, the search queries used in previous studies were created and tested by researchers in idealized settings, which may not generalize as well to searches generated by physicians in busy clinical settings

Practicing Medicine and Practicing Social Media

Mark Senak writing on Eye on FDA revisits and interview a physician Ph.D. he met in 2010 Bertaln Mesko, MD, PhD who is a medical futurist. The links from the post above to the various sites of Dr. Bertain are nothing short of a rich rich vein of knowledge that we can all use as references or just link to now and then for newbies to learn from. Take a look at Eye on FDA page and just to all the links provided. 

Here is an section from that interview:

While social media use among those in medical practice is growing, there are a lot of concerns on the part of practitioners that range from potential lapses of privacy to concerns about the return on investment.  How would you characterize the “risk-benefit” ratio of social media use by physicians?

I think there aren’t many essential differences between real-life and online communication.  I teach my students they should behave online just like they do in the offline world.  Therefore, social media can only make processes faster and more interactive, although if your offline communication as a doctor is bad, it’s going to be the same on any social media platforms as well.

There are risks, obviously, but if you know the limitations and potential problems related to the active use of social media, you know what you can do and what you should never do online.  That was the basic concept behind writing this handbook so then medical professionals worldwide would get a clear picture about the online channels and ways of communication.

Teaching tricks and rules about the Internet should get a huge emphasis in medical school, but it doesn’t get that kind of attention.  This is why I thought there is a niche for such a handbook which includes step-by-step instructions and tutorials focusing on all the major social media channels.

Lack of Information Synthesis: One of the Most Important Causes of Medical Errors

Val Jones, MD writing on Health Policy and picked up by Better Health makes a great case on ways to reduce errors slow down and listen. Here are his three recommendations: 

The solution to the healthcare cost crisis is not to increase the speed of the assembly line belt when our physicians and nurses are already dropping items on the floor. First, stop asking them to step away from the belt to do other things. Second, put a cap on belt speed. Third, insure that you have sufficient staff to handle the volume of “product” on the belt, and support them with post-belt packaging and procedures that will prevent back up. 

Now can we use this idea and help patients improve their ability to uptake, understand, and use data/information and turn it into healthcare knowledge? Perhaps if we slow the belt down and allow the HCP to engage and pay for engagement we can drive improved outcomes. 

Is Your iPad The Technological Equivalent of Typhoid Mary?

Standardized, App-Based Disinfection of iPads in a Clinical and Nonclinical Setting: Comparative Analysis

It didn’t long for someone to look at iPads and infections. Urs-Vito Albrecht, et. al. publishing in JMIR and asked the question how the hell do you clean an iPad, etc. in a clinical setting. 

We discovered a 2.7-fold (Mann-Whitney U test, z=-3.402, P=.000670) lower bacterial load on the devices used in the clinical environment that underwent a standardized daily disinfection routine with isopropanol wipes following the instructions provided by “deBac-app”. Under controlled conditions, an average reduction of the mainly Gram-positive normal skin microbiological load of 99.4% (Mann-Whitney U test, z=-3.1798, P=.001474) for the nonclinical group and 98.1% (Mann-Whitney U test, z=3.1808, P=.001469) for the clinical group was achieved using one complete disinfecting cycle.

Well the data is in clean your iPad with and isopropanol pad, pad to pad. This is a very detailed and well designed study so it should not be laughed at, well maybe a little bit

Notes & Links: August 14, 2013

We Don’t Have the Best Healthcare System in the World But We Could

The Incidental Economist makes an interesting argument until he closes with this:

“We don’t have the best health care system in the world. But we could. I long for the day when we can start talking about getting that instead of whether we should give Medicaid to people making less than the poverty line.”

I’m not sure if he saying hell with the poor and their health or let’s stop bitching about it do it, and move on to the issue at hand making what we have work better for all. Perhaps I should ask?

A Glut of Antidepressants

Roni Caryn Rabin writing in NY Times Well blog offers some insights to depression and why we have a ton o antidepressants.  (At this time is down)

Over the past two decades, the use of antidepressants has skyrocketed. One in 10 Americans now takes an antidepressant medication; among women in their 40s and 50s, the figure is one in four.

 So if you think the reason is overdiagnosed well you are right according to a study in the journal of Psychotherapy and Psychosomatics. 

“…nearly two-thirds of a sample of more than 5,000 patients who had been given a diagnosis of depression within the previous 12 months did not meet the criteria for major depressive episode as described by the psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorders (or D.S.M.).

So we are prescribing more antidepressants more quickly for longer periods of time. The article is rich in its analysis and thought but the best part of it are the comments which just speaks to medicine, science, research, and the Internet. Oh boy.

How Much of a Subsidy Will You Get in Obamacare? Here’s an Estimate.

Julie Appleby in the Washington Post (aka Amazon’s in house newsletter) presents work from the Kaiser Family Foundation they looked at the subsidies and stated they will average $5,548. 

Because that figure is an average, some families will get more and some will receive less when they enroll through new online marketplaces, which open Oct. 1.

Here is the link to  Kaiser Family Foundation

With a Name Like That and Mission It Can’t Miss

Frank H. Netter, MD School Of Medicine: Developing A New Breed Of Medical School Faculty To Change The Way We Educate Doctors 

Coming up through the ranks in advertising during the late 70s you quickly learned who Frank Netter was. His medical illustrations were revered and respected by agency art directors, creative directors, and anyone who could rub two brain cells together. So when I saw this article about a new medical school called Frank H. Netter, MD School of Medicine I stopped and had to read. 

Dr. Koeppen clearly acknowledges that the greatest need for doctors in terms of clinical service is centered around primary care. This will be a major emphasis of his school’s goals, accomplishing this in partnership with other health-related programs at Quinnipiac—Nursing, Physician Assistant, Physical Therapy, Occupational Therapy.

Dr. Wikel believes that “providing problem solving exercises in which students gain confidence an experience in their ability to solve problems ultimately helps them to be more comfortable with their ability to acquire knowledge on their own, and subsequently to become self- directed learners.”

There is great hope for this school of medicine just from the fact over 965 applications for 22 full-time faculty members and many of thos applications gave up tenure and were from the likes of Harvard, University of California, Brown, etc. 

I hope they succeed but we’ll need to wait a bunch of years to see. I wish them luck. The school logo should be a Netter illustration. 

Notes & Links: August 13, 2013

Boomer Suicide Rate Rising

Anthony Cirillo writing contributing to Healthworks Collective looks at data that was published last month regarding suicide rates for men and women of a certain age. 

The CDC analyzed National Vital Statistics System (NVSS) mortality data from 1999–2010. The results of this analysis indicated that the annual, age-adjusted suicide rate among persons aged 35–64 years increased 28.4%, from 13.7 per 100,000 population in 1999 to 17.6 in 2010. 

Among men, the greatest increases were among those aged 50–54 years and 55–59 years, (49.4%, from 20.6 to 30.7, and 47.8%, from 20.3 to 30.0, respectively). Among women, suicide rates increased with age, and the largest percentage increase in suicide rate was observed among women aged 60–64 years (59.7%, from 4.4 to 7.0). 

One of the reasons Cirillo gives for this increase in suicide is the stress of caregiving. He addresses the need for caregivers to see what they do as an opportunity. Which if you read my essay at Mayo Social Media Network agrees with his view. 

7 Ways to Get More Patients Online

Jonathan Govette contributed to Healthworks Collective and this is a great article with a lot of practical advice and tips. There are some infographics on FB G+ that ring so true not just for patients but for anyone looking to post. (Note: he says 7 I am struggling to find #7 there are only 6 listed)

According to TeleVox, 51% of people say they’d feel more valued as a patient through digital health communications. This means that it is time to strengthen your relationships with potential patients online to ensure that awareness of your practice is reaching the most amount of relevant people as possible.

All I can say is word up. And for people to feel more valued we need to know the problems they want to solve and offer them solutions that they can integrate into their experiences. 

Here are the 6 ways:

  1. Pay Per Click Advertising
  2. SEO
  3. A Healthcare Database and Booking Service
  4. Content Marketing (The most important especially if you address problems that can be solved)
  5. Social Media (Great tips and tricks here)
  6. Email Marketing 

We all know these ‘ways’ but to find them in one place is a good resource. Take a look well worth the time. Check out the optimum timing for posts on social media.

Maker Movement Meets Healthcare

If you are slow like me you scratched your head when you read Maker Movement’ and healthcare in one line. 

Basically, for one of these it’s health literacy education & outreach via hands on geek project, and for the other two, there were real world problems that have expensive, time-consuming or often inaccessible solutions, for which people came up with their own solutions and alternative

PF Anderson on her blog Emerging Technologies Librarian has share some great links. How can you not smile at a 12 year old named Sylvia on Make Magazine who shows us how to build a pendant that shows your heart beat. She is so damn perky for this early in the morning. 

Take a look great stuff.

Notes & Links: August 12, 2013

How Obamacare Affects You has a simple easy to read info graphic on Obamacare. An interesting fact about the ACA that really speaks to the complexity of healthcare in America.

It is twice as long as the Defense Authorization Act of 2010. The entirety of U.S. code is 45 million words making H.R. 39620 0.5% of all U.S. Code!

It is easier to go to war it seems. 

Americans Don’t Understand Insurance, Let Alone Obamacare Research Shows

Bruce Japsen contributing to Forbes presents some surprising data on Americans knowledge of Health Insurance.

“Researchers looked at two surveys of Americans between the ages of 25 and 64 who have private coverage.  Among their findings, researchers uncovered that just 14 percent of respondents had an understanding of the most basic insurance concepts of “deductible, copay, co-insurance and out-of-pocket maximum.”

All the more reason we need to spread the word on the excellent info graphic on Obamacare linked above. Just as more and more Americans are using the web to learn about their health and become active participants the need to understand and make decisions about health insurance will make a difference. 

Americans’ Health Insurance Illiteracy Epidemic-Simpler is Better

Jane Sarasohn-Kahn writing on her blog HealthPopuli is addressing the issue of our understanding of health insurance with an excellent review of new research by George Loewenstein from Carnegie Mellon Published in Journal of Health Economics.  

Here is a sample of a chart from that study and it is speaks volumes about what we don’t know and need to know. 

Notes & Linkes: August 8, 2013

“Validity of Web-Based Self-Reported Weight and Height: Results of the Nutrinet-Sante Study”

Lassale, Peneau, et. al. have published an article in JMIR examining the trending in healthcare of e-pidemiology and the validity and reliability of self-reported data. 

Compared with the clinical data validity was high. Intraclass correlation coefficient ranged from 0.94 for height and 0.99 for weight. They reported a slight underreporting of weight and over reporting of height which lead to underreporting of BMI (p<.05) for both men and women. I guess we all lie about our weight and height a little

Conclusions: Web-based self-reported weight and height data from the NutriNet-Santé study can be considered as valid enough to be used when studying associations of nutritional factors with anthropometrics and health outcomes. Although self-reported anthropometrics are inherently prone to biases, the magnitude of such biases can be considered comparable to face-to-face interview. Web-based self-reported data appear to be an accurate and useful tool to assess anthropometric data.

This study supports web-based self reporting and for my two cents it is another tool to aid outcomes that resides outside the office visit. But for my money it strikes me as an important step in demonstrating to providers a way to lower utilizations costs while improving physician patient engagement. 

Glad to see more studies like this every month. We need to know what is happening from a data .

“What’s CBS worth? How About Just the Programs”

If you live in NYC or LA TWC shut down CBS and Showtime (Dexter!!!!!) over money.

Doc Searls examines this issue and what may happen going forward. I know I am looking to find a way to cut the cable cord myself. Most of the tech heads I follow have done it to some degree but tend to return. There is a real opportunity for change in pricing and access to TV shows and networks. I wonder about Apple and their iTV. Networks will not roll over like the cheap suits of music due to the impeccable logic of one Steve Jobs. But with Netflicks and others producing high quality content we may just be at the cross roads. I sure hope so.

“Top 5 Reasons Hospitals Are Losing Money”

Only 5? Each one of us can identify three more. 

Danyell Jones posting in HealthWorks Collective presents the follow sobering data

With such a high cost of care, many assume that hospitals in America are turning a healthy profit; however this just isn’t the case.  In fact recent estimates indicate that nearly 67% of US hospitals are losing money, particularly when it comes to the treatment of Medicaid/Medicare patients. 

The five are:

  • Denials and Coding Issues
  • Service Level Discrepancies
  • Front Desk Processes
  • Look at your Patient Mix
  • Evaluate Your Contracts and Negotiate to Win

 Color me surprised a post on an industry supported site first blames Medicaid/Medicare patients. Gee that was easy. Listen to the Terry Gross on Fresh Air interviewed Elisabeth Rosenthal, MD from the New York Times about her series on cost of healthcare in the US. 

It costs $13,660 for an American to have a hip replacement in Belgium; in the U.S., it’s closer to $100,000.

Rosenthal examination of the issue from an investigative journalist does not lay the blame (i.e. reasons) on Medicare/Medicaid. Our system drives the need to price healthcare at an al la carte basis with layer upon layer of costs for each procedure. 

We may never change our system but all of us will be looking at costs going forward and that may help to put pressure on lowering prices while delivering care, not excess. To that point a friend just delivered a baby at a major NYC hospital and said for the two days she was there every time there was a service delivered (i.e. cleaning the room, coaching breast feeding, etc.) there was a survey immediately following. Gotta love a corporation humping outcomes. In fact my friend said for the breast feeding coaching session there were no less then four people in the room. It takes a village of al a carte services.

PS: Why does a class money filled operation like NPR hang its graphic hat on crappy stock art of the lowest order. Gee show me pills spilled on $20 bills. Nothing says cost in medicine like that. NOT! 

“Why Reports of the Death of Physician Participation in Medicare May be Greatly Exaggerated”

Dan Diamond writing in The Health Care Blog quotes the usual suspects on the demise of care for Medicare patients 

 “Half of primary care physicians in survey would leave medicine … if they had an alternative.” — CNN, November 2008

“Doctors are increasingly leaving the Medicare program given its unpredictable funding.” – ForbesJanuary 2013

And least we forget our favorite healthcare resource for evidence based knowledge 

The Wall Street Journal last month portrayed physician unhappiness with Medicare as a burning issue, with a cover story that detailed why many more doctors are opting out of the program.

And yes, the number of doctors saying no to Medicare has proportionately risen quite a bit — from 3,700 doctors in 2009 to 9,539 in 2012. (And in some cases, Obamacare has been a convenient scapegoat.)

Oh no Mr. Bill the WSJ didn’t report on some data? I am shocked. 

What the Journal didn’t report is that, per CMS, the number of physicians who agreed to accept Medicare patients continues to grow year-over-year, from 705,568 in 2012 to 735,041 in 2013.

And other providers aren’t turning down Medicare, either. The number of nurse practitioners participating in the program has only gone up, Jan Towers of the American Academy of Nurse Practitioners says. 

Yes there is frustration and HCP are pissed at low revenue and more work. My hope is as the system lowers cost overall dollars can be shifted to the HCP to care for the elderly who suck down a lot of dollars. Outcomes measures will do much to drive that balance.