Category: Blog

The Internet and CBT: Improving Care Beyond the Visit

Mansson, Ruiz, et. al published and original paper in JIMR “Development and Initial Evaluation of an Internet-Based Support System for Face-to-Face Cognitive Behavior Therapy: A Proof of Concept Study” examining Internet-delivered CBT (ICBT). The authors tested a new treatment format using a combination of ICBT and face-to-face. The study involved 15 patients with mild to moderate anxiety or depression or both. There were 8 therapists. First interview was at 9 weeks and 12 month follow-up. 

The authors noted that both the platform and iPad were thought of as beneficial by patients. Therapists found improved intersession communications and ease of sharing. Which the authors noted maintained continuity for missed sessions due to travel distance. It is worth noting there was no missing data nor dropouts from treatment. Perhaps the Internet mitigate dropout rates. And again we are seeing the movement to expansion of healthcare outside the face to face. 

Maybe Showtime Web Therapy with Lisa Kudrow is not so crazy after all.  

Diabetes Management: The Holy Grail of Self-Management Goes On-line

Chen, Chauang, et. all publishing an original paper in JMIR titled “Evaluating Self-Management Behaviors of Diabetic Patients in a Telehealthcare Program: Longitudinal Study Over 18 Months“. The goal of the study was to identify behaviors of patients with diabetes as it relates to online application, measure impact of teleheathcare, and determine changes in glycosylated hemoglobin level. Managing diabetes even for the most committed patient is a daily and ongoing task. And for those less committed it takes real effort. This is a long well designed study that cannot be easily summerized. 

The study examined 7 self-care activities and was run for 18 months used a third generation mobile telecommunications glucometer, online self management system, and phone constant service. This is a rather robust system and one that I am not sure is readily available. 

The online system was based on personal health record criteria where patients health data and personal information are captured and managed by the patients. This is interesting from a learning perspective since we can assume these patients are seeking solutions to the problems they have and are motivated as adult learners. 

Asynchronous text messages were provided and patients and caregivers could use the online diabetes self-managment system or SMS text messaging. The online system included blood glucose, BP, heart rate, weight, insulin injection, daily diet, and daily physical activities. The data entry was made as simple as possible. 

The online diabetes self-management system included the monitoring items and the diabetes-related information, such as blood glucose, blood pressure, heart rate, body weight, insulin injection, daily diet, and daily physical activities. Information that was measured with equipment that did not have transmission networks required manual input. Dietary intake could be recorded through the use of either text or images. Additional information to enable self-management and goal setting for glucose control were generated (eg, the mean, median, standard deviation, and maximum and minimum daily blood glucose values). The variations in blood glucose and other parameters are presented together graphically to enable the user to observe the effect of each behavior. The frequency of self-monitoring of blood glucose (SMBG) was recorded and compared with the set goals to determine whether adjustments were needed. Body mass index (BMI) was calculated, and the suggested calorie intake and ingredient volume for each meal were displayed. An additional care-provider interface was designed so that caregivers could get a quick overview of patient status. Case managers were able to log in and view the data uploaded by the patients, identify abnormal events, and make phone calls. The online diabetes self-management system sent an SMS text message to care providers when the data exceeded the alerting range.

This study provided a teleconsultant service to support patients with diabetes self-management. The case managers for this study, including a nurse and a dietitian, were the care providers who interacted with the patients from a distance. They were responsible for monitoring patient status, answering questions about self-care activities, regularly keeping in touch with the patients through telephone calls or text messages, and encouraging them to perform self-management. The care plans and goal setting were formulated through a discussion with each patient during his or her enrollment. The case managers monitored the data uploaded by the patients. They gave advice and reminded the patients to perform self-care activities. In this study, the case managers were not involved in medication adjustments. They did, however, collate patient data and bring the information to the clinic when the patient returned for an appointment. They communicated with physicians to suggest adjustments when needed.

Conclusions
This study showed that using a sophisticated technological design supported the patients with diabetes in self-management. It appears that telehealthcare is effective in enhancing blood glucose monitoring, and the patients in the program showed improvements in glycemic control. The self-care behaviors affected patient outcomes and the changes in behavior required time to show effects. Telehealthcare has a positive effect on patients with diabetes, and it may encourage more technological interventions for diabetes care.

From my perspective this is a terrific study that’s examining healthcare in two of the more difficult areas, diabetes and the elderly. That is no mean feat on any level. The fact they were successful is telling. But it is worth noting that this was sophisticated study using technology and telephonic support. And the time to see results was extended. The ease to duplicating this on a large scale will be a challenge but it should not stop us from doing it since diabetes and obesity will be significant issues in cost and healthcare for America.

Hey Hipster You Get Your Food Locally. What About Healthcare? Hyperlocal is the Buzz.

Could Healthcare Be Local Tech’s Next Big Opportunity? Street Fight has an interview with Medicast co-founder and CEO Sam Zebarjadi. Medicast is an Atlanta startup where patients and doctors are connected. Physicians come to patients’ homes, offices or hotels to deliver care in <2 hours. The interview is interesting since it discusses the issue of local markets which is the new black. You all know about the green market and local foods. Well we now have hyperlocal. This fits with my chestnut It’s not WebMD but MyMD…local personal and real knowledge from the person you trust the most. 

We are moving away from a large systemic healthcare approach to doctors wanting to get more local. In the next few years we will be in a transformative space, where we are going to see a lot of changes and everyone has the common goal of making healthcare more affordable, within closer reach, and of providing more preventative care.

Zebarjadi makes a cogent case for the patient physician connection that can exist beyond the appointment and waiting room or telemedicine which I did not know is outlawed in nearly 20 states. 

The entire interview is short but filled with ideas and future direction. I see this as part of the new healthcare landscape as we move forward. 

Brother Can You Spare a GB or EMR?

A favorite health economist Jane Sarasohn-Kahn writing on HealthPopuli “Data Altruism: people more likely to share personal health data for the sake of others and to save money” takes a look at finding in the Healthcare Innovation Barometer published this December. 

  • 44% of Americans would be willing to anonymously share genetic information vs. 47% of people in other countries surveyed
  •  
  • 33% of Americans would be willing to share health records, vs. 47% of other health citizens
  • 31% of Americans would be willing to share medical records versus 45% of global peers.

The following surprised Sarasohn-Kahn, “people at the global level are more willing to share information to help others in three categories, genetic info, health and medical records”. Frankly I am surprised as well. Yet it speaks to social media and its ability to erode old thinking. 

And who are affluent data altruists? They are higher income persons who are more likely to share information and have greater exposure to tech and toys. This speaks to the need help bring the lower socioeconomic demographics into an online, connected, computer world. It will move this idea of sharing forward and downward. 

This is short optimistic piece that I hope points to an upside of the technology and human needs. 

Do We Really Understand Strategic Analysis in the Digital Age?

“Most of all, strategy is becoming less about assets and capabilities and more about connections and access.  It’s not so important anymore what you have—or even what you know—but how you can forge networks of purpose which can adapt in real time.” This is from Digital Tonto’s blog post ” 5 New Principles of Strategy for the Digital Age“

How many of our marketing clients and agency partners understand I mean really understand this new world? They treat it as a series of tactics without consideration for strategies. 

Katie Couric: “Evidence Based Medicine, Who Cares. My Evidence is Jenny McCarthy.”

I am sure many of you have seen the stories, posts, article, etc. about Katie Couric’s abysmal understanding of HPV vaccination and her complete failure to address the evidence. I have linked to five articles on this topic. Please link to these or Tweet links to them so we can raise awareness for this reckless and selfish act on her part all in the name of improving her Q Score.

Her FB page has no place to leave a comment but it does have a place to ask Katie a question. I asked her if she knows what evidence based medicine is? You could do that too.

Respectful Insolence has the following post “Katie Couric on the HPV vaccine: Antivaccine or irresponsible journalist? You be the judge!” This is a long well referenced piece and the answer is clear even before you read word one. She is pandering to a fringe audience to raise her Q Score.

David Kroll contributor at Forbes “ Katie Couric and Cervical Cancer Prevention with the HPV vaccines, Gardasil and Cervarix” This is an excellent overview of the topic on HPV and cancer.

A two-dose regimen also has significant implications for preventing HPV-triggered cancers worldwide, especially in regions with poor access to sustained healthcare. Worldwide, 500,000 women are diagnosed each year with cervical cancer alone, and 250,000 will die of their disease.

Matthew Herper on the Forbes Staff “Four Ways Katie Couric Stacked the Deck Against Gardasil”. Great deconstruction of what Couric did and why it was so wrong.

But deaths – including deaths by seizures or unexplained causes – do occur for all sorts of reasons, without explanation, and just because a death happened 18 days after a vaccine was given, as in the example on Katie’s show, does not mean the vaccine caused it. So far, investigations trying to link Gardasil and Cervarix to serious side effects have come up empty.

Emily Willngham Contributor at Forbes “Katie Couric Promotes Anticancer Vaccine Alarmism“. This is a good analysis of Couric who has worked tirelessly to help prevent death from colon cancer. Willingham closes with the following:

Lives may well have been saved (colonoscopies) because of her name recognition and promotion. What will the balance become, I have to wonder, now that she has used her profile instead in ways that may very well influence parents to opt out of a life-saving anti-cancer vaccine for their children?

Alexandra Sifferlin writing on Time.com “Is Katie Couric The Next Jenny McCarthy?” The subhead on this sums it up well “A former Playboy Bunny spreading misinformation is bad enough”. We have just found a respected journalist or on air personality French kissing Jenny McCarthy…. ewwwww. gross on so many level. 

Stents, Surgery, and Medical Therapy: Will Knowledge Trickle Down?

Larry Husten a Contributor at Forbes has an excellent review “Stents Lose In Comparisons With Surgery And Medical Therapy“. He takes a look at two new meta-analyses in JAMA Internal Medicine looking at alternatives to stents percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). 

The first of the two papers by Sipahi and colleagues did a meta-analysis of six RCT comparing PCI and CABG in patients with multivessel disease. 

With an average 4.1 years of followup, CABG was associated with significant reductions in total mortality, myocardial infarction, repeat revascularization and the rate of major adverse cardiovascular and cerebrovascular events (MACCE). CABG was also associated with a trend for excess strokes.

Here are the risk ratios for CABG:

Mortality: 0.73, CI 0.62-0.86, p<0.001
MI: 0.58, CI 0.48-0.72, p<0.001
Stroke: 1.36, CI 0.99-1.86, p=0.06
Repeat revascularization: 0.29, CI 0.21-0.41, p<0.001
MACCE: 0.61, CI 0.54-0.68, p<0.001

As noted the authors concluded that “CABG should be the preferred revascularization method for most patients with multi vessel coronary artery disease.”

A second paper by Kathleen Stergiopoulos and colleagues looked at studies comparing medical therapy with PCI in >4,000 patients with stable coronary artery disease and documented ischemia and a five year median follow-up there were no significant difference in death, nonfatal MI, unplanned revascularization, or angina. 

“Finally,” the authors write, “these findings call into question the common practice of ischemia-guided revascularization (either using noninvasive testing techniques or FFR) where the presence of myocardial ischemia routinely determines patient selection for coronary angiography and revascularization.”

So we have a changing landscape in the world of stents, CABG, and medical therapy based on an excellent set of studies looking at the current available data. As Husten closes his article with PCI is “a cornerstone of daily practice in evaluation of patients with CAD and endorsed by the American College of Cardiology Foundation AHA and European Society of Cardiology guidelines”. 

Data is pointing a different direction regarding the management of ischemia guided revascularization. Do patients have to wait years until prospective studies are completed to show that this meta analysis was accurate? Will patients with CAD know enough or have enough time to find this data and ask their cardiologist about stents vs. CABG or medical therapy? Will cardiologists step up and present this data to their patients? Is this a case of trickle down knowledge where the gate keepers are the one’s performing the work?

Another Look at Healthcare Spending

Austin Frakt writing at The Incidental Economist “Chart: Health care spending growth factors“. Offers another chart from the JAMA study “The Anatomy of Health Care in the United States“. 

Frakt notes rightly so the majority of the slowdown (interesting word hints that it will pick up) is due to lower use and intensity growth. Which speaks to the economy in part and in part to what I believe are Americans become hypersensitive to healthcare, aging population seeking to improve outcomes, the screaming about the ACA. We can not go a day without a healthcare story slapping us in the face. Which is good. 

Frakt final points to the obvious “price growth remains robust by comparison”. The cynic in me sees this as the price setters are raising prices in response to the slowdown. That’s what occurs in a free market. Or is that as spending slows prices drop since more and more consumers and insurance companies are looking for low cost high value healthcare. 

Dear Hospital Administrator: You Talking to Me? I Am Not Listening.

Dan Dunlop writing on The Healthcare Marketer makes an important observation “Hospitals Failing to Connect with their Audiences” which is based on his review of a post by Dr. Bryan Vartabedian’s 33 Charts.You can talk about yourself which in reality no one gives a flying rat’s butt about or you can speak to issues that are important to your audience. I think the word is patient centric. Here is the link to 33charts. 

So what is that sound I hear? It’s reality speaking. Hospitals need to behave like responsible marketers who are selling a product in a competitive market. Everything is pointing to where we are going. I am not recommending behaving like Crazy Eddie but more like Apple or Google or any number of smart marketers. Sell solutions to problems. 

And another point that’s clear is that this issue speaks to adult learning. Adults will only learn when they are seeking a solution to a problem. This is particularly obvious in healthcare where we know adults with a chronic illness will invest time and effort on line to find information and seek support. In my view and the view of the team I am assembling our goal is to help providers differentiate their services via problem solving patient centric communication as opposed to me me me.

Speaking of Media Morons: Fox, ACA, and Reality

Aaron Carroll at The Incidental Economist responded to a Fox news story about a family that could not find a healthcare policy for their 1 1/2 year old. And of course they are blaming Obamacare since it was on Fox, no surprise there.

I have turned a deaf ear to these stories and that source in particular. But Carroll took aim and deconstructed it to the point of discrediting the spot so well. Hop to the site and read his five points. The Fox news report seriously shows to what degree the loyal opposition will go to make sure people will not sign up, hate the President, and avoid insurance.

Carroll makes a great point that does a Jon Stewart showing the hypocracy.

I’m sorry, but I find it somewhat hypocritical that only now, after decades of about 50 million people being uninsured every year, that suddenly the media is outraged by stories of people (healthy, mind you) having difficulties finding insurance. Really? Suddenly this is an issue? Didn’t seem like it before… AND THIS STORY IS ALREADY RESOLVED. AND LIKELY NOT ENTIRELY TRUE.