Beauty Health for Life

Playing whacamole

"Immunizations cause autism." 

"Health care blogging will never lead any serious beer money."

"Disease management coaching focuses exclusively on just one disease."

These are three falsehoods that bubble up in the unlikeliest of places, including cable news outlets, replying to the DMCB spouses asking "and what did you do today?" and webinars, webcasts and other educational meetings about population health and disease management.

While the Disease Management Care Blog finds all three vexing, the most irksome is the canard that the commercial health coaching service providers purposely limit their programs to just one chronic condition, like diabetes, weight loss or readmission prevention.

While that may have been the case in the earliest versions of disease management, that narrow approach was dropped years ago. Thats because patients typically seek advice for a wide range of overlapping concerns and the good nurses hired by the vendors will respond to them.  The vendors also understand that their shared risk and performance guarantees depend on claims expense that is driven by the synergies of multiple co-morbidities. 

While a purchaser, insurer or accountable provider organization may start out with a focus on a population defined by a single condition - such as diabetes mellitus - that doesnt mean their protocols and care plans wont span the continuum of care and include hypertension, tobacco abuse, depression, housing, chatting about the grandkid and responding to concerns whether this will be finally be NBA superstar LeBron James year.

And the published literature supports the DMCBs contention that modern population health management is multifaceted.  Examples include this seven-condition program for dually eligible Medicaid beneficiaries in Georgia, this Midwest employer-sponsored program that enrolled persons with multiple care needs and this physician-focused program that used pay-for-performance to improve measures across multiple conditions.  Check out some vendor web sites and youll see erences to "whole person health," the "interrelated aspects of social, emotional, and physical health" and "a holistic view of member health across internal and external care management initiatives."

That being said, the DMCB knows that perception and reality can be two different things. Given the whac-a-mole persistence of the "single disease" myth, the DMCB says the population health management community may benefit clarifying the broadness as well as the depth of their offerings as they continue to build their brand.

Image from Wikipedia

You know, how sometimes, when you discover something no one else knows about, you get all excited, but a little hesitant to share your newfound knowledge, because it wouldn’t be JUST YOURS anymore?

I used to feel that way about music. My friend H. introduced me to Jeff Buckley in 1995, my freshman year of college. His Grace album became a touchstone of our existence, with the final track, a cover of Leonard Cohen’s Hallelujah, as its crowning achievement. And even though H. shared Buckley with me, I was hesitant to pass him on to anyone else. I felt like it would take the specialness away.

Well, here’s the thing. If something’s really good, odds are people will find out about it anyway. Buckley drowned in 1997. In 2002, The West Wing used Hallelujah for a death scene. Two years later, it popped up on the season finale of The O.C. Now, Simon Cowell counts it among his favorite tunes, and it appears on American Idol every other second.

I’m okay with this. Because, I figure, the mass acceptance of Hallelujah will nudge Buckley toward … man, I hate the word “immortality” in this context, but I can’t think of another one … so, immortality. It’s good for him. It’s good for his family. It’s good for music.

Subsequently, I resolve to share things that are good. It makes no sense keeping them to myself. And Moosewood’s Simple Suppers may be my new favorite thing on Earth, never mind just the Cookbook category.

I’m trying to experiment with a wider range of recipe tomes, so I’m not so reliant on my favorite sources. A quick trip to the library yielded Simple Suppers, which has now produced three smashing dishes. I go into the other two in detail at Serious Eats. White Bean and Mushroom Ragout is here. Potato Salad with White and Green Beans can be found at the top of this post. They are both drool-worthy.

The latest dish is Lemony Couscous with Chickpeas. It’s a delicious simple grain salad you can customize to your heart’s content, because it will still retain its essential, uh, lemony … couscousy … chickpeaness. Yeah. One batch gave us food for DAYS, and we served it both hot and cold.

So readers, what are your favorite little-knowns? Let us know, and maybe we can make them big-knowns. It could be a good thing.

~~~

If this recipe seems enticing, these will tempt your pants off:

• Breakfast Couscous Custard with Peaches
• Gazpacho Pasta Salad
• Israeli Couscous Salad

~~~

Lemony Couscous with Chickpeas
Makes at least 8 side servings.
Adapted from Moosewood’s Simple Suppers.


1 1/2 cups plain or spinach couscous
1/2 teaspoon salt
2 1/2 cups boiling water
2 lemons
3 tablespoons olive oil
1 14-ounce can chickpeas, rinsed and drained
1 cup chopped black olives (about 20 large)
1/8 cup slivered almonds, toasted

Optional (but use at least one):
2 tablespoons dill, minced
1/2 cup parsley, chopped
1/2 cup scallions, chopped
1/2 cup mint, chopped

1) In a medium bowl, combine couscous and salt. Pour water on top. Cover. Walk away for ten minutes. Water should be gone and couscous fluffy when time is up.

2) Meanwhile, zest both lemons into a smaller bowl. Then juice them to get 1/4 cup, and pour that into the same bowl. Add olive oil. Whisk together.

3) Fluff couscous. Add chickpeas, olives, dressing, and herbs. Stir thoroughly to combine. Salt and pepper to taste if desired (but you might not need it). Sprinkle with almonds. Serve hot or cold.

Approximate Calories, Fat, Fiber, Protein, and Price Per Serving
With parsley and scallions: 263 calories, 8.1 g fat, 4.6 g fiber, 7.5 g protein, $0.80

Calculations
Note: I used parsley and scallions for my dish. Those are being factored in here.
1 1/2 cups plain couscous: 976 calories, 1.6 g fat, 13 g fiber, 33.1 g protein, $2.28
1/2 teaspoon salt: negligible calories, fat, fiber, and protein, $0.01
2 1/2 cups boiling water: negligible calories, fat, fiber, and protein, FREE
2 lemons (zest & 1/4 cup juice): 16 calories, 0 g fat, 0.3 g fiber, 0.2 g protein, $0.66
3 tablespoons olive oil: 358 calories, 40.5 g fat, 0 g fiber, 0 g protein, $0.36
1 14-ounce can chickpeas, rinsed and drained: 500 calories, 4.6 g fat, 18.5 g fiber, 20.8 g protein, $0.66
1 cup chopped black olives (about 20 large): 125 calories, 10 g fat, 0 g fiber, 0 g protein, $0.91
1/8 cup slivered almonds, toasted: 85 calories, 7.5 g fat, 1.5 g fiber, 2.9 g protein, $0.23
1/2 cup parsley, chopped: 11 calories, 0.2 g fat, 1 g fiber, 0.9 g protein, $0.99
1/2 cup scallions, chopped: 32 calories, 0.2 g fat, 2.6 g fiber, 1.8 g protein, $0.33
TOTAL: 2103 calories, 64.6 g fat, 36.9 g fiber, 59.7 g protein, $6.43
PER SERVING (TOTAL/8): 263 calories, 8.1 g fat, 4.6 g fiber, 7.5 g protein, $0.80

Morbidly fascinated by the 2008 financial meltdown that destroyed Bear Sterns, bankrupted Lehman, brought AIG to its knees, froze the credit markets and destroyed gazillions of dollars of real estate worth?

Even if you arent, Frontlines report Money Power and Wall Street may still be worth your time.  Insightful nuggets abound.  For example, the Disease Management Care Blog learned that "collateralized debt obligations" (CDOs) were the clever weekend invention of a small cabal of 20-something financial brainiacs.  They had discovered an unregulated way to uncouple and transfer risk from a host of otherwise capital intensive loan instruments that freed up their customers balance sheets. The DMCB also found out that that the crafty candidate Obama had an "insider" feeding him key intelligence during the frenzied Treasury attempts to restore order to the U.S. markets. 

Most telling of all was the astonishing inability of very sophisticated investors to understand what they were getting into. Not only did a huge secondary trading "market" for CDOs spring up, synthetic CDOs fueled the feeding frenzy. Once the risk materialized, it all achieved critical mass and invaded the financial systems "blood stream." Too-big-to-fail titans of industry had no choice but to grab ahold of Uncle Sams Troubled Asset Relief Program (TARP) lifeline.

All of which prompted the DMCB to wonder if the titans of the health care industry really understand all of the dimensions of risk transfer collectively erred to a shared savings. After looking at this New England Journal of Medicine article several times, many of the assumptions underlying Medicares version of accountable care organizations (ACOs) are way out of the DMCBs depth. This table only makes things more scary.  Will bad mistakes lead some too-big-to-fail health systems having to be rescued?  Are there other young brainiacs out there, figuring out how to mischieviously move nebulous health insurance claims and risk around?

Maybe the DMCB is getting too paranoid thanks to watching too much Frontline. Time will tell if the financial markets are all that different from health care. 

The DMCB says stay tuned.

Red wine and green and white tea could give athletes and players a boost in the sports arena by increasing the amount of performance-enhancing hormone testosterone in their bodies, according to researchers from Londons Kingston University.

However not only could the beverages help them to trophy success, it could also allow them to beat anti-doping tests. A team led by Professor Declan Naughton, from the Universitys School of Life Sciences, found that and green and white tea might reduce the amount of testosterone excreted by the body, which could distort the findings of drug tests taken from urine samples.

Testosterone is a naturally-occurring steroid hormone present in both men and women. It can increase muscle mass, boost stamina and speed up recovery. Sportspeople, however, are prohibited from taking it, or a synthetic version of it, to try to gain a competitive edge.

Although red wine is not a banned substance away from the sports field, Professor Naughtons team has erred its findings to the World Anti-Doping Agency because of the newly-discovered side effect of potential change to the amount of testosterone in the body.

"Previous research has shown the effect over-the-counter anti-inflammatory drugs can have on enzymes," Professor Naughton explained. "Since many of these drugs are derived from plants, we decided to look at the effect particular foods and beverages can have on enzymes involved in testosterone excretion. We chose green tea and then red wine because both have a huge variety of natural molecules and we wanted to see if they affected the amount of testosterone excreted in urine."

"The catechins stop enzymes tagging molecules for excretion so the kidneys dont recognise them as needing to be removed and leave them circulating in the body," Professor Naughton explained. "We found that green and white tea could inhibit the enzyme by about 30 per cent. The levels of catechins in a strong cup of green tea matched those we used in our experiments."

The increased levels of testosterone from drinking green and white teas may provide a boost. "Its like having extra testosterone without actually taking any," Professor Naughton said. "By not excreting it from the body, athletes could potentially increase their testosterone levels for improved performance.

The team found that a compound in red wine, known as quercetin, partially blocked the action of an enzyme called UGT2B17, which looks for testosterone and then sends a message to the kidneys to excrete it.

Professor Naughton stressed that the research had so far been conducted in test tube experiments and had yet to be trialled on humans. "A full clinical study would be needed to determine the effects on people but, if the same results were found, it would confirm that compounds in red wine can reduce the amount of testosterone in urine and give a boost to testosterone levels," he explained.

The effect of red wine on an individual would vary because of factors such as weight, fitness, health and diet, making it hard to estimate how much was needed to improve performance, Professor Naughton said.

Teetotallers are not exempt from the effects. In fact, the alcohol content of red wine has very little impact because non-alcoholic molecules are responsible for inhibiting testosterone excretion.

The team also found the results were the same for red wine extract in supplement form. The active compounds such as quercetin are found in many foodstuffs as well as supplements.

The findings have been published in leading international journal Nutrition.

Health conscious individuals have been closely following Vitamin D research for the past decade as volumes of scientific evidence prove this prohormone has been selected through our evolution to provide critical protection against many inflammatory and immune mediated diseases.

Osteoarthritis (a.k.a "degenerative arthritis) of the hip and knee just... sucks. Characterized by activity-related pain in the affected joint, many otherwise physically fit persons have to resort to pills, injections and, finally, an appointment with an orthopedic surgeon to talk about joint replacement surgery.

What is less appreciated is that osteoarthritis can have a waxing and waning course with periods of relative remissions. Whats more, conservative treatment options can lessen or delay the need for surgery. Last but not least, the surgery itself involves months of recovery and the possibility of a nasty complication.

The primary care physician Disease Management Care Blog presided over this many times with its arthritis patients.  It was generally reluctant to er a patient to an orthopedic surgeon because it knew that the patients would be more interested in the potential benefits and pay less attention to the downsides of surgery.

Enter shared decision making (SDM). Defined as care that is respectful of and responsive to individual patient perences, needs, and values and ensures that patient values guide all clinical decisions, the premise is that by giving patients the information they need, theyll be able to ultimately determine the course of their care.  That would include patients with severe hip or knee osteoarthritis who are thinking about surgery but who also need to consider the option of conservative management.

Thats why this just-published Health Affairs study is noteworthy. All the 27 orthopedic surgeons in the 5 Group Health Cooperative clinics introduced shared decision making (SDM) for patients who were being evaluated with knee or hip osteoarthritis.  The intervention consisted of DVDs and booklets (from this company) that were ordered by the surgeon prior to an appointment.  The materials could also be viewed on Group Healths website at any time.

The study itself was quasi-experimental.  To be included in the study, patients had to 1) have knee or hip arthritis, 2) ) be continuously enrolled in the Group Health Plan for 12 months prior to the orthopedic clinic visit and 3) have a visit itself that was first index visit by the patient for that problem being evaluated by that particular specialty.

Outcomes from the 18 months of the SDM intervention period (January 2009 through July of 2010) were compared to the observation period of January 2007 through July of 2008.

Recall that the surgeon had to proactively order the SDM prior to the visit.  As a result, only 41% of the hip patients and 28% of the knee patients received the DVD, pamphlet or viewed the on-line materials.
 
Nonetheless, during the 6 months after the initial visit, the SDM patient population had 0.34 hip operations per 180 person-days (your DMCB offers an explanation of this counter-intuitive metric below*), compared to the control population of 0.46.  The difference was statistically significant. 

There was also a statistically significant reduction in knee operations: 0.09 per 180 person-days vs 0.16 per 180 person-days. 

All the differences held up after the authors statistically adjusted for differences in age, sex, obesity, co-morbid conditions, use of prior x-rays, joint injections, insurance factors and the clinic site.

Like all good authors writing in a high quality journal, they point out that this research was not pristine. The comparison period may not have been a representative baseline and, from 2008 to 2009, other factors may have caused a drop in hip and knee surgeries.

Nonetheless, this is an example of a "real world" study that credibly demonstrates that when osteoarthritis patients are exposed to SDM, more will opt for conservative management.  While that helps decrease health care utilization and ultimately costs, thats not the most important point: the patients who really wanted surgery got it and the patients who were less sure about the benefits of surgery chose not to have it.  Whats more, this didnt involve a lot of expensive face-to-face care management, it involved some DVDs.

The DMCB cautions that this successful study was carried out in a highly integrated delivery system and may not be transferable to other practice settings.  That being said, as Accountable Care Organizations struggle to meet their patients expectations and save money, this application of SDM may represent an important option.

*The DMCB interprets "180 patient days" as one patient being followed for the entire 6 months of the study.  If thats correct, the average SDM knee patient erred to a Group Health orthopedist had a 34% chance of getting surgery versus a 46% chance in the prior control group.  For the knee patients, it was 9% vs. 16%

Ive got another fun find from the farmers market this week: callaloo. Im a sucker for leafy greens‚ especially one Ive never tried before.

Turns out Id had callaloo before; also known as amaranth greens, which Ive received in CSA shares past, callaloo is a Caribbean green similar in taste to and a tad heartier than spinach. Once you rinse away the dirt and cast off the stems, the deep green leaves are ready for any recipe that calls for leafy greens.

Since I spent the last month away from my stove, I was inspired to dig out an old favorite cookbook and fire up the hot box. I found the perfect recipe: Jamaican Cook-up Rice from Jay Solomons The Global Vegetarian. It combines traditional Caribbean flavors and whatever you’ve got hanging around your kitchen into a one-pot wonder.

I added some roasted tofu with a simple marinade to the party. If you want to keep things simple and all-in-one pot‚ stick with Solomons protein of choice: red beans or pigeon peas. And you can use any vegetables you like too; choose your own root veg, greens, and/or sub the eggplant with summer squash or zucchini.

CB, my cutie pal JBF, and I loved it. Rice, vegetables, and warm spices make this dish a perfect, stick-with-you lunch or supper. And it goes great alongside corn-on-the-cob thats perfectly in season.

Have you tried callaloo before? Whats your favorite leafy green? Spill in the comments! I could talk about greens all day.

~~~

If you dig this recipe, you may fancy

• Tunisian-style Beans and Greens
• Gumbo Zherbes
• Pasta with Nettles, Sorrel, and Lemon

~~~

Jamaican Cook-up Rice with Callaloo and Roasted Tofu
Makes 5 servings.
Adapted from The Global Vegetarian by Jay Solomon


1 tbsp canola oil
1 medium white onion, diced
1 medium green bell pepper, diced
6 small Japanese eggplants (about 12 oz), diced
1 habanero pepper, seeded and minced
2 cups vegetable stock
1 cup almond milk
1 cup brown rice
2 cups carrots, diced
1/4 cup fresh parsley, chopped
2 tsp fresh thyme, minced
1 tsp dried allspice
2 tsp salt
6 cups callaloo greens or spinach, torn

Caribbean Roasted Tofu
14 oz roasted tofu, cubed
2 tsp fresh thyme, minced
1 tsp dried allspice
1 tsp salt
black pepper to taste
1 tbsp lime juice
2 tsp canola oil

1) Preheat oven to 400F. Combine 2 tsp fresh thyme, 1 tsp allspice, salt, pepper, lime juice, and canola oil in a medium mixing bowl.

2) Toss cubed tofu in marinade until coated.

3) Spread evenly over baking sheet.

4) Bake for 30 minutes, stirring once.

5) In a large saucepan or stewpot, heat oil over medium heat. Combine onion, green and habanero peppers, and eggplant in pot and sauté for 7 minutes or until soft.

6) Add liquids (almond milk and veggie stock), rice, carrots, and spices. Cover and simmer over medium-low heat for 20 minutes or until rice is cooked through and liquid is absorbed, stirring occassionally. Add water as necessary to keep rice from sticking to the pot.

7) Stir in greens and tofu (or beans), and cook until greens are wilted. Serve warm with corn-on-the-cob.

8) Rejoice.

Approximate Calories, Fat, Fiber, Protein, and Price per Serving
348.4 calories, 8.9g fat, 13.6g fiber, 27.25g protein, $1.61

Calculations
Jamaican Cook-up Rice
1 tbsp canola oil: 120 calories, 14g fat, 0g fiber, 0g protein, $0.08
1 medium white onion: 40 calories, 0.2g fat, 0g fiber, 0g protein, $0.50
1 medium green bell pepper: 33 calories, 0g fat, 3g fiber, 1g protein, $0.49
12 oz Japanese eggplants: 79.5 calories, 0.75g fat, 11.25g fiber, 3.75g protein, $1.50
1 habanero pepper: 2.75 calories, 0g fat, 0g fiber, 0.25g protein, $0.12
2 cups vegetable stock: 40 calories, 0.2g fat, 0g fiber, 0g protein, $0.38
1 cup almond milk: 40 calories, 3g fat, 1g fiber, 1g protein, $0.50
1 cup brown rice: 720 calories, 6g fat, 12g fiber, 12g protein, $0.76
2 cups carrots: 100 calories, 0g fat, 8g fiber, 4g protein, $0.64
1/4 cup fresh parsley: 5.2 calories, 0g fat, 0g fiber, 0g protein, $0.28
2 tsp fresh thyme: 2 calories, 0g fat, 0g fiber, 0g protein, $0.08
1 tsp dried allspice: negligible calories, fat, fiber, protein, $0.02
2 tsp salt: negligible calories, fat, fiber, protein, $0.02
6 cups callaloo: 36 calories, 0g fat, 4.5g fiber, 2.25g protein, $1.50

Caribbean Roasted Tofu
14 oz tofu: 437.5 calories, 22.4g fat, 28g fiber, 112g protein, $0.98
2 tsp fresh thyme: 2 calories, 0g fat, 0g fiber, 0g protein, $0.08
1 tsp dried allspice: negligible calories, fat, fiber, protein, $0.02
1 tbsp lime juice: 4.75 calories, 0.02g fat, 0g fiber, 0g protein, $0.05
2 tsp canola oil: 79.2 calories, 9.2g fat, 0g fiber, 0g protein, $0.05
1 tsp salt: negligible calories, fat, fiber, protein, $0.02
Totals: 1741.9 calories, 44.57g fat, 67.75g fiber, 136.25g protein, $8.07
Per serving: 348.4 calories, 8.9g fat, 13.6g fiber, 27.25g protein, $1.61

Nice medical home laptop, but how do I feel about it?

Over the years, the Disease Management Care Blog has repeatedly reminded the spouse of her particularly good fortune in marriage. Her lingering skepticism, however, has prompted the DMCB to amass further evidence of her marital bliss by

a) asking other spouses in similar relationships if they feel as fortunate and, if so,

b) collecting data about the DMCB-like personality traits in their husbands.

Bonhomie? Check.

Willingness to share the TV remote? Check.

Cooking the occasional meal at great personal sacrifice? Check.

Announcing how good that meal is? Check.

Yet, when confronted with the indisputable statistical associations that correlate nuptial happiness and DMCB"ness," the spouse has remained stubbornly unmoved. At the spouses pointed request, the DMCB is rechecking the math.

Readers will probably also remain unmoved about this publication that uses a similar approach to examining the impact of the Patient Centered Medical Home (PCMH) on clinic staff morale, satisfaction and burnout. Sara Lewis and colleagues surveyed the staff of 65 "safety net" clinics participating in a "5 Year Safety Net Medical Home Initiative" that had been co-funded by the Commonwealth Fund.

At the time of the survey, the 65 clinics were in the process of implementing becoming PCMHs but had not yet attained that status. The authors used a Likert-style survey to assess PCMH-"like" attributes among these non-PCMH clinics, such as patient access, data tracking, care management and quality improvement.  The survey also asked about staff morale, satisfaction and burnout.  The authors then correlated whether individual scores or a total roll-up score of all the PCMH-like attributes correlated with better clinic morale, higher satisfaction and less burn out.

There were 773 providers and staff members and 603 (78%) responded. 33% rated morale as good, 54% rated job satisfaction as very good and 40% had some burnout.  Based on an analysis of odds ratios, some features of a PCMH - particularly quality improvement - resulted in up to a three fold improvement in the three measures. However, while the total PCMH score was associated with better morale, it looked like there was also a greater association with worse burn-out, which had a statistically significant lower odds ratio of .48.

The DMCB finds these up and down results about the PCMH in nonPCMH clinics unconvincing.  It believes the attributes of a PCMH, if carried out as envisioned, should add up to more than the sum of its parts.  While some of the parts that are outside of a medical home seem, according to this paper, to correlate with morale, satisfaction and burnout, this gives little insight on how medical staff would really react to the transformation of a primary care clinic.  By the way, this is not the first time a PCMH-"like: methodology has been used, which makes the DMCB wonder if fully functioning PCMHs are less common than we think.

What is striking, however, are the basic measures of morale, stress and burnout. Based on these data, it would appear that these safety net clinics have some serious staff issues with 67% not having good morale, 46% not having good job satisfaction and just under half having burn out.

More evidence of primary cares travails says the DMCB.

The good news is that the DMCB remains optimistic that the math will eventually bring the DMCB spouse around.  Maybe the enthusiasm - and the math - about the PCMH will similarly prevail someday.  Until then, this papers approach doesnt lend much insight about the real potential of the PCMH. Last but not least, if these 65 clinics are representative of primary care morale, satisfaction and burnout in general, the DMCB far less optimistic about their future with or without the PCMH.

Investors just ponied up well over $100 billion for a piece of the social media giant Facebook. While Mr. Zuckerberg and his co-founders deserve a hearty congratulations, the Disease Management Care Blog finds some eerie parallels between Facebook and accountable care organizations.  The similarity does not bode well for either business model.

1. The users are not the customers: Facebook sells its users to marketeers.  ACOs sells its patients health care utilization to insurers. 

2. Its the data and its not yours: Facebooks targeted ads are constructed off of prior usage patterns. ACOs shared savings calculations are built off off actuarially determined health care utilization patterns.

3. Sovereign hostility: Washington DC views information technology and health care as distractions from the true task at hand: restoring the U.S. manufacturing base.

4. Do you care, really? Now that the wunderkids in charge of Facebook have made their millions, it remains to be seen if theyll work as hard in delivering value to its users.  Ditto for all the salaried docs working for ACOs, who no longer have to arrive early, skip lunch and stay late.

5. The long term: Yahoo once was the darling of internet investors.  Even if ACOs have initial success, is a better care model being developed as you are reading this?