Beauty Health for Life

Common oral problems have been linked to heart disease, diabetes, premature birth, and more.
Its easy to ignore the effects of poor oral hygiene because theyre hidden in your mouth. But gum disease produces a bleeding, infected wound thats the equivalent in size to the palms of both your hands, says Susan Kara bin, (Doctor of Dental Surgery) DDS, a New York periodontist and president of the American Academy of Period ontology.

"If you had an infection that size on your thigh, youd be hospitalized," Karabin says. "Yet people walk around with this infection in their mouth and ignore it. Its easy to ignore because it doesnt hurt ... but its a serious infection, and if it were in a more visible place, it would be taken more seriously."

You may think that the worst consequence of poor dental health would be lost teeth and painful times in the dentists chair. But some studies have linked common oral problems to illnesses, including heart disease, stroke, diabetes, premature birth, osteoporosis, and even Alzheimers disease. In most cases, the strength and exact nature of the link is unclear, but they suggest that dental health is important for preserving overall health.

"We need to educate the public that the mouth isnt disconnected to the rest of the body," says Sally Cram, DDS, a periodontist in Washington, D.C., and spokeswoman for the American Dental Association.
How Gum Disease Spreads

Periodontal disease is an infection caused by unhealthy bacteria that lodge between the teeth and gums. Simply brushing your teeth is enough to put some of those bacteria into your bloodstream, says Robert J. Genco, DDS, PhD, an oral biologist at the University of Buffalo. The bacteria then travel to major organs where they can spur new infections.

Inflammation also plays a role in spreading the effects of bad oral health. Red and swollen gums signal the bodys inflammatory response to periodontal bacteria. "If you have inflammation in your mouth, certain chemicals are produced in response that can spread [through the bloodstream] and wreak havoc elsewhere in the body," Cram says.

Evidence is mounting of the importance of the "mouth-body connection," as it is known, as dental problems are being linked to a growing list of other ailments.
Oral Health and Diabetes

Karabin has diagnosed several cases of diabetes from her dentists chair. "When I see a patient with multiple abscesses in their mouth ... I immediately think diabetes. I will send that patient for a glucose tolerance test." Nearly one-third of people with diabetes are unaware that they have it, and dentists can play a big role in diagnosing these patients, Genco says.

Diabetes and gum disease can interact in a vicious circle. Infections of any kind, including gum disease, cause the body to produce proteins called cytokines, which increase insulin resistance and make blood sugar more difficult to control, Karabin says. Conversely, uncontrolled diabetes impairs the bodys healing mechanism, which makes it harder to control gum disease, Cram says.

Diabetic patients who avoid dentists out of fear or anxiety will have problems that go beyond tooth loss, says John Buse, MD, PhD, director of the Diabetes Care Center at the University of North Carolina School of Medicine. "You probably wont be able to do a good job taking care of diabetes unless you go to a dentist."

Gum disease may also speed the progression to full-blown diabetes in the 54 million Americans who are classified as prediabetic. According to the American Diabetes Association, many people first become aware they have diabetes when they develop dental disease.

In a 2007 study, Danish researchers compared prediabetic rats with gum disease to prediabetic rats without gum disease. The rats with gum disease soon displayed increased insulin resistance and other signs of progression toward type 2 diabetes.
Oral Health and Heart Disease

People with periodontal disease are nearly twice as likely to suffer from coronary artery disease as those without, according to the American Academy of Periodontology. One theory is that oral bacteria attach to fatty plaques in the coronary arteries and contribute to the clots that can lead to heart attacks. Another is that inflammation increases plaque buildup.

Although evidence has been mixed, more than 20 "good-sized" studies have demonstrated the relationship between gum disease and heart disease, Genco says. But that relationship is still not confirmed as with other known risk factors such as smoking or obesity. Genco is planning a major study to see whether treating gum disease can forestall a second heart attack in people who have already had one.

Recent analysis suggests that common oral problems could increase the risk of cardiac problems. Indra Mustapha, DDS, a periodontist who teaches at Howard University in Washington, D.C., and colleagues analyzed the results of other research studies and found that periodontal disease with signs of bacterial exposure was associated with greater risk of heart disease.

The American Heart Association states, "At this time, promoting dental treatment expressly to prevent atherosclerotic cardiovascular disease and/or acute cardiovascular events is not recommended."
Oral Health and Premature Birth

"Ob-gyns always knew that preterm and low-birth-weight births could be triggered by infections in the body," says Karabin. "They looked for urinary tract infections and throat infections, but never really thought about the mouth until a periodontic researcher looked into it."

Karabin says that severe periodontal disease in the mother may lead to an increase in the risk of premature birth. Remember those cytokines? Turns out they also increase the level of the hormone prostaglandin, which triggers labor, says Karabin. Fortunately, studies show that early treatment of gum disease and improved oral hygiene in women can reduce their risk of premature birth.

Other conditions that indicate a link between dental health and overall health include:

    Osteoporosis. Osteoporosis and tooth loss often go hand in hand because the same decrease in mineral density that boosts the risk of hip and other fractures affects the jawbone and teeth. Measures taken to prevent or treat osteoporosis in postmenopausal women are likely to also help prevent severe gum disease, Genco says.
    Rheumatoid arthritis. A study released in June 2008 found that patients with rheumatoid arthritis (RA) were nearly eight times more likely to have periodontal disease. RA, like periodontal disease, is an inflammatory disorder, which may help explain the link, Karabin says.
    Alzheimers disease. A 2005 study of identical twins showed that in twin pairs where one had dementia and the other didnt, the ones with dementia were four times more likely to have gum disease by midlife. The study doesnt say that good oral heath prevents Alzheimers, but that inflammation early in life can have severe consequences later.

Healthy Mouth, Healthy Body

With the mouth and body so closely linked, dentists and physicians should collaborate more closely, Karabin says. "Physicians need to be trained to examine the mouth, and dentists need to understand more about systemic disease so they can pick up on some of the cues."

The findings also serve to bring home the importance of oral hygiene. Brush twice a day with a toothbrush with soft or medium bristles, Genco says. Clean between your teeth daily with floss, or try some of the interdental picks available at drugstores. If your gums bleed with flossing and dont stop after three to four days, see your dentist

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.

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Almost a century ago, in the early part of the 20th century, a dentist named Weston A. Price performed some of the most important research in the history of nutrition and health science.  As a dentist, he was concerned about the epidemic of dental deformities, like crooked teeth and cavities, so he set out to find traditional societies all over the globe didnt suffer from such problems.  Sure enough, he found several "primitive" societies isolated from the industrialized world who, despite a complete lack of dental hygiene, had perfectly straight teeth and little to no tooth decay.  And beyond that, chronic diseases like cancer and heart disease were completely absent.  He showed that, like all other animals, humans are healthy and robust when they eat, move, and live the way theyre designed.  Then, he watched as these healthy societies became civilized, adopted white flour and sugar, and their health declined. 

Traditional Swiss: ornery because they got all them teeth but no toothbrush

Modernized Swiss: even West Virginia doesnt want them

That is Weston A. Price in a nutshell, but I encourage you to read his book "Nutrition and Physical Degeneration" for the full story.  Although the societies Price studied ate a variety of diets, he noticed something that they all shared... all of these diets were particularly high in three fat-soluble vitamins:  A, D, and something he called "Activator X".  He determined that these three vitamins were critical and worked in synergy for tooth and bone formation, as well as general health.  After returning to America, Price applied what he had learned on his own patients.  He used a combination of high-vitamin butter oil (Activator X) and cod liver oil (A and D) to successfully prevent and reverse dental cavities in many of his patients.  Pretty amazing huh?  These three vitamins, when used in conjunction, can reverse cavities.  Fast forward to today... has anyone in the medical profession ever heard of this research?  Probably not.  To them, crooked teeth are just genetic, and the only way to fix a cavity is to get a filling.  Oh how wrong they are...


Price never identified this mystery vitamin he called "Activator X".  Weve all heard of vitamins A and D, but Activator X seems to have been lost in time.  Until now, that is.  Science has now uncovered its true identity, and research is beginning to confirm what Price learned almost a century ago.  Activator X is... Vitamin K2.

Mother Goose, with a liver full of K2

• Goose liver
• Grass-fed butter and cream
• Grass-fed milk and cheese
• Free-range egg yolks
• Fish eggs

Okay, I think thats enough.  If you eat any of these foods on the regular, youre lying.  Nobody in America eats this stuff; although its interesting to note that the French are particularly fond of goose liver and fine cheeses... no doubt this contributes to their low rates of heart disease, but more importantly, it could be the reason why their women are so strikingly beautiful.  But I digress... back to America.  I would venture a guess that nearly 100% of Americans need more K2; it is by far more deficient in our diets than its partners, vitamins A and D, and as you now know, it would go a long way to fighting chronic disease.  So what are you to do?

You could obviously start eating the foods listed above, that will surely help.  Get a hold of some local, pastured eggs, or some grass-fed butter like Kerrygold.  Theyre high in vitamins A and K2, plus they taste good.  You could also get a K2 supplement (menatetranone, or MK-4, is the one you want).  That would likely help; after all, it worked in the osteoporosis studies.  But remember, since they work in synergy, A, D, and K2 function best when theyre in balance with each other...  there must be a way to get all three of them in one place.  And there is!  Remember the butter oil/cod liver oil blend I mentioned that Dr. Price used in his practice?  Well, lucky for us, Green Pasture produces that very same product today.  Sure its a little expensive, but its top quality and it makes getting your A, D, and K2 extremely easy.  Now you dont have to choke down goose liver.  Youre welcome.


So go out and get your K2, however it is you choose to do it.  Eat goose liver, pig out on fish eggs, whatever you want to do... just do it!  You cant afford not to.  Your arteries and bones will thank you.  And you will thank them.  And you will both live a long, healthy, happy life together, just you and your arteries and bones.  And hopefully a spouse... and her arteries and bones.  And kids with perfect faces and teeth.  Maybe grandkids... okay you get the point.  Get your K2 on!

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.

If youre looking for new insights on the government shutdown and what it means for U.S. healthcare orm, head on over to Joe Padudas hosting of the Health Wonk Review.  The Review is a periodic summary of the best of the health policy bloggers who have information that you just cant find in the mainstream media.

Calcium or combination supplement reduces osteoporosis risk

While calcium supplements noticeably improved bone health in postmenopausal women, vitamin D supplements did not reduce bone turnover, according to a recent study accepted for publication in The Endocrine Societys Journal of Clinical Endocrinology & Metabolism (JCEM).

Bone turnover is the bodys natural process for breaking down old bone. In young people, the body forms enough new bone to replace what is lost. After age 30, however, bone mass in women begins to decline and the process speeds up after menopause. Osteoporosis develops when the body cannot replace bone as fast as it is broken down.

"Vitamin D and calcium interact to suppress bone turnover by decreasing parathyroid hormone levels," said the studys lead author, John Aloia, MD, of Winthrop University Hospital in Mineola, NY. "This can be beneficial in women who are vitamin D deficient. In women who already are receiving the recommended daily allowance of vitamin D, however, the study found there was no advantage to adding a vitamin D supplement."

The double-blind, placebo-controlled, parallel group, longitudinal factorial design study divided 159 postmenopausal women into four groups. One group received a combination of vitamin D and calcium, one was given 1,200 milligrams of calcium daily, one took 4,000 IU of vitamin D daily and the last group received placebos. To measure the effect supplements had on bone health, researchers measured bone turnover markers, such as parathyroid hormone levels in the blood, over the course of six months. In all, 120 women completed the study.

Researchers found a significant decline in bone turnover markers among women who were given daily calcium supplements. The vitamin D supplements did not have any effect on bone turnover markers, although the supplements did decrease parathyroid hormone levels.

"These findings suggest that vitamin D supplements over the recommended dietary allowance (RDA) do not protect bone health, whereas calcium supplements do have an effect," Aloia said. "Women do need to be cautious about the possibility of vascular side effects from too much calcium and should consult their physicians about whether their diet is adequate or whether they should take supplements at all."

A new study demonstrates what researchers consider conclusive evidence that the red wine compound resveratrol directly activates a protein that promotes health and longevity in animal models. Whats more, the researchers have uncovered the molecular mechanism for this interaction, and show that a class of more potent drugs currently in clinical trials act in a similar fashion. Pharmaceutical compounds similar to resveratrol may potentially treat and prevent diseases related to aging in people, the authors contend.

These findings are published in the March 8 issue of Science.

For the last decade, the science of aging has increasingly focused on sirtuins, a group of genes that are believed to protect many organisms, including mammals, against diseases of aging. Mounting evidence has demonstrated that resveratrol, a compound found in the skin of grapes as well as in peanuts and berries, increases the activity of a specific sirtuin,SIRT1, that protects the body from diseases by revving up the mitochondria, a kind of cellular battery that slowly runs down as we age. By recharging the batteries, SIRT1 can have profound effects on health.

Mice on resveratrol have twice the endurance and are relatively immune from effects of obesity and aging. In experiments with yeast, nematodes, bees, flies and mice, lifespan has been extended.

"In the history of pharmaceuticals, there has never been a drug that binds to a protein to make it run faster in the way that resveratrol activates SIRT1," said David Sinclair, Harvard Medical School professor of genetics and senior author on the paper. "Almost all drugs either slow or block them."

In 2006, Sinclairs group published a study showing that resveratrol could extend the lifespan of mice, and the company Sirtris Pharmaceuticals, which was started by HMS researchers, was founded to make drugs more potent than resveratrol. (Sinclair is a co-founder of Sirtris, a GlaxoSmithKline company, and remains a scientific advisor. Sirtris currently has a number of sirtuin-activating compounds in clinical trials.)

But while numerous studies, from Sinclairs lab and elsewhere, underscored a direct causal link between resveratrol and SIRT1, some scientists claimed the studies were flawed.

The contention lay in the way SIRT1 was studied in vitro, using a specific chemical group attached to the targets of SIRT1 that fluoresces more brightly as SIRT1 activity increases. This chemical group, however, is synthetic and does not exist in cells or in nature, and without it the experiments did not work. As a response to this, a paper published in 2010 surmised that resveratrols activation of SIRT1 was an experimental artifact, one that existed in the lab, but not in an actual animal. SIRT1 activity in mice was, the paper claimed, at best an indirect result of resveratrol, and perhaps even a sheer coincidence.

As a result, a debate erupted over the particular pathway that resveratrol and similar compounds affected. Does resveratrol directly activate SIRT1 or is the effect indirect? "We had six years of work telling us that this was most definitely not an artifact," said Sinclair. "Still, we needed to figure out precisely how resveratrol works. The answer was extremely elegant."

Sinclair and Basil Hubbard, then a doctoral student in the lab, teamed up with a group of researchers from both the National Institutes of Health and Sirtris Pharmaceuticals to address this question.

First, the team addressed the problem of the fluorescent chemical group. Why was it required for resveratrol to rev up SIRT1 in the test tube? Instead of dismissing the result as an artifact, the researchers surmised that the chemical might be mimicking molecules found naturally in the cell. These turned out to be a specific class of amino acid, the building blocks of proteins. In nature, there are three amino acids that resemble the fluorescent chemical group, one of which is tryptophan, a molecule abundant in turkey and notable for inducing drowsiness. When researchers repeated the experiment, swapping the fluorescing chemical group on the substrate with a tryptophan residue, resveratrol and similar molecules were once again able to activate SIRT1.

"We discovered a signature for activation that is in fact found in the cell and doesnt require these other synthetic groups," said Hubbard, first author of the study. "This was a critical result, which allowed us to bridge the gap between our biochemical and physiological findings.

"Next, we needed to identify precisely how resveratrol presses on SIRT1s accelerator," said Sinclair. The team tested approximately 2,000 mutants of the SIRT1 gene, eventually identifying one mutant that completely blocked resveratrols effect. The particular mutation resulted in the substitution of a single amino acid residue, out of the 747 that make up SIRT1. The researchers also tested hundreds of other molecules from the Sirtris library, many of which are far more powerful than resveratrol, against this mutant SIRT1. All failed to activate it.

The authors propose a model for how resveratrol works: When the molecule binds, a hinge flips, and SIRT1 becomes hyperactive.

Although these experiments occurred in a test tube, once the researchers identified the precise location of the accelerator pedal on SIRT1—and how to break it—they could test their ideas in a cell. They replaced the normal SIRT1 gene in muscle and skin cells with the accelerator-dead mutant. Now they could test precisely whether resveratrol and the drugs in development work by tweaking SIRT1 (in which case they would not work) or one of the thousands of other proteins in a cell (in which they would work). While resveratrol and the drugs tested revved up mitochondria in normal cells (an effect caused activating by SIRT1), the mutant cells were completely immune.

"This was the killer experiment," said Sinclair. "There is no rational alternative explanation other than resveratrol directly activates SIRT1 in cells. Now that we know the exact location on SIRT1 where and how resveratrol works, we can engineer even better molecules that more precisely and effectively trigger the effects of resveratrol."

"This message will self-destruct...."

The international arm of the Disease Management Care Blog is working on a presentation for the upcoming Hauptstadtkongreß in Berlin Germany.  Its "Mission Impossible" is to explain the U.S. health care system to a group of German hospital executives in a half hour.

This, in a Nußschale, is what the DMCB intends to say, using approximately eighteen PowerPoint slides:

1. While rising health care costs, as a percentage of U.S. GDP, has always been a problem, rising health care costs as a percentage of U.S. debt is widely viewed as a highly significant threat. We mean it this time.

2. The conservative vs. liberal debate over how to reduce health care costs for the U.S. government is ultimately about transferring its insurance risk.  The conservatives want to transfer risk to patients in the form of vouchers, while the liberals want to transfer risk to providers in the form of bundled payments and gain-sharing.  The liberals, so far, are handily winning the debate.

3. Risk is only half the health orm story.  The other half is quality. There is bipartisan consensus that a) U.S. health care quality could be better, and b) greater quality will mitigate insurance risk, resulting in fewer medical complications, emergency room visits and readmissions.
   
4. There is additional bipartisan consensus that a) insurance risk can be managed and b) quality can be increased when care is provided in large vertically integrated and regional provider systems.

5. If the twin exigencies of risk and quality are not addressed in the next 3-5 years, disappointment could lead to the unraveling of Obamacare and the introduction of a public payer option.

Image from Wikipedia

In the prestigious medical journal JAMA, Georgetown Universitys William Novelli, Kaiser CEO George Halvorson and Consumer Reports John Santa summarize the results of a patient survey and focus group results on the topic of shared decision making. The study was sponsored by the prestigious Institute of Medicine.

The results show that when it comes to treatment, patients want their doctors to present all relevant options, including the option of doing nothing.  Most also want to know each options risk.  Once they have good understanding, the majority are comfortable with letting their physician lead on chosing the "best" decision.  This approach is likewise associated with greater patient satisfaction.

Yet, despite their perence on how to best reconcile competing treatment options, few can recall it actually happening that way.

While this may be newsworthy to JAMA readers, the results should be of no surprise to anyone working in the population health management (PHM) field.  PHM service providers have been advocating for shared decision making for years. Theyve also developed business models that bridge the gap between JAMAs academic ideals and the real world inhabited by flesh and blood patients with busy doctors who need help now.

As testimony to the blurring between the theoretical and the possible, the Disease Management Care Blog has pasted 4 quotes below.  One is from a concluding paragraph of the JAMA paper, while the remainder are from the web sites associated some commercial care management vendors.

See if you can spot which is which:

physician-guided health care delivery system designed to develop and engage informed and activated patients over time to address both illness and long term health (link)

can ensure that in the trilogy of opinions, the patients opinion and perspective are core, helping fulfill the promise of better health at lower cost (link)

constantly make decisions that impact their health and provides them with the tools they need to make the decisions that are right for them (link)

based on each individuals readiness-to-change and what health issues they want to address, personalized interventions connect the widest range of health management solutions, devices and diagnostic tests (link)

Inspired by zoological bard Tony Hoagland, the ever romantic Disease Management Care Blog shares in the population-health inspired paean to commitment, support and caring.



  ....it is just our second telephonic encounter and I languidly sit with headset in a faceless building with the silent hum of desktops, not looking at you for eye contact is not necessary....

And if I were a medical home right now, I would securely message the physician, confident there is no time for her read it.... or act.... 

And if I were an ACO, I would lovingly attribute you, unless your baseline costs were already low so Id drop you fast and surpass the savings threshold.... 

And if you had moved beyond precontemplation, you would engage with my complex care plan and self-care your chronic condition and no longer bother me with your symptoms...and unhappiness.

And if I were an employer sponsored health plan, I would outsource the wellness program and demand fee clawbacks if target PMPMs were not achieved.

And if she were inside the risk corridor, we would avoid any clawbacks, earning me my bonus this year.....

which means we sit in silence and that your insurance wont cost less and ice cream cones wont be any more affordable for you for it is my ROI that we eat together.

While the physician Disease Management Care Blog understands the logic behind essential health benefit determinations, believes good health care includes access to reproductive services and also knows that an unintended pregnancy poses special threats to a womans health, it also sympathizes with the U.S. Catholic Bishops stand on birth control pills. 

Such is the luxury of cognitive dissonance.  Yet, the DMCBs real discomfort is over the broader health policy implications of defining BCPs as an essential health benefit that must be covered with only a few exceptions:

1. There are really two ultimate paths to a federal takeover health care.  The first is obvious: formal through the "nationalization" of either the payment or delivery of services. The second is de facto is through the creation of laws, regulations and standards that amount to an expanding domination of the payment or delivery of services. From an end-user perspective, the DMCB thinks there is little difference between the two and believes we are underestimating the ultimate end game for this and multiple other rules and regulations.

2. Decision-making like this can cut both ways.  While womens health advocates can take comfort in the Obama Administrations courage in the face of the Bishops push-back, its possible that future hyper-rational, inflexible, evidence-based, legalistic, uniformist and technocratic decision-making like this will result in endless legalistic, politically charged and awkward decision-making that will always vex some big constituency.  This is the same science used to provoke the controversy over the merits of mammography in women less than age 50 as well as prostate cancer screening in men.  To make the point, the DMCB poses this silly but troubling thought experiment:  since men are just as responsible and should be given every incentive to not cause unwanted pregnancy, should condoms be an essential health benefit?  If persons with cancer run out of treatment options, should a right to control their own bodies and its technical availability make assisted suicide an essential health benefit? 

This time it was the Catholics turn.  The next one could be yours.

3.  Without some sort of accommodation (which may be in the works), the Bishops arent going to back down.  While a majority of their parishioners may believe in and have used birth control, that test fails at two levels: 1) societys institutions are supposed to stand for a higher standard and 2) decades and even centuries of religious interpretation are not up for a vote.  Standing for something is what faith is all about and Church leaders are simply not going to roll over on insurance that covers birth control for their employees and theyre not going to offer access to birth control pills in the course of the provision of health care. Their only choice, other than millions in fines is to exit the health care arena.  David Brooks has an excellent discussion of why thats a problem. 

4.  It is said that the art of politics is the art of the possible: to work out compromise where everyone can walk away a winner.  While coverage of birth control pills is a victory for womens health advocates that a "base" can feel good about, this is also arguably a failure for a President who was committed to bridging differences and creating a health care system that had broad support.

Image from Wikipedia

Suspecting that the poorly controlled [insert name of chronic condition here] is the result of not taking the medication as prescribed, the doctor says: "Remember to take the [insert name of pharmaceutical here]!"

After silently concluding that the benefit of the medicine is less than the cost, hassles, side effects and long-term risks, the patient thinks "Like hell!"

That scenario has probably been played out thousands of times today in clinics across the United States.  According to Zachary Marcum and colleagues writing in the May 22 JAMA, thats costing $100 billion a year. 

Doctors like the Disease Management Care Blog have responded to "medication nonadherence" with entreaties to take the pills as prescribed. When docs take the time to address the issue with patients, research shows it can make a positive difference.

Marcum et al believe physicians can do better if they understand the six types of behaviors that lead to medicines going unused:

1. Insufficient understanding of the link to health and well-being

2. A decision that the benefit is exceeded by the costs.

3. Complexity of the medication management overwhelms the patient

4. Inattention (or what the authors describe as low vigilance)

5. Irrational or conflicting beliefs about medicine

6. Perceived lack of efficacy

What does the population health management service provider community need to know about this?

1. There are a variety of screening surveys that can be used to identify each of the patterns above; unfortunately for DMCB readers, however, there is no single survey that can do it all. 

2. There is also no single intervention that has been shown to consistently increase medication compliance.  Instead, multiple concurrent supports are needed, including education and behavioral support.  This paper by Ho et al echoes that assessment, pointing out that there is ample evidence that other valuable supports include reducing the number of pills, use of special containers, telemonitoring with interactive voice response, non-physician (nurse or pharmacist) one-on-one involvement and regular clinical follow-up with reminders.  Last but not least this paper in the Annals points out that reducing out of pocket patient costs can also make a difference.

Image from Wikipedia

Exposing skin to sunlight may help to reduce blood pressure, cut the risk of heart attack and stroke – and even prolong life, a study suggests.

Researchers have shown that when our skin is exposed to the suns rays, a compound is released in our blood vessels that helps lower blood pressure.

The findings suggest that exposure to sunlight improves health overall, because the benefits of reducing blood pressure far outweigh the risk of developing skin cancer.

The study has been carried out by the University of Edinburgh.

Heart disease and stroke linked to high blood pressure are estimated to lead to around 80 times more deaths than those from skin cancer, in the UK.

Production of this pressure-reducing compound – called nitric oxide – is separate from the bodys manufacture of vitamin D, which rises after exposure to sunshine. Until now it had been thought to solely explain the suns benefit to human health, the scientists add.

The landmark proof-of-principle study will be presented on Friday in Edinburgh at the worlds largest gathering of skin experts.

Researchers studied the blood pressure of 24 volunteers who sat beneath tanning lamps for two sessions of 20 minutes each. In one session, the volunteers were exposed to both the UV rays and the heat of the lamps. In the other, the UV rays were blocked so that only the heat of the lamps affected the skin.

The results showed that blood pressure dropped significantly for one hour following exposure to UV rays, but not after the heat-only sessions. Scientists say that this shows that it is the suns UV rays that lead to health benefits. The volunteers vitamin D levels remained unaffected in both sessions.

Dr Richard Weller, Senior Lecturer in Dermatology at the University of Edinburgh, said: "We suspect that the benefits to heart health of sunlight will outweigh the risk of skin cancer. The work we have done provides a mechanism that might account for this, and also explains why dietary vitamin D supplements alone will not be able to compensate for lack of sunlight.

"We now plan to look at the relative risks of heart disease and skin cancer in people who have received different amounts of sun exposure. If this confirms that sunlight reduces the death rate from all causes, we will need to reconsider our advice on sun exposure."

Every practicing physician using an electronic health record (EHR) has seen them.  Past diagnosis zombies that stumble endlessly through every encounter record.  "Coronary heart disease" that the patient never really had, "diabetes" that was only one possibility among many and a "fracture" that never appeared on any x-ray.

These undead conditions clutter the technology-enabled health system basically because of two EHR value propositions:

1) saving physician time by using automatic templates that vacuum up every past diagnosis entry and importing them into the encounter note, and

2) enabling a higher payment "complexity" level by documenting every past diagnostic consideration.

So, if someone somewhere anywhere in the past enters "Ehlers Danlos Syndrome" as an unlikely, but possible, diagnosis or a reason to perform additional testing, the EHR will spawn the same immortal entry of "Ehlers Danlos" forever.  That diagnosis will emerge from the HIT server-cloud crypts each and every time the patient sees a physician.

But you dont have to take the DMCBs word for it.

Dr. Faith Fitzgerald chose a far less gruesome allegory. Using Hans Christian Andersons "The Emperors New Clothes," this University of California Davis professor wrote a biting essay on the topic of lingering electronic untruths in a recent Annals of Internal Medicine.  She describes a patient who, despite having none of the features of Ehlers Danlos, is aggressively treated for it because the condition has been repeatedly listed in the EHR as a diagnosis.  Yet, unlike the boy who pointed out the Emperor was naked, Dr. Fitzgerald was unable to overcome her colleagues unconditional willingness to assume the EHRs information was correct.

"Zombie" and  "Emperors New Clothes" are only two ways to characterize this particular shortcoming of the EHR. dbs Medical Rants has a third, describing it as documentation inertia.  

Whatever the allegory, fable or jargon, the phenomenon is real.  The DMCB did a quick literature search to see if the frequency of untrue electronic diagnoses has been measured, and it cant find any studies.

If readers know of any please share.  In the meantime, the DMCB will continue to periodically revisit the issue.