Category: Medical Practice

Beyond the Scale: How organizations should evaluate the success of obesity management solutions

Sep 8, 2023

By CAITLYN EDWARDS

Obesity treatment is often framed as a race to the bottom — how much weight can someone lose? Five percent? Ten percent? And with recent scientific advancements in anti-obesity medications such as GLP-1s, what about even 15-20%?

Obesity treatment, though, isn’t just about the number on the scale. It’s about moving the needle on biomarkers that really matter to overall health. Seven out of the top ten leading causes of death and disability in the United States today are chronic diseases that have links to overweight and obesity. The metabolic benefits of just 5% weight loss can be life-changing for many people with obesity-related comorbidities. This means that for organizations looking to treat their chronic conditions, obesity care shouldn’t be all about striving for the lowest possible weight.

Indeed, consensus and practice statements from groups including the American Heart Association, the American College of Cardiology, the American Diabetes Association, and The Obesity Society, support weight loss programs that achieve clinically significant weight loss outcomes, defined as greater than or equal to 5% of an individual’s baseline body weight. This number is derived from decades of research demonstrating that even modest weight loss has impacts on physiological health including type 2 diabetes, dyslipidemia, hypertension, and many kinds of cancer.

People who attain just 5% weight loss see the following health improvements:

Reductions in systolic and diastolic blood pressure
Risk reductions of developing type 2 diabetes by almost 60%
Reductions in HbA1c and fasting blood glucose levels
Greater insulin sensitivity
Decreased need for newly prescribed diabetes, hypertension, and lipid-lowering medications

Understanding that obesity outcomes include more than just the number on the scale, how can benefit managers and health plan leaders measure success? Here are some things organizations should look for when evaluating an obesity management solution:

N-size of outcomes

While a high weight loss average may sound impressive, it doesn’t tell the whole story. A better measure might be the number of people in a program able to achieve greater than 5% weight loss. The fact is that weight loss averages are easily skewed by outliers. An exceptionally high average may not be representative of what is actually taking place at the individual level. What matters is that a large percentage of people in the program are able to see clinically significant results.

Emphasis on behavior change

Another way to measure the success of an obesity management solution is by the sustainability of its outcomes — primarily through adopting healthier behaviors. Intensive behavioral therapy is crucial to obesity treatment and can reduce the risk of type 2 diabetes. Support from expert dietitians and coaches can help promote a healthy relationship with food for optimal weight loss.

Through medical nutrition therapy, dietitians create personalized calorie and macronutrient goals to foster weight loss in a healthy, sustainable way. Also, self-directed cognitive behavioral therapy can help people become more aware of underlying thoughts and behavior patterns around food.

Step therapy approach to treatment

Some obesity management solutions avoid medications entirely while others rely solely on expensive GLP-1s. But both of those methods fall short of providing the best care to the most people at the lowest cost possible.

The best obesity management solutions take a clinically rigorous step-therapy approach to treatment. This way, they carefully manage access to expensive anti-obesity medications while achieving meaningful outcomes. Many of their members will achieve clinically significant weight loss through behavior change alone. Some may need a boost from lower-intensity, lower-cost anti-obesity medications to reach their goals. Others, with severe obesity or multiple cardio-metabolic conditions, may require higher-intensity anti-obesity medications like GLP-1s. Treatment levels can be safely tried in succession with needs and costs in mind.

It’s likely only 5-10% of a given population would end up using GLP-1s with this step-therapy approach, while the majority of people would still get clinically meaningful results without such intensive treatment.

Address SDOH to personalize care

One-size-fits-all solutions — like those that insist on a highly restrictive diet — miss the mark on health equity. Not everyone can afford expensive meat-heavy diets and they don’t always line up with people’s cultural preferences. Similarly, a program that simply doles out GLP-1s without helping people manage side effects doesn’t work and will only drain budgets.

The key to unlock improved outcomes is by helping people address SDOH challenges like food insecurity, language barriers, cultural factors, physical environment, and more. A good obesity solution should expand access to bilingual registered dietitians who are trained in dietary considerations and eating patterns for many different cultures and ethnic groups. They can help folks plan meals around limited budgets and specific dietary needs.

Conclusion

Organizations have much to consider when evaluating obesity solutions for their population. It’s easy to be swayed by simple metrics that seem indisputable. But, in the end, outcomes like 5% weight loss and reductions in HbA1c for the majority of an eligible population are what counts. Sustainable outcomes rely on real behavior change, a careful step-therapy approach to medication, and personalized care when it comes to social determinants of health.

Caitlyn Edwards, PhD, RDN, is a Senior Clinical Research Specialist at Vida Health

How to Talk to a Doc

Aug 3, 2023

BY KIM BELLARD

For better and for worse, our healthcare system is built around physicians. For the most part, they’re the ones we rely on for diagnoses, for prescribing medications, and for delivering care. And, often, simply for being a comfort.

Unfortunately, in 2023, they’re still “only” human, and they’re not perfect. Despite best intentions, they sometimes miss things, make mistakes, or order ineffective or outdated care. The order of magnitude for these mistakes is not clear; one recent study estimated 800,000 Americans suffering permanent disability or death annually. Whatever the real number, we’d all agree it is too high.

Many, myself included, have high hopes that appropriate use of artificial intelligence (AI) might be able to help with this problem. Two new studies offer some considerations for what it might take.

The first study, from a team of researchers led by Damon Centola, a professor at the Annenberg School for Communication at the University of Pennsylvania, looked at the impact of “structured information–sharing networks among clinicians.” In other words, getting feedback from colleagues (which, of course, was once the premise behind group practices).

Long story short, they work, reducing diagnostic errors and improving treatment recommendations.

Outpatient Vascular Care: Good, bad or ugly?

Jul 24, 2023

BY ANISH KOKA

Filling in the holes of recent stories in the New York Times, and Propublica on the outpatient care of patients with peripheral arterial disease

Most have gotten used to egregiously bad coverage of current events that fills the pages of today’s New York Times, but even by their now very low standards a recent telling of a story about peripheral artery disease was very bad.

The scintillating allegation by Katie Thomas, Jessica Silver-Greenberg and Robert Gebeloff is that “medical device makers are bankrolling doctors to perform artery clearing procedures that can lead to amputations”.

The reporters go on to tell a story about patient Kelly Hanna, who presented to a physician, Dr. Jihad Mustapha, in a private clinic with a festering wound. After being diagnosed with a poor flow to her leg that was likely contributing to the wound, Dr. Mustapha performed multiple procedures on her leg to improve blood flow in an attempt to ward off a future amputation. The procedures were unsuccessful, and Ms. Hanna ultimately did need an amputation.

Truthfully, the Physician Shortage Doesn’t Exist!

Jul 21, 2023• 1

BY HANS DUVEFELT

Conclusion: For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work. (Sinsky et al, 2016)

If we only had the tools and the administrative support that just about every one of us has been asking for, there wouldn’t be a doctor shortage.

The quote here is from 7 years ago and things have gotten even worse since then.

Major league baseball players don’t handle the scoring and the statistics of their games. They just play ball.

Somehow, when the practice of medicine became a corporate and government business, more data was needed in order to measure productivity and quality (or at least compliance with guidelines). And somehow, for reasons I don’t completely understand and most definitely don’t agree with, the doctors were asked not only to continue treating our patients, but also to more than double our workload by documenting more things than we ourselves actually needed in order to care for our patients. Even though we were therefore becoming data collectors for research, public health and public policy, we were not given either the tools or the time to make this possible – at least not without shortchanging our patients or burning ourselves out.

We didn’t sign up to do all this, we signed up to care for our patients. And we were given awkward tools to work with that in many ways have made it harder to document and share with our colleagues what our clinical impressions and thinking are.

Reviewing the all-in-pod heart health segment

Jul 20, 2023

BY ANISH KOKA

The All-in podcast is a fairly popular show that features successful silicon valley investors commenting about everything worth commenting on from politics to health. The group has good chemistry and interesting insights that breaks the mold of the usual tribal politics that controls legacy media analysis of current events.

Last week, the podcast touched on a topic I spend a fair amount of time on: Cardiology.

Brad Gerstner, who is actually a guest host for this particular episode starts off by referencing something called Heartflow to evaluate the heart that has been recommended by one of the other hosts: Chamath Palihapitiya. Brad apparently asked his primary care physician about Heartflow and was instead directed to get a calcium scan.

Heartflow is a proprietary technology that purports to evaluate the presence of significant narrowing in the coronary arteries just by doing a heart CT scan. A calcium score is a low-dose CT scan used to identify the presence of calcium in coronary vessels.

The segment ends with a recommendation for everyone over the age of 40 to get some type of heart scan, so I thought it would be worth reviewing some of the main claims.

Question 1. Does Brad need a calcium scan?

Brad notes that his primary care physician told him he was young, fit, and had a low bad cholesterol (LDL) and needed a calcium scan rather than a heart flow scan. The answer to this question and the questions to follow depend on what outcome Brad is looking for. If the goal is to feel happier knowing if he has coronary calcium than the resounding answer is to get the calcium scan. But if the goal is to live longer and healthier, there is nothing to suggest a calcium scan will help. Most cardiologists believe that the lower the LDL, the better cardiovascular outcomes are. So if a calcium scan convinces Brad to NOT lower his LDL further either naturally or with medications, a calcium scan may be detrimental.

We have zero evidence to suggest patients who get calcium scans lower their risk of future mortality.

Question 2. Does Brad need a Heartflow scan?

Data Democracy! ‘Dr. Google’ (2023) Vs. ‘Every Man His Own Physician’ (1767)

Jul 7, 2023

BY MICHAEL MILLENSON

Every Man His Own Physician - Google Books — In the 18th-century, a pre-Google guide offered democratization of medical information

In 1767, as American colonists’ protestations against “taxation without representation” intensified, a Boston publisher reprinted a book by a British doctor seemingly tailor-made for the growing spirit of independence.

Talk about “democratization of health care information,” “participatory medicine” and “health citizens”! Every Man His Own Physician, by Dr. John Theobald, bore an impressive subtitle: Being a complete collection of efficacious and approved remedies for every disease incident to the human body. With plain instructions for their common use. Necessary to be had in all families, particularly those residing in the country.

Theobald’s fellow physicians no doubt winced at the quotation from the 2^nd-century Greek philosopher Celsus featured prominently on the book’s cover page.

“Diseases are cured, not by eloquence,” the quote read, “but by remedies, so that if a person without any learning be well acquainted with those remedies that have been discovered by practice, he will be a much greater physician than one who has cultivated his talent in speaking without experience.”

Translation: You’re better off reading my book than consulting inferior doctors.

To celebrate Americans’ independent spirit, I decided to compare a few of Dr. Theobald’s recommendations to those of his 21st-century equivalent, “Dr. Google.” Like Dr. Google, which receives a mind-boggling 70,000 health care search queries every minute, Dr. Theobald also provides citations for his advice which, he assures readers, is based on “the writings of the most eminent physicians.”

At times, the two advice-givers sync across the centuries. “Colds may be cured by lying much in bed, by drinking plentifully of warm sack whey, with a few drops of spirits of hartshorn in it,” writes Dr. Theobald, citing a “Dr. Cheyne.” Dr. Google’s expert, the Mayo Clinic Staff, proffers much the same prescription: Stay hydrated, perhaps using warm lemon water with honey in it, and try to rest. Personally, I think “sack whey” – sherry plus weak milk and sugar – sounds like more fun.

Moral Injury: A Physician’s Premature Retirement

Jun 28, 2023

BY HAYWARD ZWERLING

Synopsis:

After a 3 decade career in a solo private practice the healthcare environment shifted
As an employed physician, my institution’s policies hindered my ability to care for my patients
The consequent moral injury left me unwilling to re-engage with the healthcare industry

I retired early from the profession that I loved because the devolution of the healthcare system had made it impossible for me to provide care to my patients in a manner which met my own standards. The resultant “moral injury” left me leary of again becoming involved with our healthcare system in the near future.

My Early Career

Although I had originally planned a career as a physician-scientist, it became apparent toward the end of my training that this was not the best career path for me and I choose to pursue a career in private practice.

My first post-training job was as a physician working in a clinic owned by Blue Cross and Blue Shield (1989-1991.) After two years in this relatively low stress environment it became clear that taking care of young, healthy patients was not much fun nor interesting.

I then joined Dr. LP’s private medical practice where I learned how to run a private practice. It was in this setting that I began to create an electronic medical record program for my practice, ComChart EMR. ComChart evolved into a minor commercial endeavor, it was a hobby that earned me some money, and it connected me to many interesting physicians around the US, some of whom I continue to hear from to this day.

After a couple of years practicing alongside Dr. LP I decided it was time to strike out on my own. I built out a new office and soon thereafter added a nurse practitioner.

Vaccine myocarditis update from Korea

Jun 9, 2023• 1

BY ANISH KOKA

A national study from Korea published in the European Heart Journal sheds important new light on complications related to COVID vaccine related myocarditis. While US public health authorities have been convinced from the very beginning about how safe and effective the new vaccines are, researchers in other countries with far smaller budgets have been testing that theory.

It was Israeli researchers that first highlighted the novel mRNA vaccines as potentially causing myocarditis in the Spring of 2021, but it has proven difficult to quantify the risk of severe complications beyond scattered case reports of severe morbidity and mortality. In part, US researchers are hampered by vaccine reporting systems in the US that are passive surveillance systems relying on voluntary reporting of vaccine adverse events. This has the potential of under-reporting adverse events, which was exactly the conclusion of an earlier JAMA analysis on US VAERS vaccine myocarditis cases.

Diving deep into the methods and results of the study

The South Korean approach was to organize a national reporting system under the auspices of the Korean Disease Control and Prevention Agency (KDCA). The KDCA also established a reporting system with a legal obligation for special adverse events including myocarditis and pericarditis after COVID-19 vaccination. To evaluate all reported cases of suspected myocarditis or pericarditis after COVID-19 vaccination, the KDCA organized an “Expert Adjudication Committee on COVID-19 Vaccination Pericarditis/Myocarditis”. The committee comprised 7 experts in cardiology, 1 in infectious disease, 2 in epidemiology, epidemiologic investigators in 16 regional centers, and officials from the KDCA.

Among 44,276,704 subjects vaccinated from 26 February to 31 December 2021, 1533 cases of suspected myocarditis were reported to the KDCA. The committee adopted the myocarditis case definition and classification of the Brighton Collaboration (BC) (see figure below) for the diagnosis and degree of certainty of a Vaccine Related Myocarditis (VRM) diagnosis.

Don’t Blame Burnout

May 31, 2023

BY SANJ KATYAL

It is hard to open a medical journal in any specialty without seeing an article on burnout. There are statistics, trends, and of course a myriad of causes detailed in these articles. A few even offer some sensible solutions – flexible scheduling, peer support, delegation of clerical work and an increased focus on personal well-being activities are steps in the right direction.

I have previously written that “the absence of burnout does not equal wellness” just as the absence of disease does not imply health. We deserve more than simply the ability to function, we deserve to flourish. This is where a field such as positive psychology, or what many call the science of happiness, can offer some evidence-based guidance.

What has become clear over the past few years is that many people are giving new buzzwords like burnout or moral injury too much credit for their unhappiness. Many of us are not well, either personally or professionally. It’s not as if we are joyful, peaceful and fulfilled at home and then suddenly begin to suffer only when we go to work.

Our jobs, colleagues or even the draconian healthcare system are not to blame for our discontent. Many of us may feel burned out but it has little to do with our career choice. Not many of us are fulfilled. Not many of us are content. Not many of us are free of stress and anxiety. Most of us seem to be restless and want to feel better all the time. So we blame our jobs, our bank account, people around us, even the world, and call it burnout. Burnout, while a significant problem for some people is now conveniently being used by many to shift the blame away from ourselves. We are the problem. But the good new is that we are also the solution. It is our lack of understanding that causes us to feel perpetually discontent and frantically chase happiness in various forms. It can only be understanding that will set us free.

What is it that we have not understood? What are the questions deep within us that we never have the courage to ask?

Why are we not fulfilled? Why are we restless and anxious much of the time? Why do we crave distractions in phones, TV and alcohol?

Categories

Everything you always wanted to know about the Health Care system. But were afraid to ask.

Category: Medical Practice

Beyond the Scale: How organizations should evaluate the success of obesity management solutions

How to Talk to a Doc

Outpatient Vascular Care: Good, bad or ugly?

Truthfully, the Physician Shortage Doesn’t Exist!

Reviewing the all-in-pod heart health segment

Data Democracy! ‘Dr. Google’ (2023) Vs. ‘Every Man His Own Physician’ (1767)

Moral Injury: A Physician’s Premature Retirement

Vaccine myocarditis update from Korea

Don’t Blame Burnout

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