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Author Archives: Dr. Bob

About Dr. Bob

Over the years I have experienced the health care system from several points of view. I practiced Internal Medicine then developed & directed condition management programs guiding nurses in their conversations with people dealing with chronic conditions, such as asthma, diabetes and heart disease. About 8 years ago I ended up on the other side of the stethescope and experienced both the life saving benefits of the American health care system, as well as some of its frustrations. Since then I continue to work in the chronic condition arena and am involved with some of the more promising changes to our system. They say when you write a blog you should focus on a topic about which you are passionate. My experiences lead me to focus this For Your Health blog on these two areas, 1. Changing behaviors to lead a healthier lifestyle 2. Learning how to navigate the healthcare system Each of these can be thought of as learning how to self-manage your health and wellness. So here goes, I'm launching this blog in the hopes that some people will find my thoughts useful and entertaining. Thanks, Dr. Bob

Exercise For Those Over 65 Or With Chronic Conditions

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What about exercise for older people?  An article, entitled “Physical Activity and Public Health in Older Adults: Recommendation From the American College of Sports Medicine and the American Heart Association.” (1) published in Circulation in August 2007 provides recommendations for physical activity in those over 65 or those who have chronic medical conditions, low fitness levels or physical limitations. It is similar to that for adults but also takes into account the older adult’s aerobic fitness, and recommends activities that maintain or increase flexibility and those that improve balance to prevent falls. Such an individual may progress more slowly and walking at a slow pace may be the equivalent of moderate intensity activity for them. Their muscle training should consist of more repetitions (10-15) than for their younger counterparts. This suggests that the weights should be light enough to enable them to perform 10-15 repetitions before their muscles fatigue. The flexibility training may take the form of at least 10 minutes of stretching of major muscle groups with 10-30 seconds of static stretch and 3-4 repetitions for each stretch. These should be done on the days when aerobic and strength training are done.

The point is made that exercise programs in these people must take into account the treatment aspects of exercise for many of the chronic conditions such as, hypertension, coronary heart disease, type 2 diabetes and elevated cholesterol to name a few. Fortunately, in many instances the therapeutic recommendations are similar to the preventive ones. However with certain conditions the emphasis may change. For example someone with osteoporosis would follow the preventive recommendation of aerobic, muscle strengthening, and balance activities, but they would emphasize weight-bearing activities and possibly high impact activities, such as jumping if tolerated. Of note, not every aerobic activity is weight-bearing. Swimming and cycling are not and have little, if any, preventive benefit for osteoporosis even though they are aerobic activities. They do benefit the cardiovascular and respiratory systems of the body.

The recommendation also emphasizes the fact that “There is substantial evidence that older adults who do less activity than recommended still achieve some health benefits…For example, lower risks of cardiovascular disease have been observed with just 45-75 minutes of walking per week.” (2)

In the next post I’ll talk about some of the risks of exercise.

For Your Health – Dr. Bob

Footnotes:
(1) M. E. Nelson, et al. Circulation. 2007;116:1094-1105; originally published online Aug. 1, 2007

(2) Ibid. pg. 1101

Everyone’s Focus – Preventing Hospital Readmissions

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So picking up from my last post, it seems like decreasing hospital readmissions is an opportunity perfect for the ACO.  Quality can be improved and unnecessary costs lowered.  Everyone would benefit.  You might think that the only possible exception would be the hospitals since decreasing readmissions would decrease their revenue.  Until recently that was the case.  But one of the provisions of the Accountable Care Act has established a financial penalty for hospitals whose readmission rates for Medicare patients with heart failure, heart attack or pneumonia exceeded the national average in the past.  The penalties began in October of 2012 and can decrease a hospital’s reimbursement from Medicare by up to 1% of its charges during 2013.  It is estimated that the penalties will amount to $250 million dollars in 2013.  The maximum percentage penalty will increase to 2% and then 3% in the next two years for hospitals that don’t lower their rate.  So hospitals now also have a strong reason to support programs designed to prevent readmissions.

 Preventing Readmissions

No matter who manages it, a program to prevent readmissions must have some basic components:

  • Patient identification – It is critical that the team responsible for the program gets notification of the patient’s discharge as promptly as possible.
  • Patient prioritization (if possible) – This can help the team focus on the patients more likely to be readmitted.
  • Patient outreach to
    • Schedule an office visit with the patient’s physician to check on their progress.  The patient is also told what symptoms should cause them to contact the physician immediately and not wait until the scheduled appointment since deterioration can sometimes occur very rapidly.
    • Assess needs and make sure components of the discharge plan are being implemented as intended.
    • Medication reconciliation to make sure the patient is taking the right medications.  This includes addressing any problems the patient may have in obtaining the medications.

Who Should Run A Readmission Avoidance Program?

While a hospital can run such a program, they will have to make sure they have adequate staff to manage the care coordination pieces.  Integration with the patient’s physician can also be a problem.  However, a common part of most ACOs is a team of clinical staff, usually nurses, who work with the patients’ physicians to coordinate their care.  This team is focused on the needs of the physicians’ patients so it is natural for them to play the role of reaching out to the discharged patient to assess and address their needs.  So, an ACO seems to have an advantage in conducting a readmission avoidance program.  Their only critical need is getting real-time notification of the patient’s discharge.  Thanks to the recent Medicare penalties for readmissions, hospitals have an incentive to get the ACO prompt discharge information so the ACO can reach out to the patient.

In the next post I’ll provide more details about how these program components can be put into operation in different communities.

For Your Health – Dr. Bob

Recent Recommendations for Healthy Adults

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The next logical question is what kinds of activity are recommended? The
answer lies in a newly published article in Circulation
which is the Journal of the American Heart Association, entitled, “Physical
Activity and Public Health: Update Recommendation for Adults From the American
College of Sports Medicine and the American Heart Association.”(1)
For all healthy adults aged 18 to 65 years of age the recommendation is a
minimum of moderate intensity aerobic (endurance) physical activity for a
minimum of 30 minutes on five days each week or vigorous intensity aerobic
physical activity for a minimum of 20 minutes on three days each week. A common
way to estimate energy expenditure for a given activity and understand what is
meant by these intensity designations is to use the concept of METs or
metabolic equivalents. When someone is sitting quietly, they expend 1 MET. The
moderate intensity activities expend from 3.0 to 6.0 METs and the vigorous
activities exceed 6 METs. In terms of METs, the minimum goal is to expend 450
to 750 METs per week in moderate intensity activities, vigorous intensity
activities or a combination of the two. A person can meet the minimum by a
combination of moderate and vigorous intensity activity. Moderate intensity
activity is generally equal to a brisk walk and noticeably increases the
heart rate. Vigorous intensity aerobic activity causes rapid breathing and a
substantial increase in the heart rate. Jogging is one example of vigorous
intensity activity. The table below gives some examples of common activities
and classifies them in these categories.

MET   Equivalents of Common Physical Activities From Ainsworth, et al. 2000

Light < 3.0   METS

Moderate 3.0 –   6.0 METs

Vigorous >   6.0 METs

Walking

Walking

Walking, Jogging & Running
Walking   slowly = 2.0 Walking   3.0 mph = 3.3 Walking   at a very, very brisk pace (4.5 mph) = 6.3
Walking   at a very brisk pace (4.0 mph) = 5.0 Walking/hiking   at moderate pace and grade with no or light pack (<10 lb.) = 7.0
Hiking   at steep grade & pack 10-42 lb = 7.5-9.0
Jogging   at 5 mph = 8.0
Jogging   at 6 mph = 10.0
Running   at 7 mph = 11.50

Household & Occupation

Household & Occupation

Household & Occupation
Sitting   – using computer, work at desk using hand tools = 1.5 Cleaning   – heavy; washing windows, car, clean garage = 3.0 Shoveling   sand, coal, etc. – 7.0
Standing   performing light work such as making bed, washing dishes, ironing, preparing   food or store clerk = 2.0-2.5 Sweeping   floors or carpet, vacuuming, mopping = 3.0-3.5 Carrying   heavy loads such as bricks = 7.5
Carpentry   – general = 3.6 Heavy   farming such as bailing hay = 8.0
Carrying   & stacking wood = 5.5 Shoveling, digging ditches = 8.5
Mowing lawn – walk power mower = 5.5
*MET values can vary substantially from person to person during swimming as a result of different strokes & skill levels.

The recommendation also indicates that bouts of moderate intensity aerobic activity at least 10 minutes in duration can count towards the 30 minute recommendation. Furthermore, because of the dose response relation of physical activity and health, people who wish to further reduce their risks for chronic diseases may do so by exceeding the minimum recommendations for activity. From the standpoint of weight loss, 60-90 minutes of moderate intensity physical activity daily seems to be necessary to maintain a weight loss of 30-50 lbs. The recommendation also calls for every adult to perform activities that maintain muscular strength or endurance at least two non-consecutive days a week. That should include 8-10 exercises involving all major muscle groups. This exercise should include sufficient weights to cause muscle fatigue after 8-12 repetitions of each exercise.

In the next post I’ll talk about exercise and people over the age of 65 or with chronic conditions.

For Your Health – Dr. Bob

Footnotes:
(1) W. L. Haskell, et al. Circulation. 2007;116:1080-1093; originally published online Aug. 1, 2007

Hospital Discharges – An Opportunity for ACOs

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After reading my last post on ACOs you may be wondering how an ACO consisting of primary care physicians can hope to save money on the costs of the Medicare patients attributed to them when so much of the care is beyond their control.  After all, the beneficiary can see any specialist they choose, and many hospitalizations can take place without the PCP’s knowledge.  That’s true, so there may always be components of a person’s care that cannot be well-coordinated, but there are still a lot of opportunities that an ACO can address if they are willing to invest in the system changes that are necessary.

I’d like to spend the rest of this post explaining why focusing on the transitions of care that a patient goes through is a prime target of most ACOs.  When I use the term “transition” it applies to any change of care setting for a patient.  It includes going from their home into a hospital, from a hospital to a rehabilitation hospital or from the hospital back to their home.  At each of these transitions there needs to be a communication of all elements of the care the patient has been receiving and what needs to continue or be changed going forward.  This is especially critical for a patient with multiple chronic medical problems such as high blood pressure or diabetes.  Probably the time when most miscommunications take place is when a patient is discharged from the hospital to their home.

Transitions of Care – Hospital Discharge

When a patient is discharged from an acute care hospital after being treated for something like severe pneumonia or a heart attack, someone from the clinical staff gives them a written copy of discharge instructions and discusses those instructions with them to make sure the patient understands them.  Unfortunately, what was often clear in the hospital isn’t so clear at home.  Lack of clarity around discharge instructions can lead to complications, reversal of the improvement that began in the hospital and hospital readmission.  There are studies that find that about 50% of these readmissions can be prevented.

Size of the Opportunity

Medicare estimates that 20% of patients discharged from a hospital are readmitted within 30 days.  One example of the financial consequences can be found in data for Knoxville, TN published by Qsource, a Quality Improvement Organization (QIO).  They found that in 2009 14% of the approximately 188,000 Medicare beneficiaries in Knoxville were hospitalized.  Consistent with Medicare’s national findings, 20% of those individuals had one or more readmission which cost $57 million and the 241 beneficiaries who had 4 or more readmissions had costs totaling $10 million.  Not every readmission is preventable, but when you look at the issues that lead to many of them, there are clear opportunities to improve the quality of care and prevent unnecessary and costly readmissions.  The challenge is to identify those whose readmission can be prevented and deliver the needed information and services to keep them healthy.

In the next post I’ll discuss some new regulations from Medicare that focus on the readmission issue and other strategies that can be used by ACOs.

For Your Health – Dr. Bob

Benefits of Exercise

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So how does exercise relate to weight loss? Well we know that to lose weight you need to take in fewer calories as food than you burn through exercise and other activities. Exercise can help you burn more calories than without it, so weight loss should be helped by increased activity. While that’s true, it’s a bit more complex than that with real implications for losing weight. Before we discuss that we need to better understand some concepts that a discussion of exercise and prevention can best illustrate.

Beyond its effect on weight loss, one of the major benefits of exercise is in prevention. A recent study (1) in women underscores these key relationships. This study built upon the large Nurses’ Health Study. This study looked at data on over 88,000 women ages 39 to 59 from 1980 through 2000. None of these women had heart disease or cancer when the study began. Over the 20 years of the study, the women reported their diet, physical activity level and waist circumference every 2 years. The results found that women who were inactive and obese had nearly 3.5 times the risk of having coronary heart disease than those who were active and lean. The lead researcher, Dr. Frank B. Hu, noted, “A high level of physical activity did not eliminate the risk of coronary heart disease with obesity, and leanness did not counteract the increased coronary heart disease risk associated with inactivity.”

In the next post I’ll talk about some recommendations for exercise in healthy adults.

For Your Health – Dr. Bob

Footnotes: (1) Circulation. 2006;113:499-506