In a later chapter Groopman reports a frank discussion

Index pages are approximate, contents settle during transport
P2
How we think: "All my mistakes have the same things in common."
P4
Obama
P5
Nursing shortage
P5
ARRA/Obama
P9
AIG
P 14
PCMH
P 16
Transformed
P 17
recall
Welch Allyn AED 10 and and MRL Jumpstart Defibrillators Class I
P 18
Simian Malaria in a U.S. Traveler --- New York, 2008
P 24 The systems men’s a view from the 50s and 60s.
P 25
Intuition vs insight
P 27
ARRA
P 28
W. Edwards Deming
P 37
PQRI see also P 99
P 40
Open access scheduling
P 41
LBJ and David Blumenthal (National Coordinator for Health Information
Technology).
P 43
Edward Kennedy and David Blumenthal
P 45
IBM and the PCMH
P 44
CVS pays 2.24 Million Dollars to settle HIPAA privacy suit
P 49
Stimulus Package Federalizes Health Information Breach Notifications
P 58
Latest in diets
P 58
Fish in U.S. Rivers Tainted With Common Medications
P 60
reflex
The World’s BEST Restaurant; Norovirus enhanced Gastro-colic
P 63
Third-generation Smallpox Vaccine LC16m8 Proven Safe and
Immunogenic
P 66
Flies May Spread Drug-Resistant Bacteria from Poultry
Pharma pled guilty that it mislead physicians about Oxycontin’s addiction
P 68
risk.
P 69
PLANT
PROGRESSIVE INFLAMMATORY NEUROPATHY @ PORK
P 71
Medicated Patches During MRIs
P 72
Toxic cadmium poisoning similar to 'itai itai'
P 74
meningococcal meningitis at the University of
Pennsylvania
P 78
TB et. al
P 81
Coccidioidomycosis
P 88
Medicare 101
P 94
-
Wal-Mart Inc, already in low-cost healthcare with walk-in clinics offers
EHR
P 96
Change
Pay for performance for Medical Groups may stimulate Practice
P 99
Google Health Offers Sharable Personal Health Records
P 99
More PQRI see P 37
P 100
MRSA among football team, NYC 2007
P 106
For the Techies in the crowd…..
109
Opium/heroin/Afghanistan
In a later chapter Groopman reports a frank discussion with Dr. James E. Lock,
chief of cardiology at Boston Children's Hospital. During their conversation,
Groopman asks the world-renowned cardiologist about the times in his career
when he made mistakes in patient treatment.
To the query, Lock gives the cryptic response, "All my mistakes have the same
things in common."
Lock then elaborates, discussing recommendations he made to repair specific
heart defects in neonates that ultimately led to worse clinical outcomes and
potentially avoidable deaths. The recommendations he made were based on a
purely logical understanding of cardiac physiology. The crucial point of Lock's
discussion came with his confession:
Impeccable logic doesn't always suffice. My mistake was that I reasoned from
first principles when there was no prior experience. I turned out to be wrong
because there are variables that you can't factor in until you actually do it. And
you make the wrong recommendation, and the patient doesn't survive. I didn't
leave enough room for what seems [sic] like minor effects--the small fluctuations
in oxygen levels, which might amount to one or two or three percent but actually
can signal major problems in the heart....[The proposed treatment] is very sound
logic. But it's wrong...These children developed right heart failure and clinically
they became worse.
Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment —
distinguishing strep throat from viral pharyngitis, for example. But they quickly fall
apart when a doctor needs to think outside their boxes, when symptoms are
vague, or multiple and confusing, or when test results are inexact. In such cases
— the kinds of cases where we most need a discerning doctor — algorithms
discourage physicians from thinking independently and creatively. Instead of
expanding a doctor's thinking, they can constrain it. How does a doctor think
when he is forced to improvise, when confronted with a problem for which there
is little or no precedent? (Here algorithms are essentially irrelevant and statistical
evidence is absent). Ignorance inhibits us from successfully communicating.
Acknowledging uncertainty and the need to take a clinical leap and act
Cogent medical judgments meld first impressions — gestalt — with deliberate
analysis. This requires time.
Medical students are taught that the evaluation of a patient should proceed in a
discrete, linear way: you first take the patient's history, then perform a physical
examination, order tests, and analyze the results. Only after all the data are
compiled should you formulate hypotheses about what might be wrong. These
hypotheses should be winnowed by assigning statistical probabilities, based on
existing databases, to each symptom, physical abnormality, and laboratory test;
then you calculates the likely diagnosis. This is Bayesian analysis, a method of
decision-making favored by those who construct algorithms and strictly adhere to
evidence-based practice. But, in fact, few if any physicians work with this
mathematical paradigm. The physical examination begins with the first visual
impression in the waiting room, and with the tactile feedback gained by shaking a
person's hand. Hypotheses about the diagnosis come to a doctor's mind even
before a word of the medical history is spoken.
************************************************************************
The American source said: "Obama is overwhelmed. There is a zero sum tension
between his ability to attend to the economic issues and his ability to be a
proactive sculptor of the national security agenda.
The one real serious flaw I see in Barack Obama is that he thinks he can
manage all this," the well-known figure told a Washington official, who spoke to
this newspaper. "He's underestimating the flood of things that will hit his desk." A
Democratic strategist, who is friends with several senior White House aides,
revealed that the president has regularly appeared worn out and drawn during
evening work sessions with senior staff in the West Wing and has been forced to
make decisions more quickly than he is comfortable.
He said that on several occasions the president has had to hurry back from
eating dinner with his family in the residence and then tucking his daughters in to
bed, to conduct urgent government business. Matters are not helped by the
pledge to give up smoking.
"People say he looks tired more often than they're used to," the strategist said.
"He's still calm, but there have been flashes of irritation when he thinks he's
being pushed to make a decision sooner than he wants to make it. He looks like
he needs a cigarette."
Mr. Obama was teased by the New York Times on Thursday in a front page story
which claimed to have detected a greater prevalence of grey hairs since he
entered the White House.
The Democratic strategist stressed that Mr. Obama's plight was nothing new. "He
knew it was going to be tough; he said as much throughout the campaign. But
there's a difference between knowing it is going to be tough and facing the sheer
relentless pressure of it all."
U.S. healthcare system pinched by
nursing shortage
By Will Dunham –AP – Yaima Milian, left, who is in a nursing residency program,
uses a light to check on patient Marta Gonzalez …
WASHINGTON (Reuters) – The U.S. healthcare system is pinched by a
persistent nursing shortage that threatens the quality of patient care even as tens
of thousands of people are turned away from nursing schools, according to
experts.
The shortage has drawn the attention of President Barack Obama. During a
White House meeting on Thursday to promote his promised healthcare system
overhaul, Obama expressed alarm over the notion that the United States might
have to import trained foreign nurses because so many U.S. nursing jobs are
unfilled.
Democratic U.S. Representative Lois Capps, a former school nurse, said
meaningful healthcare overhaul cannot occur without fixing the nursing shortage.
"Nurses deliver healthcare," Capps said in a telephone interview.
An estimated 116,000 registered nurse positions are unfilled at U.S. hospitals
and nearly 100,000 jobs go vacant in nursing homes, experts said.
The shortage is expected to worsen in coming years as the 78 million people in
the post-World War Two baby boom generation begin to hit retirement age. An
aging population requires more care for chronic illnesses and at nursing homes.
"The nursing shortage is not driven by a lack of interest in nursing careers. The
bottleneck is at the schools of nursing because there's not a large enough pool of
faculty," Robert Rosseter of the American Association of Colleges of Nursing said
in a telephone interview.
Nursing colleges have been unable to expand enrollment levels to meet the
rising demand, and some U.S. lawmakers blame years of weak federal financial
help for the schools.
Almost 50,000 qualified applicants to professional nursing programs were turned
away in 2008, including nearly 6,000 people seeking to earn master's and
doctoral degrees, the American Association of Colleges of Nursing said.
PAY DIFFERENCES
One reason for the faculty squeeze is that a nurse with a graduate degree
needed to teach can earn more as a practicing nurse, about $82,000, than
teaching, about $68,000.
Obama called nurses "the front lines of the healthcare system," adding: "They
don't get paid very well. Their working conditions aren't as good as they should
be."
The economic stimulus bill Obama signed last month included $500 million to
address shortages of health workers. About $100 million of this could go to
tackling the nursing shortage. There are about 2.5 million working U.S. registered
nurses.
Separately, Senator Dick Durbin and Representative Nita Lowey, both
Democrats, have introduced a measure to increase federal grants to help nursing
colleges.
Peter Buerhaus, a nursing work force expert at Vanderbilt University in
Tennessee, said the nursing shortage is a "quality and safety" issue. Hospital
staffs may be stretched thin due to unfilled nursing jobs, raising the risk of
medical errors, safety lapses and delays in care, he said.
A study by Buerhaus showed that 6,700 patient deaths and 4 million days of
hospital care could be averted annually by increasing the number of nurses.
"Nurses are the glue holding the system together," Buerhaus said.
Addressing the nursing shortage is important in the context of healthcare reform,
Buerhaus added. Future shortages could drive up nurse wages, adding costs to
the system, he said.
And if the health changes championed by Obama raise the number of Americans
with access to medical care, more nurses will be needed to help accommodate
them, Buerhaus Stimulus Basics for Electronic Health Records
On February 17, 2009, President Obama signed into law the American Recovery
& Reinvestment Act to stimulate the U.S. economy. Deciphering details of the bill
is challenging and time consuming, so here is a quick summary of key healthcare
IT provisions within the bill.
The HITECH Act appropriates $19.2 billion to encourage healthcare
organizations to adopt and utilize Electronic Health Records (EHR), establish
regional health information exchange networks, and ensure that deployed
systems protect patient privacy.
Within 11 years the Congressional Budget Office predicts that 90% of physicians
and 70% of hospitals will be using comprehensive, robust Electronic Health
Records. This represents an unprecedented opportunity for healthcare IT to
transform our nation’s healthcare system, save billions of dollars, and improve
the coordination and delivery of patient care.
The HITECH Act
So where does all the money go? There are two large buckets; one immediately
provides $2 billion to the Department of Health & Human Services (HHS) and the
newly created Office of the National Coordinator for Health IT (ONC), a second
sets aside $17.2 billion that will be paid to healthcare providers who can
demonstrate effective utilization of Electronic Health Records.
The $2 billion:
HHS is required to spend $300 million to establish regional/local health
information exchange (HIE) initiatives, and assist existing HIEs make progress in
connecting providers. There’s also $20 million to ensure consistent standards
across products and care settings. Beyond those two provisions this portion of
the bill remains non specific. Allocation and distribution of remaining funds need
to be determined within a 90 day window (May 2009) by the incoming HHS
secretary and ONC. Key areas specifically called out for investment include:
Providing Federal grants funding through state agencies/designees,
AHRQ, CMS, HRSA, and the CDC for healthcare organizations needing
upfront help to fund adoption of Electronic Health Records.
Establishing a Health IT Research Center, and regional extensions to
objectively inform healthcare providers on best practices, vendor
selection, training, implementation, etc.
Clarifying and further developing interoperability and privacy related
standards.
Developing infrastructure for the advancement of telemedicine.
Expanding health IT in public health departments.
The $17 billion in incentives for physicians and hospitals:
Actually $17.2 billion. The bulk of funding within the HITECH Act is dedicated to
payments that will reward physicians and hospitals for effectively utilizing robust,
connected Electronic Health Records. One program is designed for those that
accept Medicare, another for those that see large volumes of Medicaid patients.
Qualifying for the incentive payments requires physicians and hospitals to meet
three criteria:
1. Use of a certified Electronic Health Records product with e-Prescribing
capability that meets current HHS standards.
2. Connectivity to other providers that improves access to full visibility of a
patient’s health history.
3. The capability to report on their use of technology to HHS.
All incentives include payments for up to five years but ―front load‖ the largest
payments early in the program. Those that don’t adopt will eventually be
penalized through lower reimbursements starting in 2015. The incentive
payments begin in 2011 to ensure the providers have time to adopt and learn to
use the Electronic Health Records.
American Recovery and Reinvestment Act Updates
As mentioned, allocation and distribution of funds is still being determined. Stay
up to date on announcements about the American Recovery and Reinvestment
Act.
Stimulus Incentives for Medicare, Medicaid and
FQHCs
Provisions for Electronic Health Record Incentives
and Infrastructure Enhancements
The American Recovery & Reinvestment Act makes
special provisions for physicians accepting Medicare
and Medicaid through the HITECH Act, which
appropriates $19.2 billion to encourage healthcare
organizations to adopt and utilize Electronic Health
Records. Outside of the HITECH Act, additional funds
are included for infrastructure enhancements to
Federally Qualified Health Centers or FQHCs.
Here are some details about how those incentives are expected to roll out to
these target groups.
Medicare Incentives: Physicians who accept Medicare can receive up to
$44,000 over the five years. Additionally, physicians operating in a "provider
shortage area" will be eligible for an incremental increase of 10%. Those
delivering care entirely in a hospital environment, such as anesthesiologists,
pathologists and ED physicians, are ineligible.
According to the Medicare HIT provisions in the economic recovery legislation,
physicians who "meaningfully use" an approved HIT system beginning in 2011
are eligible to receive as much as 75 percent of their Medicare allowed charges
as an HIT incentive, up to the maximum incentive payment for that year.
The bill provides an even higher payment ceiling for "early adopters," defined as
physicians who first begin "meaningful use" of HIT systems in 2011 -- the first
year payment incentives will be available -- or 2012. These physicians could
receive as much as $18,000 the first year they adopt the technology. For
example, if such a physician's allowed charges in 2011 or 2012 total $24,000 or
more, he or she would receive the full $18,000 bonus that year.
Potential annual incentives per provider through 2016
Electronic Health Record utilization first demonstrated in 2011: $44,000
Electronic Health Record utilization first demonstrated in 2012: $42,000
Electronic Health Record utilization first demonstrated in 2013: $39,000
Electronic Health Record utilization first demonstrated in 2014: $24,000
Electronic Health Record utilization first demonstrated in 2015 or after: $0
Medicaid Incentives: Physicians who see more than 30% of patients paying
with Medicaid (20% for pediatricians) are eligible for payments of up to $64,000
over five years. The incentives will be calculated through a formula that factors in
the exact Medicaid mix seen by the provider as well as amounts ranging from
$25,000 in the first year to $10,000 in subsequent years. Because pediatricians
are required to meet a lower threshold they are only eligible for 66% of the
incentive payments described above.
Federally Qualified Health Centers: Separate from the HITECH Act but
included in the Stimulus bill is funding to support building and renovating
Federally Qualified Health Centers and increasing their use of health IT,
Electronic Health Records. Also included are provisions for telemedicine services
adoption for Indian Health Services organizations, and improving the technology
used to process disability claims (and what role Electronic Health Records can
play in that modernization effort). Sage Systems
As we express our gratitude, we must never forget that the highest appreciation
is not to utter words, but to live by them. JFK
Who got AIG's bailout billions?
By Toni Reinhold – Sun Mar 8, 8:30 am ET
AP – Senate Banking Committee member Sen. Bob Corker, R-Tenn., left, talks
with Eric Dinallo, right, the Superintendent …
NEW YORK (Reuters) – Where, oh where, did AIG's bailout billions go? That
question may reverberate even louder through the halls of government in the
week ahead now that a partial list of beneficiaries has been published.
The Wall Street Journal reported on Friday that about $50 billion of more than
$173 billion that the U.S. government has poured into American International
Group Inc since last fall has been paid to at least two dozen U.S. and foreign
financial institutions.
The newspaper reported that some of the banks paid by AIG since the insurer
started getting taxpayer funds were: Goldman Sachs Group Inc, Deutsche Bank
AG, Merrill Lynch, Societe Generale, Calyon, Barclays Plc, Rabobank, Danske,
HSBC, Royal Bank of Scotland, Banco Santander, Morgan Stanley, Wachovia,
Bank of America, and Lloyds Banking Group.
Morgan Stanley and Goldman Sachs declined to comment when contacted by
Reuters. Bank of America, Calyon, and Wells Fargo, which has absorbed
Wachovia, could not be reached for comment.
The U.S. Federal Reserve has refused to publicize a list of AIG's derivative
counterparties and what they have been paid since the bailout, riling the U.S.
Senate Banking Committee.
Federal Reserve Vice Chairman Donald Kohn testified before that committee on
Thursday that revealing names risked jeopardizing AIG's continuing business.
Kohn said there were millions of counterparties around the globe, including
pension funds and U.S. households.
He said the intention was not to protect AIG or its counterparties, but to prevent
the spread of AIG's infection.
The Wall Street Journal, citing a confidential document and people familiar with
the matter, reported that Goldman Sachs and Deutsche Bank each got about $6
billion in payments between the middle of September and December last year.
Once the world's largest insurer, AIG has been described by the United States as
being too extensively intertwined with the global financial system to be allowed to
fail.
The Federal Reserve first rode to AIG's rescue in September with an $85 billion
credit line after losses from toxic investments, many of which were mortgage
related, and collateral demands from banks, left AIG staring down bankruptcy.
Late last year, the rescue packaged was increased to $150 billion. The bailout
was overhauled again a week ago to offer the insurer an additional $30 billion in
equity.
AIG was first bailed out shortly after investment bank Lehman Brothers was
allowed to fail and brokerage Merrill Lynch sold itself to Bank of America Corp.
Bankruptcy for AIG would have led to complications and losses for financial
institutions around the world doing business with the company and policy holders
that AIG insured against losses.
Representative Paul Kanjorski told Reuters on Thursday that he had been
informed that a large number of AIG's counterparties were European.
"That's why we could not allow AIG to fail as we allowed Lehman to fail, because
that would have precipitated the failure of the European banking system," said
Kanjorski, a Democrat from Pennsylvania who chairs the House Insurance
Subcommittee.
TOXIC ASSETS/TOXIC WASTE
As part of its business, AIG insured counterparties on mortgage-backed
securities and other assets. The collapse of the U.S. subprime mortgage market,
which triggered a global financial crisis, left the insurer and some of its policy
holders facing possible ruin as the value of assets declined.
U.S. regulators failed to recognize how much risk AIG was piling on in creditdefault swaps, and by the time they understood, they had no choice but to pour
in billions of public dollars, Kohn and other officials told the Senate panel.
Senators were outraged by the lack of details about where the bailout money has
gone.
"That we find ourselves in this situation at all is ... quite frankly, sickening," said
Senator Christopher Dodd, the Democrat who chairs the committee. "The lack of
transparency and accountability in this process has been rather stunning."
Eric Dinallo, superintendent of New York State's Insurance Department, railed on
Friday against AIG's failed business model, likening its insuring credit-default
swaps as gambling with somebody else's money.
"It's like taking insurance on your neighbor's house and even maybe contributing
to blowing it up," he said at a panel sponsored by New York University's Stern
School of Business.
U.S. lawmakers have said they are running out of patience with regulators'
refusal to identify AIG's counterparties.
On Thursday, Richard Shelby, the top Republican on the banking committee,
said: "The Fed and Treasury can be secretive for a while but not forever."
Some lawmakers have threatened to impose a 100 percent tax on the A.I.G.
bonuses and Senator Chuck Grassley, Republican of Iowa, even wildly
suggested that the company’s executives consider suicide for their culpability.
But moral outrage and public rebuke do not provide legal grounds for backing out
of a contract.
If you are courageous, and have that entrepreneurial spirit.
If you are charismatic, inspiring, empowering and lead by example, if you are
coachable, open to personal growth, and want the benefits of owning a (patient
centered medical) home based business , the invest your time and money in
your own practice!!! What a deal!!! You work, you own it, you take responsibility
for your actions!!
Axolotlt
Regional Health Information Organizations (RHIOs), Virtual Health Record
(VHR)
Health Information Exchange (HIE) , Integrated Delivery Networks (IDNs),
Hospital Information Management (HIM)
Who knew that doctor chatter could be so profitable?
The two major physician-only social networking sites, Sermo and Medscape Physician Connect, are making news, as this piece in Newsweek notes
how both the pharmaceutical and the financial industries are listening in on the conversations.
These sites, however, are a relatively new phenomenon, and some wonder what would happen if doctors post something unsavory, or even illegal, on
the forums.
"Is Sermo obligated to notify regulators if a doctor says she's using yak's milk to treat cancer or nine times the approved dose of a drug?" writes
resident physician Ford Vox. "What if comments are pertinent to a malpractice case?"
All good questions, and reasons I would be very careful on what I would post on these sites. As medical ethicist Arthur Caplan comments, "It's a new
arena of ethics for sure."
JAMA crushes dissent and calls a critic a "nobody and a nothing"
Posted: 16 Mar 2009 11:10 AM PDT
Is the cover-up becoming worse than the proverbial crime?
According to the WSJ Health Blog, Jonathan Leo, a professor of neuro-anatomy from a small university in Tennessee, critiqued a study published in
JAMA, and pointed out an association between the study's author and a pharmaceutical company. He posted his thoughts on the website of the
British Medical Journal.
None too happy, Leo then received calls from JAMA's executive deputy editor Phil Fontanarosa, and surprisingly, editor-in-chief Catherine DeAngelis
got involved by asking Leo's superiors to retract his post from the BMJ's site.
The WSJ called Dr. DeAngelis for comment, and this is how the interview went:
―This guy is a nobody and a nothing‖ she said of Leo. ―He is trying to make a name for himself. Please call me about something important.‖ She added
that Leo ―should be spending time with his students instead of doing this.‖
When asked if she called his superiors and what she said to them, DeAngelis said ―it is none of your business.‖
From this corner, this is a PR disaster for JAMA, and especially Dr. DeAngelis, who must have known she was on the record with a national
newspaper.
Always a good idea to have ALL of your bases covered and a treatment plan is
most certainly a base to cover! If the doctors here in (unnamed country) will think
that they better to have a plan and not worry, the doctors here will let you know
they are not shy and very sure of themselves. Having a treatment plan will allow
you to be able to make good choices about future treatment. It doesn't hurt but if
you don't have them you will have nothing to fall back on or refer to.
Good luck!!! And remember there's no place like home!
Above taken from Yahoo social networking site.
Among patients with spinal disorders, the National Medical Expenditure Panel
Survey showed a 108% increase in opoid prescriptions from 1997 through 2004.
The combination of increasing use and higher drug prices resulted in a 423%
inflation-adjusted increase in expenditures
Recent studies document a 629% increase in Medicare expenditures for epidural
steroid injections; a 423% increase in expenditures for opioids for back pain; a
307% increase in the number of lumbar magnetic resonance images among
Medicare beneficiaries; and a 220% increase in spinal fusion surgery rates. The
limited studies available suggest that these increases have not been
accompanied by population-level improvements in patient outcomes or disability
rates
Spine imaging rates vary dramatically across geographic regions, and surgery
rates are highest where imaging rates are highest. When judged against
guidelines, one-third to two-thirds of spinal computed tomography imaging and
MRI may be inappropriate. Many factors probably underlie the growth of imaging,
including patient demand, the compelling nature of visual evidence, fear of
lawsuits, et. al.
Despite the limited benefit of epidural injections, Medicare claims showed a
271% increase during a recent 7-year interval. Facet joint injections increased
231%. Earlier Medicare claims analyses also demonstrated rapid increases in
spinal injection rates. For patients with axial back pain without sciatica there is no
evidence of benefit from spinal injections; however, many injections given to
patients in the Medicare population seemed to be for axial back pain alone.
Charges per injection rose 100% during the past decade (after inflation), and the
combination of increasing rates and charges resulted in a 629% increase in fees
for spinal injections.
Guaranteeing health insurance for all Americans may cost about $1.5 trillion over
the next decade, health experts say. That's more than double the $634 billion
'down payment' President Barack Obama set aside for health reform in his
budget, raising the prospect of sticker shock at a time of record federal spending.
Administration officials have pointedly avoided providing a ballpark estimate,
saying it depends on details to be worked out with Congress.
"It's impossible to put a price tag on the plan before even the basics have been
finalized," said White House spokesman Reid Cherlin. "Here's what we do know:
The reserve fund in the president's budget is fully paid for and provides a
substantial down payment on the cost of the reforming our health care system."
New Report: Pilot Test Shows Patient-Centered Medical Homes
for Primary Care Can Reduce Hospital Admissions and Total
Medical Costs
September 10, 2008
New York, NY, September 10, 2008—Geisinger Health System in Pennsylvania
reduced hospital admissions by 20 percent and saved 7 percent in total medical
costs by providing a patient-centered medical home (PCMH) model of care—
including around-the-clock access to primary and specialty care, and physician
and patient access to electronic health records (EHRs)—according to first-year
results from pilot-test sites. The findings, released in the September/October
issue of Health Affairs, provide the first evidence that the PCMH model can
improve quality of care and reduce health care costs. The article also describes
Geisinger Health System's efforts to redesign its care delivery infrastructure and
to create incentives aligned to enhanced health care value.
"These findings point to the potential for innovative and integrated delivery
systems to improve health care quality," said Glenn Steele, M.D. CEO of the
Geisinger Health System. "When hospitals, specialists, and primary care
practices work together, with the support of quality improvement and innovation
units and information technology systems, they gain the efficiencies and focus
needed to deliver high quality care."
"This is the direction in which we need to move our fragmented, broken health
care system," said Commonwealth Fund President Karen Davis, who is a board
member of the Geisinger Health System and co-authored the article, "Continuous
Innovation in Health Care: Implications of the Geisinger Experience," with
Geisinger's Chief Technology and Innovation Officer Ronald Paulus, M.D., and
President and CEO Glenn Steele, M.D.
The authors point to lessons from the Geisinger success that can inform national
policies aimed at improving value in health care, including:
By offering new payment schemes and incentives, such as acute episode
global fees and payments for patient-centered medical homes,
commercial insurers, Medicaid, and Medicare could encourage a broader
array of providers to implement these improvements.
Electronic health records are necessary but not sufficient to improve
health care delivery and value; health care delivery systems need to be
organized in ways that can take full advantage of the benefits of EHRs.
Collaboration by public and private payers to align incentives which
improve health care can help replicate these successes.
Geisinger's innovations show considerable promise for improving quality and
enhancing value. For their best practices and care models to spread more
broadly, health policies to align payment incentives, encourage greater
organization of care delivery, and adoption of modern information technology are
needed.
The person spoke on condition of anonymity because he was not authorized to
discuss the closed-door proceedings
The goal of the command must be to urge the recipient of the command to
accept the current mission
"The encouragement which is given before an action is undertaken and that
which is given at the actual time of the deed, are two distinct issues entirely."
Section 204 of the Tax Relief & Health Care Act of 2006 mandates a
demonstration in up to 8 states to provide targeted, accessible, continuous and
coordinated care to Medicare beneficiaries with chronic or prolonged illnesses
requiring regular medical monitoring, advising or treatment. A link to the
legislation is provided below. Mathematica Policy Research provided assistance
in the demonstration design. Thomson/Reuters will assist with implementation.
Send questions to [email protected].
2003, about $1 billion was taken from Iraq's Central Bank by Saddam
Hussein and his family, just hours before the United States began
bombing Iraq, biggest bank robbery in history!!
THE 9 MODULES OF THE MHIQ
• Patient Centered Medical Home
• Practice Management
• Health Information Technology
• Quality & Safety
• Practice-Based Team Care
• Continuity of Care Services
• Practice Services
• Access to Care and Information
• Care Management
From Transformed
PPC PCMH NCQA News Release > January 8, 2008
pass at least five of the following 10 elements:
Written standards for patient access and patient communication
Use of data to show standards for patient access and communication are
met
Use of paper or electronic charting tools to organize clinical information
Use of data to identify important diagnoses and conditions in practice
Adoption and implementation of evidence-based guidelines for three
chronic conditions
Active patient self-management support
Systematic tracking of test results and identification of abnormal results
Referral tracking, using a paper or electronic system
Clinical and/or service performance measurement, by physician or across
the practice
Performance reporting, by physician or across the practice
Champion Sponsors for PCMH: Pfizer Merck Lilly
The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by
more than 90 percent of America's health plans to measure performance on
important dimensions of care and service.
From: U.S. Food & Drug Administration (FDA)
<[email protected]>
Date: Mon, Mar 16, 2009 at 2:27 PM
Subject: FDA MedWatch - Welch Allyn AED 10 and MRL JumpStart Defibrillators
Class I recall
FDA and Welch Allen notified healthcare professionals and consumers of a
nationwide Class I recall of 14,054 AED 10 and MRL JumpStart external
defibrillators manufactured between October 3, 2002 and January 25, 2007.
These devices may experience low energy shock, unexpected device shutdown,
and/or susceptibility to electromagnetic noise interference. If such issues arise, it
may prevent defibrillation of a patient in cardiac arrest and could lead to death.
Class 1 recalls are the most serious type of recall and involve situations in which
there is a reasonable probability that use of the product will cause serious injury
or death. See the Recall Notice for additional instructions and contact
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March 13, 2009 / 58(09);229-232
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5809a3.htm?s_cid=mm5809a3
_e
Simian Malaria in a U.S. Traveler --- New York, 2008
Four species of intraerythrocytic protozoa of the genus Plasmodium (P.
falciparum, P. vivax, P. ovale, and P. malariae) are known to cause malaria in
humans. However, recent reports from Asia suggest the possibility that a fifth
malaria species, Plasmodium knowlesi, is emerging as an important zoonotic
human pathogen. Although more than
20 species of Plasmodium can infect nonhuman primates, until recently, naturally
acquired human infections of simian malaria were viewed as rare events lacking
public health significance. When viewed by light microscopy (the gold standard
for laboratory diagnosis of malaria),
many of the simian species are almost indistinguishable from the four
Plasmodium species that cause infection in humans (Table). Molecular
techniques, such as polymerase chain reaction (PCR) amplification and
microsatellite analysis, are needed for definitive species determination. This
report describes the first recognized case of
imported simian malaria in several decades in the United States, diagnosed in
2008 in a patient from New York who had traveled to the Philippines. Atypical
features of the parasite seen on light microscopy triggered further molecular
testing, which confirmed the diagnosis of P. knowlesi. To date, all simian malaria
species have been susceptible to chloroquine treatment. Molecular analysis of
certain malaria parasites isolated from ill travelers returning to the United States
from Asia or South America can more accurately assess the burden of simian
malaria parasite infections in humans.
The first recognized case of naturally acquired simian malaria was a 1965 case
of P. knowlesi infection in an employee of the U.S. Army who had returned home
from an assignment in Southeast Asia (1); subsequent reports were few and
unconfirmed. In 2002, investigators in Malaysia
noted an increasing number of P. malariae cases with atypical features, including
increased clinical severity and higher parasitemia (2). By using a nested PCR
assay, more than 50% of these malaria cases were determined to be P.
knowlesi; none were P. malariae, as originally determined by microscopy (2). In a
retrospective evaluation
by the same investigators during 2001--2006, 28% of 960 specimens from
patients in Sarawak, Malaysian Borneo, were found to be P. knowlesi, after being
morphologically diagnosed most often as P. malariae (3).
The group also reported four unusual fatalities attributed to severe malaria
caused by P. malariae that was later confirmed as P. knowlesi by PCR.
Additional cases of naturally occurring P. knowlesi infection in humans have
been reported from Singapore (4), the Thai-Burma border
(5), the Philippines (6), Yunnan Province in China (7), and Finland, where a
returning traveler from Malaysia was misdiagnosed initially as having infection
with P. falciparum (8).
Case Report
In the recent U.S. case, a woman aged 50 years with no previous history of
malaria who was born in the Philippines but had lived in the United States for 25
years, returned to her home country to visit friends and relatives on October 17,
2008. While there, she stayed on the island of Palawan in a cabin located at the
edge of a forested area known to be a habitat for long-tailed macaques. She had
not taken malaria chemoprophylaxis and had not used any mosquito-avoidance
measures, both of which are recommended preventive measures for travelers to
this area.
The woman returned to the United States on October 30, 2008, and noted the
onset of a headache. Fever and chills ensued, and symptoms persisted for
several days, after which she sought medical attention.
In the emergency department, she was noted to be hypotensive and to have
thrombocytopenia. Examination of thick and thin malaria smears (Figure 1) was
ordered, and an initial, erroneous diagnosis of babesiosis was made by a
laboratory technician. Upon review by the laboratory supervisor the following
morning, the diagnosis was
reassessed as malaria with 2.9% of red cells parasitized. However, the atypical
appearance of the Plasmodium sp. seen in the smears prevented a speciesspecific diagnosis. The woman was treated successfully with atovaquoneproguanil and primaquine for Plasmodium of undetermined species.
An ethylenediaminetetraacetic acid (EDTA) blood tube and two stained smears
were sent to New York state's Wadsworth Center Parasitology Reference
Laboratory for confirmation of malaria and molecular determination of species by
PCR. The Wadsworth Center confirmed the presence of atypical rings and
schizonts of a Plasmodium species (Figure 1), but conventional PCR targeting
the small subunit (SSU) of
rRNA did not yield a product consistent with any of the four species of
Plasmodium known to infect humans. The specimen also was negative for the
variants of P. ovale, which are commonly seen in Southeast Asia. However,
primers specific for the SSU rDNA of the genus Plasmodium yielded a 1,055-bp
PCR product that was sequenced and noted to be a 99% match over its full
length to the SSU rRNA gene from P.
knowlesi (H strain) (9). These data confirmed that the infection was caused by P.
knowlesi.
Reported by: JG Ennis, AE Teal, A Habura, PhD, S Madison-Antenucci, PhD, JS
Keithly, PhD, Div of Infectious Diseases, New York State Dept of Health. PM
Arguin, MD, JW Barnwell, PhD, WE Collins, PhD, S Mali,
MPH, L Slutsker, MD, A Dasilva, DSc, Div of Parasitic Diseases, National Center
for Zoonotic, Vector-Borne, and Enteric Diseases; J Hwang, MD, EIS Officer,
CDC.
Editorial Note:
Several conditions need to coincide for simian species of Plasmodium to infect
humans: 1) human erythrocytes must be susceptible to invasion by simian
parasites, 2) humans must be near or in forests where nonhuman simians are
infected, and 3) anopheline mosquitoes that feed on both humans and
nonhuman simians must be present (10). Many areas in Asia and South America
have overlapping populations of nonhuman primates that serve as reservoirs for
simian malaria and
competent Anopheles mosquito vectors that are necessary to transmit the
infection to humans (Table, Figure 2) (1). For P. knowlesi in Asia, the normal
hosts are long-tailed and pig-tailed macaques and mitered-leaf monkeys, which
are found with Anopheles mosquito vectors of the Leucosphyrus group, enabling
transmission of infection (1).
Other simian malaria species known to infect humans include P. simium and P.
brasilianum in South America and P. cynomolgi and P. inui in Asia (1,10).
Most simian malaria infections in humans can cause mild or moderate disease
but often are self-limited, not requiring antimalarial therapy (1). However, P.
knowlesi, with its 24-hour asexual replication cycle, can result in large parasite
burden and severe, life-threatening disease (3). Severe malaria imported from
Asia should alert the physician to the possibility of infection with P. knowlesi.
Health-care providers also should consider hospitalization if the patient with
malaria reports travel to forested areas of Asia, where P. knowlesi transmission
occurs. Simian Plasmodium species are susceptible to all available antimalarials
in the United States.
Although definitive diagnosis as a simian species of Plasmodium cannot be
made in time to guide selection of antimalarials at the initiation of therapy,
treatment for undetermined Plasmodium species will effectively treat all simian
species. Use of current treatment and chemoprophylaxis guidelines are
appropriate for treating and preventing simian malaria infections in humans.
Health-care providers of patients with malaria and laboratories that diagnose
malaria imported from Asia or non-falciparum malaria from South America should
refer appropriate specimens to a Clinical Laboratory Improvement Amendments
(CLIA)- verified state health reference laboratory or CDC's Division of Parasitic
Diseases Reference Laboratory for species confirmation by molecular testing. In
the United States, approximately 1,500 malaria cases are reported each year,
almost all imported from areas where malaria is endemic; approximately 200 of
these cases are imported from Asia or South America. In the United States, the
potential for not recognizing a
Plasmodium infection of simian origin is high because diagnosis usually relies on
microscopic examination of Giemsa-stained smears rather than diagnosis by
molecular techniques. Only a few laboratories (including state and federal public
health reference and commercial
laboratories) routinely use molecular assays, and even fewer have the capacity
to confirm simian species.
The substantial number of recent human cases of simian malaria reported in
Malaysia and the wider region (including the travel-associated case described in
this report) underscores the need to define the scope and magnitude of the
problem (2--8). Persons wishing to send specimens for species confirmation by
CDC should
collect pretreatment blood in EDTA or acid citrate dextrose blood collection
tubes. Instructions and specimen submission forms are available online at
http://www.cdc.gov/malaria/smscs.htm. Contact
information for local or state health department laboratories is available at
http://www.aphl.org/aboutaphl/aboutphls/pages/memberlabs.aspx.
As with all suspected cases of malaria, health-care providers with questions
regarding diagnosis or treatment should call the CDC Malaria Hotline at 770-4887788 (Monday--Friday, 8:30 a.m. to 4:30 p.m., EST).
Health-care providers seeking emergency consultation after hours should call
770-488-7100 and request to speak with a CDC Malaria Branch clinician.
References
1. Coatney RG, Collins WE, Warren M, Contacos PG. The primate malarias.
Bethesda, MD: US Department of Health, Education, and Welfare; 1971.
2. Singh B, Kim Sung L, Matusop A, et al. A large focus of naturally acquired
Plasmodium knowlesi infections in human beings. Lancet 2004;363:1017--24.
3. Cox-Singh J, Davis TM, Lee KS, et al. Plasmodium knowlesi malaria in
humans is widely distributed and potentially life threatening. Clin Infect Dis
2008;46:165--71.
4. Ng OT, Ooi EE, Lee CC, et al. Naturally acquired human Plasmodium
knowlesi infection, Singapore. Emerg Infect Dis 2008;14:814--6.
5. Jongwutiwes S, Putaporntip C, Iwasaki T, Sata T, Kanbara H. Naturally
acquired Plasmodium knowlesi malaria in human, Thailand. Emerg Infect Dis
2004;10:2211--3.
6. Luchavez J, Espino F, Curameng P, et al. Human infections with Plasmodium
knowlesi, the Philippines. Emerg Infect Dis 2008;14:811--3.
7. Zhu HM, Li J, Zheng H. Human natural infection of Plasmodium knowlesi
[Chinese]. Zhongguo Ji Sheng Chong Xue Yu Ji Sheng Chong Bing Za Zhi
2006;24:70--1.
8. Kantele A, Marti H, Felger I, Mueller D, Jokiranta TS. Monkey malaria in a
European traveler returning from Malaysia. Emerg Infect Dis 2008;14:1434--6.
9. Pain A, Bohme U, Berry AE, et al. The genome of the simian and human
malaria parasite Plasmodium knowlesi. Nature 2008;455:799--803.
10. Deane LM. Simian malaria in Brazil. Mem Inst Oswaldo Cruz 1992;87(Suppl
3):1--20.
FIGURE 1. Giemsa-stained blood smears (1,000x magnification) from a reported
case of Plasmodium knowlesi infection, highlighting the various features that
often are mistaken for Plasmodium malariae or Plasmodium falciparum* — New
York, 2008
http://www.cdc.gov/mmwr/preview/mmwrhtml/figures/m809a3f1.gif
FIGURE 2. Overlapping distributions of competent Anopheles vectors and
potential simian reservoirs for Plasmodium brasilianum and Plasmodium /simium
in South America and Plasmodium knowlesi in Asia
http://www.cdc.gov/mmwr/preview/mmwrhtml/figures/m809a3f2.gif
TABLE. Simian malaria species in Asia and South America with their associated
geographic distribution and morphologic similarity to one of four human
Plasmodium species*
http://www.cdc.gov/mmwr/preview/mmwrhtml/figures/m809a3t.gif
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Univ. N. Carolina School Public Health
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The systems men’s most fundamental weakness was the fuzziness of allround expertise in management methods as a claim to professional expertise.
Indeed, they complained that systems departments were liable to be the first to
be cut when a company fell on hard times. As the systems men frequently
lamented, it was very hard to turn recognition as an expert on forms into a
mandate to reorganize processes across departmental boundaries. A 1959
warning given by a leading British practitioner captured their dilemma:
[H]e claims to be an expert in a subject which most other business
people claim to be equally expert. What does the system man know
that the office manager, or indeed, any other manager does not
know? . . . There are already growing up in the office field a number
of other techniques which do not suffer from these disadvantages.
There is the computer programmer who has learned a secret
language. There is the operations research man who, as a
mathematician, employs unassailable mathematical techniques. . . .
Each has his esoteric techniques to sell. But what has the systems
man which is not the everyday currency of everyone else in
business?[
The systems men’s claims to a generalized authority based on information
acumen did not go unchallenged. Their most vociferous critic was John Dearden,
an expert on financial controls at the Harvard Business School. From his
warning, in 1964, that ―systems specialists have been developing an approach to
management information systems which, if left unchecked, could cause serious
problems to the companies that adopt it‖ to his insistence, in 1972, that ―no sane
manufacturing or marketing executive would delegate the responsibility for his
information system,‖ he mounted a sustained challenge to the aspirations of the
systems men. Dearden criticized management’s willingness to be seduced by the
scientific allure of the computer. He insisted that senior management had little
real use for masses of logistical data on their company’s operations, however
conveniently and rapidly it could be delivered. The information pyramid simply did
not exist.[48]
Dearden’s most fundamental challenge to MIS was his insistence that no
generalized set of principles or practices linked different kinds of management
information. Dearden observed that the systems men had achieved some
success in tackling the problems many corporations were experiencing in
logistics by tying together production, distribution, and ordering procedures. This
area had been an organizational vacuum in many firms, and he was willing to
concede that it deserved to be one of a small number of firmwide ―vertical‖
information systems, joining better-established systems for accounting and
personnel. But he ridiculed the idea that such techniques could be applied to the
provision of information and control systems in areas like finance or marketing,
whose information needs were entirely separate. The ―systems approach,‖ he
added, ―is merely an elaborate phrase for good management.‖ If companies were
having problems with their financial-control systems, then the answer was to
recruit better managers. The only advantage that computerization could possibly
offer would be lower administrative costs.[49]
Thomas Haigh is a Ph.D. candidate in the History and Sociology of Science department
of the University of Pennsylvania.
The industry will only change when it feels the pain of the loss of its old way of
making money. No pain no change. These days there is a lot of pain.
Intuition, which is often described in the popular literature as an alternative
thought process, is merely another manifestation of insight. In this process,
multiple bits of seemingly unrelated data are linked together and a hypothesis or
plan of action is generated. Usually this process is generated in a novel situation.
Such a circumstance links data which had hitherto seemed unrelated. The
categories and analytical process, however, are not distinct from any other form
of insight.
The only difference is the degree of novelty of the stimulus. To form an insight
the frontal lobe searches through the temporal lobes in search of the data bits. It
has been hypothesized that the apparently intuitive mode uses a right temporal
search. The majority of insights are derived from the left temporal lobe.
Hard to make decisions with information that is scarce, vague, inconsistent, or
incomplete is frustrating and risky.
It is a challenging task to compare several courses of action and then select one
action to be implemented.
Decision making is almost always accompanied by conditions of uncertainty.
Clearly, the more information the decision maker has, the better the decision will
be.
As the exactness of a statistical model increases, the level of
improvements in decision-making increases. That's why we need
probabilistic modeling. Probabilistic modeling arose from the need
Knowledge is more than knowing something technical. Knowledge
needs wisdom. Wisdom is the power to put our time and our
knowledge to the proper use. Wisdom comes with age and
experience. Wisdom is the accurate application of accurate
knowledge and its key component is to knowing the limits of your
knowledge. Wisdom is about knowing how something technical can
be best used to meet the needs of the decision-maker. Wisdom, for
example, creates statistical software that is useful, rather than
technically brilliant. For example, ever since the Web entered the
popular consciousness, observers have noted that it puts
information at your fingertips but tends to keep wisdom out of
reach.
Considering the uncertain environment, the chance that "good decisions" are
made increases with the availability of "good information." The chance that "good
information" is available increases with the level of structuring the process of
Knowledge Management.
ARRA 2009 (Pub.L. 111-5, PDF, H.R. 1, S. 1) is an Act of Congress enacted by
the 111th United States Congress and signed into law by President Barack
Obama on February 17, 2009.
More than 11% of the total bill is allocated to help states with Medicaid
Total: $147.7 billion
$86.6 billion for Medicaid
$24.7 billion to provide a 65 percent subsidy of health care insurance
premiums for the unemployed under the COBRA program
$19 billion for health information technology
$10 billion for health research and construction of National Institutes of
Health facilities
$1.3 billion for medical care for service members and their families
(military)
$1 billion for prevention and wellness
$1 billion for the Veterans Health Administration
$2 billion for Community Health Centers
$1.1 billion to research the effectiveness of certain healthcare treatments
$500 million to train healthcare personnel
$500 million for healthcare services on Indian reservations
Six Sigma has two key methods: DMAIC and DMADV, both inspired by Deming's
Plan-Do-Check-Act Cycle.[9] DMAIC is used to improve an existing business
process; DMADV is used to create new product or process designs.[9]
DMAIC
The basic method consists of the following five steps:
Define high-level project goals and the current process.
Measure key aspects of the current process and collect relevant data.
Analyze the data to verify cause-and-effect relationships. Determine what
the relationships are, and attempt to ensure that all factors have been
considered.
Improve or optimize the process based upon data analysis using
techniques like Design of experiments.
Control to ensure that any deviations from target are corrected before they
result in defects. Set up pilot runs to establish process capability, move on
to production, set up control mechanisms and continuously monitor the
process.
DMADV
The basic method consists of the following five steps:
Define design goals that are consistent with customer demands and the
enterprise strategy.
Measure and identify CTQs (characteristics that are Critical To Quality),
product capabilities, production process capability, and risks.
Analyze to develop and design alternatives, create a high-level design and
evaluate design capability to select the best design.
Design details, optimize the design, and plan for design verification. This
phase may require simulations.
Verify the design, set up pilot runs, implement the production process and
hand it over to the process owners.
DMADV is also known as DFSS, an abbreviation of "Design For Six Sigma".
William Edwards Deming (October 14, 1900 – December 20, 1993) was an
American statistician, professor, author, lecturer, and consultant. Deming is
widely credited with improving production in the United States during World War
II, although he is perhaps best known for his work in Japan. There, from 1950
onward he taught top management how to improve design (and thus service),
product quality, testing and sales (the last through global markets) through
various methods, including the application of statistical methods.
Deming made a significant contribution to Japan's later renown for innovative
high-quality products and its economic power. He is regarded as having had
more impact upon Japanese manufacturing and business than any other
individual not of Japanese heritage. Despite being considered something of a
hero in Japan, he was only beginning to win widespread recognition in the U.S.
at the time of his death.
Overview
Dr. Deming's teachings and philosophy can be seen through the results they
produced when they were adopted by the Japanese, as the following example
shows: Ford Motor Company was simultaneously manufacturing a car model with
transmissions made in Japan and the United States. Soon after the car model
was on the market, Ford customers were requesting the model with Japanese
transmission over the USA-made transmission, and they were willing to wait for
the Japanese model. As both transmissions were made to the same
specifications, Ford engineers could not understand the customer preference for
the model with Japanese transmission. It delivered smoother performance with a
lower defect rate. Finally, Ford engineers decided to take apart the two different
transmissions. The American-made car parts were all within specified tolerance
levels. On the other hand, the Japanese car parts had much closer tolerances
than the USA-made parts - e.g. if a part was supposed to be one foot long, plus
or minus 1/8 of an inch - then the Japanese parts were within 1/16 of an inch.
This made the Japanese cars run more smoothly and customers experienced
fewer problems. [3].
Deming received a B.S. in electrical engineering from the University of Wyoming
at Laramie (1921), an M.S. from the University of Colorado (1925), and a Ph.D.
from Yale University (1928). Both graduate degrees were in mathematics and
physics. Deming had an internship at Bell Telephone Laboratories while studying
at Yale. He subsequently worked at the U.S. Department of Agriculture and the
Census Department.
While working under Gen. Douglas MacArthur as a census consultant to the
Japanese government, he famously taught statistical process control methods to
Japanese business leaders, returning to Japan for many years to consult and to
witness economic growth that he had predicted as a result of application of
techniques learned from Walter Shewhart at Bell Laboratories. Later, he became
a professor at New York University while engaged as an independent consultant
in Washington, D.C.
Deming was the author of Out of the Crisis (1982–1986) and The New
Economics for Industry, Government, Education (1993), which includes his
System of Profound Knowledge and the 14 Points for Management (described
below). Deming played flute & drums and composed music throughout his life,
including sacred choral compositions and an arrangement of The Star Spangled
Banner
In 1993, Deming founded the W. Edwards Deming Institute in Washington, D.C.,
where the Deming Collection at the U.S. Library of Congress includes an
extensive audiotape and videotape archive. The aim of the W. Edwards Deming
Institute is to foster understanding of The Deming System of Profound
Knowledge to advance commerce, prosperity and peace.
The philosophy of W. Edwards Deming has been summarized as follows:
"Dr. W. Edwards Deming taught that by adopting appropriate principles of
management, organizations can increase quality and simultaneously
reduce costs (by reducing waste, rework, staff attrition and litigation while
increasing customer loyalty). The key is to practice continual improvement
and think of manufacturing as a system, not as bits and pieces."
In the 1970s, Dr. Deming's philosophy was summarized by some of his Japanese
proponents with the following 'a'-versus-'b' comparison:
(a) When people and organizations focus primarily on quality, defined by
the following ratio, quality tends to increase and costs fall over time.
(b) However, when people and organizations focus primarily on costs,
costs tend to rise and quality declines over time.
The Deming System of Profound Knowledge
"The prevailing style of management must undergo transformation. A system
cannot understand itself. The transformation requires a view from outside. The
aim of this chapter is to provide an outside view—a lens—that I call a system of
profound knowledge. It provides a map of theory by which to understand the
organizations that we work in.
"The first step is transformation of the individual. This transformation is
discontinuous. It comes from understanding of the system of profound
knowledge. The individual, transformed, will perceive new meaning to his life, to
events, to numbers, to interactions between people.
"Once the individual understands the system of profound knowledge, he will
apply its principles in every kind of relationship with other people. He will have a
basis for judgment of his own decisions and for transformation of the
organizations that he belongs to. The individual, once transformed, will:
Set an example;
Be a good listener, but will not compromise;
Continually teach other people; and
Help people to pull away from their current practices and beliefs and move
into the new philosophy without a feeling of guilt about the past."
Deming advocated that all managers need to have what he called a System of
Profound Knowledge, consisting of four parts:
1. Appreciation of a system: understanding the overall processes involving
suppliers, producers, and customers (or recipients) of goods and services
(explained below);
2. Knowledge of variation: the range and causes of variation in quality, and
use of statistical sampling in measurements;
3. Theory of knowledge: the concepts explaining knowledge and the limits
of what can be known;
4. Knowledge of psychology: concepts of human nature.
Deming explained, "One need not be eminent in any part nor in all four parts in
order to understand it and to apply it. The 14 points for management in industry,
education, and government follow naturally as application of this outside
knowledge, for transformation from the present style of Western management to
one of optimization."
"The various segments of the system of profound knowledge proposed here
cannot be separated. They interact with each other. Thus, knowledge of
psychology is incomplete without knowledge of variation.
"A manager of people needs to understand that all people are different. This is
not ranking people. He needs to understand that the performance of anyone is
governed largely by the system that he works in, the responsibility of
management. A psychologist that possesses even a crude understanding of
variation as will be learned in the experiment with the Red Beads (Ch. 7) could
no longer participate in refinement of a plan for ranking people."
The Appreciation of a system involves understanding how interactions (i.e.
feedback) between the elements of a system can result in internal restrictions
that force the system to behave as a single organism that automatically seeks a
steady state. It is this steady state that determines the output of the system
rather than the individual elements. Thus it is the structure of the organization
rather than the employees, alone, which holds the key to improving the quality of
output.
The Knowledge of variation involves understanding that everything measured
consists of both "normal" variation due to the flexibility of the system and of
"special causes" that create defects. Quality involves recognizing the difference
in order to eliminate "special causes" while controlling normal variation. Deming
taught that making changes in response to "normal" variation would only make
the system perform worse. Understanding variation includes the mathematical
certainty that variation will normally occur within six standard deviations of the
mean.
The System of Profound Knowledge is the basis for application of Deming's
famous 14 Points for Management, described below.
Deming's 14 points
Deming offered fourteen key principles for management for transforming
business effectiveness. The points were first presented in his book Out of the
Crisis (p. 23-24).
1. Create constancy of purpose toward improvement of product and service,
with the aim to become competitive and stay in business, and to provide
jobs.
2. Adopt the new philosophy. We are in a new economic age. Western
management must awaken to the challenge, must learn their
responsibilities, and take on leadership for change.
3. Cease dependence on inspection to achieve quality. Eliminate the need
for inspection on a mass basis by building quality into the product in the
first place.
4. End the practice of awarding business on the basis of price tag. Instead,
minimize total cost. Move towards a single supplier for any one item, on a
long-term relationship of loyalty and trust.
5. Improve constantly and forever the system of production and service, to
improve quality and productivity, and thus constantly decrease cost.
6. Institute training on the job.
7. Institute leadership (see Point 12 and Ch. 8 of "Out of the Crisis"). The aim
of supervision should be to help people and machines and gadgets to do a
better job. Supervision of management is in need of overhaul, as well as
supervision of production workers.
8. Drive out fear, so that everyone may work effectively for the company.
(See Ch. 3 of "Out of the Crisis")
9. Break down barriers between departments. People in research, design,
sales, and production must work as a team, to foresee problems of
production and in use that may be encountered with the product or
service.
10. Eliminate slogans, exhortations, and targets for the work force asking for
zero defects and new levels of productivity. Such exhortations only create
adversarial relationships, as the bulk of the causes of low quality and low
productivity belong to the system and thus lie beyond the power of the
work force.
11. a. Eliminate work standards (quotas) on the factory floor. Substitute
leadership.
b. Eliminate management by objective. Eliminate management by
numbers, numerical goals. Substitute workmanship.
12. a. Remove barriers that rob the hourly worker of his right to pride of
workmanship. The responsibility of supervisors must be changed from
sheer numbers to quality.
b. Remove barriers that rob people in management and in engineering of
their right to pride of workmanship. This means, inter alia, abolishment of
the annual or merit rating and of management by objective (See Ch. 3 of
"Out of the Crisis").
13. Institute a vigorous program of education and self-improvement.
14. Put everyone in the company to work to accomplish the transformation.
The transformation is everyone's work. "Massive training is required to
instill the courage to break with tradition. Every activity and every job is a
part of the process."
Seven Deadly Diseases
The Seven Deadly Diseases (also known as the "Seven Wastes"):
1.
2.
3.
4.
5.
6.
7.
Lack of constancy of purpose.
Emphasis on short-term profits.
Evaluation by performance, merit rating, or annual review of performance.
Mobility of management.
Running a company on visible figures alone.
Excessive medical costs.
Excessive costs of warranty, fueled by lawyers who work for contingency
fees.
A Lesser Category of Obstacles:
1.
2.
3.
4.
Neglecting long-range planning.
Relying on technology to solve problems.
Seeking examples to follow rather than developing solutions.
Excuses, such as "Our problems are different."
Dr. Deming's advocacy of the Plan-Do-Check-Act cycle, his 14 Points, and
Seven Deadly Diseases have had tremendous influence outside of
manufacturing and have been applied in other arenas, such as in the relatively
new field of sales process engineering.
Quotations and concepts
In his later years, Dr. Deming taught many concepts, which he emphasized by
key sayings or quotations that he repeated. A number of these quotes have been
recorded. Some of the concepts might seem to be oxymorons or contradictory to
each other; however, the student is given each concept to ponder its meaning in
the whole system, over time.
"There is no substitute for knowledge." This statement emphasizes the
need to know more, about everything in the system. It is considered as a
contrast to the old statement, "There is no substitute for hard work" by
Thomas Alva Edison (1847–1931). Instead, a small amount of knowledge
could save many hours of hard work.
"The most important things cannot be measured." The issues that are
most important, long term, cannot be measured in advance. However,
they might be among the factors that an organization is measuring, just
not understood as most important at the time.
"The most important things are unknown or unknowable." The factors that
have the greatest impact, long term, can be quite surprising. Analogous to
an earthquake that disrupts service, other "earth-shattering" events that
most affect an organization will be unknown or unknowable, in advance.
Other examples of important things would be: a drastic change in
technology, or new investment capital.
"Experience by itself teaches nothing." This statement emphasizes the
need to interpret and apply information against a theory or framework of
concepts that is the basis for knowledge about a system. It is considered
as a contrast to the old statement, "Experience is the best teacher" (Dr.
Deming disagreed with that). To Dr. Deming, knowledge is best taught by
a master who explains the overall system through which experience is
judged; experience, without understanding the underlying system, is just
raw data that can be misinterpreted against a flawed theory of reality.
Deming's view of experience is related to Shewhart's concept, "Data has
no meaning apart from its context" (see Walter A. Shewhart, "Later
Work").
"By what method?... Only the method counts." When information is
obtained, or data is measured, the method, or process used to gather
information, greatly affects the results. For example, the "Hawthorne
effect" showed that people just asking frequently for opinions seemed to
affect the resulting outcome, since some people felt better just being
asked for their opinion. Dr. Deming warned that basing judgments on
customer complaints alone ignored the general population of other
opinions, which should be judged together, such as in a statistical sample
of the whole, not just isolated complaints: survey the entire group about
their likes and dislikes. The extreme complaints might not represent the
attitudes of the whole group. Similarly, measuring or counting data
depends on the instrument or method used.
"You can expect what you inspect." Dr. Deming emphasized the
importance of measuring and testing to predict typical results. If a phase
consists of inputs + process + outputs, all 3 are inspected to some extent.
Problems with inputs are a major source of trouble, but the process using
those inputs can also have problems. By inspecting the inputs and the
process more, the outputs can be better predicted, and inspected less.
Rather than use mass inspection of every output product, the output can
be statistically sampled in a cause-effect relationship through the process.
"Special Causes and Common Causes": Dr. Deming considered
anomalies in quality to be variations outside the control limits of a process.
Such variations could be attributed to one-time events called "special
causes" or to repeated events called "common causes" that hinder quality.
Acceptable Defects: Rather than waste efforts on zero-defect goals, Dr.
Deming stressed the importance of establishing a level of variation, or
anomalies, acceptable to the recipient (or customer) in the next phase of a
process. Often, some defects are quite acceptable, and efforts to remove
all defects would be an excessive waste of time and money.
The Deming Cycle (or Shewhart Cycle): As a repetitive process to
determine the next action, the Deming Cycle describes a simple method to
test information before making a major decision. The 4 steps in the
Deming Cycle are: Plan-Do-Check-Act (PDCA), also known as Plan-DoStudy-Act or PDSA. Dr. Deming called the cycle the Shewhart Cycle, after
Walter A. Shewhart. The cycle can be used in various ways, such as
running an experiment: PLAN (design) the experiment; DO the experiment
by performing the steps; CHECK the results by testing information; and
ACT on the decisions based on those results.
Semi-Automated, not Fully Automated: Dr. Deming lamented the problem
of automation gone awry ("robots painting robots"): instead, he advocated
human-assisted semi-automation, which allows people to change the
semi-automated or computer-assisted processes, based on new
knowledge. Compare to Japanese term 'jidoka' (which can be loosely
translated as "automation with a human touch").
"The problem is at the top; management is the problem." Dr. Deming
emphasized that the top-level management had to change to produce
significant differences, in a long-term, continuous manner. As a
consultant, Deming would offer advice to top-level managers, if asked
repeatedly, in a continuous manner.
"What is a system? A system is a network of interdependent components
that work together to try to accomplish the aim of the system. A system
must have an aim. Without an aim, there is no system. The aim of the
system must be clear to everyone in the system. The aim must include
plans for the future. The aim is a value judgment. (We are of course
talking here about a man-made system.)"
"A system must be managed. It will not manage itself. Left to themselves
in the Western world, components become selfish, competitive. We can
not afford the destructive effect of competition."
"To successfully respond to the myriad of changes that shake the world,
transformation into a new style of management is required. The route to
take is what I call profound knowledge—knowledge for leadership of
transformation."
"The worker is not the problem. The problem is at the top! Management!"
Management’s job. It is management’s job to direct the efforts of all
components toward the aim of the system. The first step is clarification:
everyone in the organization must understand the aim of the system, and
how to direct his efforts toward it. Everyone must understand the damage
and loss to the whole organization from a team that seeks to become a
selfish, independent, profit centre."
"They realized that the gains that you get by statistical methods are gains
that you get without new machinery, without new people. Anybody can
produce quality if he lowers his production rate. That is not what I am
talking about. Statistical thinking and statistical methods are to Japanese
production workers, foremen, and all the way through the company, a
second language. In statistical control, you have a reproducible product
hour after hour, day after day. And see how comforting that is to
management, they now know what they can produce, they know what
their costs are going to be."
"I think that people here expect miracles. American management thinks
that they can just copy from Japan—but they don't know what to copy!"
"What is the variation trying to tell us about a process, about the people in
the process?" Dr. Shewhart created the basis for the control chart and the
concept of a state of statistical control by carefully designed experiments.
While Dr. Shewhart drew from pure mathematical statistical theories, he
understood that data from physical processes never produce a "normal
distribution curve" (a Gaussian distribution, also commonly referred to as a
"bell curve"). He discovered that observed variation in manufacturing data
did not always behave the same way as data in nature (Brownian motion
of particles). Dr. Shewhart concluded that while every process displays
variation, some processes display controlled variation that is natural to the
process, while others display uncontrolled variation that is not present in
the process causal system at all times. Dr. Deming renamed these
distinctions "common cause" for chance causes and "special cause" for
assignable causes. He did this so the focus would be placed on those
responsible for doing something about the variation, rather than the
source of the variation. It is top management’s responsibility to address
"common cause" variation, and therefore it is management’s responsibility
to make improvements to the whole system. Because "special cause"
variation is assignable, workers, supervisors or middle managers that
have direct knowledge of the assignable cause best address this type of
specific intervention.
(Deming on Quality Circles) "That's all window dressing. That's not
fundamental. That's not getting at change and the transformation that
must take place. Sure we have to solve problems. Certainly stamp out the
fire. Stamp out the fire and get nowhere. Stamp out the fires puts us back
to where we were in the first place. Taking action on the basis of results
without theory of knowledge, without theory of variation, without
knowledge about a system. Anything goes wrong, do something about it,
overreacting; acting without knowledge, the effect is to make things worse.
With the best of intentions and best efforts, managing by results is, in
effect, exactly the same, as Dr. Myron Tribus put it, while driving your
automobile, keeping your eye on the rear view mirror, what would
happen? And that's what management by results is, keeping your eye on
results."
"Knowledge is theory. We should be thankful if action of management is
based on theory. Knowledge has temporal spread. Information is not
knowledge. The world is drowning in information but is slow in acquisition
of knowledge. There is no substitute for knowledge." This statement
emphasizes the need for theory of knowledge.
"The most important figures that one needs for management are unknown
or unknowable (Lloyd S. Nelson, director of statistical methods for the
Nashua corporation), but successful management must nevertheless take
account of them." Deming realized that many important things that must
be managed couldn’t be measured. Both points are important. One, not
everything of importance to management can be measured. And two, you
must still manage those important things. Spend $20,000 training 10
people in a special skill. What's the benefit? "You'll never know," answered
Deming. "You'll never be able to measure it. Why did you do it? Because
you believed it would pay off. Theory." Dr. Deming is often incorrectly
quoted as saying, "You can't manage what you can't measure." In fact, he
stated that one of the seven deadly diseases of management is running a
company on visible figures alone.
"By what method?" When information is obtained, or data is measured,
the method, or process used to gather information, affects the results. Dr.
Deming warned that basing judgments on customer complaints alone
ignored the general population of other opinions, which should be judged
together, such as in a statistical sample of the whole. Changing the
method changes the results. Aim and method are essential. An aim
without a method is useless. A method without an aim is dangerous. It
leads to action without direction and without constancy of purpose.
Deming used an illustration of washing a table to teach a lesson about the
relationship between purpose and method. If you tell someone to wash a
table, but not the reason for washing it, they cannot do the job properly
(will the table be used for chopping food or potting plants?). That does not
mean just giving the explanation without an operational definition. The
information about why the table needs to be washed, and what is to be
done with it, makes it possible to do the job intelligently.
Physician Quality Reporting Initiative
NEW - Click on the "Spotlight" link to the left to view
"What's New" for PQRI
NEW! 2007 PQRI Reporting Experience. A report describing the 2007 PQRI
reporting experience is available in the "Downloads" section below. This report
provides a detailed analysis of the 2007 program. It outlines the issues identified
for 2007 and CMS plans for modifications to the analytics for the 2008 PQRI. In
addition, CMS will apply these modifications to the 2007 PQRI data and re-run
the data. CMS expects that additional eligible professionals will qualify for an
incentive payment for both 2007 and 2008 based on these efforts. It is
anticipated that these activities will be completed by the fall 2009.
Background. The 2006 Tax Relief and Health Care Act (TRHCA) (P.L. 109432) required the establishment of a physician quality reporting system, including
an incentive payment for eligible professionals (EPs) who satisfactorily report
data on quality measures for covered services furnished to Medicare
beneficiaries during the second half of 2007 (the 2007 reporting period). CMS
named this program the Physician Quality Reporting Initiative (PQRI).
For additional information about PQRI legislative requirements, click on the
"Statute/Regulations/Program Instructions" link at left.
2009 PQRI. The Medicare Improvements for Patients and Providers Act of 2008
(MIPPA) (Pub. L. 110-275) made the PQRI program permanent, but only
authorized incentive payments through 2010. EPs who meet the criteria for
satisfactory submission of quality measures data for services furnished during
the reporting period, January 1, 2009 - December 31, 2009, will earn an incentive
payment of 2.0 percent of their total allowed charges for Physician Fee Schedule
(PFS) covered professional services furnished during that same period (the 2009
calendar year).
As required by the Medicare, Medicaid, and SCHIP Extension Act of 2007
(MMSEA) (Pub. L. 110-173), CMS has established 2 alternative reporting periods
for the reporting of measures groups and for the submission of data on PQRI
quality measures through clinical data registries. The 2 alternative reporting
periods are: January 1, 2009 – December 31, 2009 and July 1, 2009 – December
31, 2009. In total, there are 9 options for satisfactorily reporting quality measures
data for the 2009 PQRI that differ based on the reporting period an EP chooses
to report on, whether an EP chooses to report through claims or an approved
clinical registry, and whether an EP chooses to report on individual measures or
measures groups.
The 2009 PQRI consists of 153 quality measures and 7 measures groups. For
further information on the 2009 PQRI quality measures, click on the
"Measures/Codes" link to the left.
Detailed information about the 2009 PQRI, including the criteria for satisfactory
reporting can be found in section O1 of the 2009 PFS final rule with comment
period (73 FR 69817 through 69847), which was published in the Federal
Register on November 19, 2008. To view the entire 2009 PFS final rule with
comment period, click on the relevant link in the "Related Links Outside CMS"
section below.
EPs do not need to sign-up or pre-register in order to participate in the
2009 PQRI. Submission of quality data codes for the 2009 PQRI quality
measures to CMS through claims or a qualified registry will indicate your
intent to participate in the 2009 PQRI.
2008 PQRI. The MMSEA authorized CMS to make PQRI incentive payments for
satisfactorily reporting quality measures data in 2008. EPs who meet the criteria
for satisfactory submission of quality measures data for services furnished during
the reporting period, January 1, 2008 - December 31, 2008, will earn an incentive
payment of 1.5 percent of their total allowed charges for Physician Fee Schedule
(PFS) covered professional services furnished during that same period (the 2008
calendar year).
MMSEA authorized CMS to establish alternative reporting criteria and alternative
reporting periods for the reporting of measures groups and for the submission of
data on PQRI quality measures through clinical data registries. The document
that establishes the new alternative reporting criteria and periods: "2008 PQRI
Establishment of Alternative Reporting Periods and Reporting Criteria" is
available as a downloadable file on the "Statute/Regulations/ Program
Instructions" link at left.
The 2008 PQRI consists of 119 quality measures, including 2 structural
measures, and 4 measures groups. EPs can report either through the claimsbased method or through approved clinical registries. For further information on
2008 PQRI measures and detailed specifications, click on the
"Measures/Codes" link in the left-hand column on this page.
2007 PQRI. PQRI was implemented on July 1, 2007 using Medicare's existing
claims processing system as the mechanism for EPs to report quality data to
CMS. The 2007 reporting period was July 1, 2007 to December 31, 2007. A total
of 74 measures were available for the 2007 program.
A 2007 PQRI confidential Feedback Report is available by Tax Identification
Number (TIN). If an EP correctly reported at least one quality data code for the
2007 reporting period a Feedback Report is available via the PQRI Portal on the
Quality Net website. A link to the Quality Net website may be found in the
"Related Links Outside CMS" section below. For more information on how to
access your 2007 PQRI Feedback Report, click on "PQRI 2007 General
Information" on the left.
Updated tools are available to assist professionals in PQRI reporting. To access
these tools, click on the "PQRI Tool Kit" link at left.
Please visit the Education section by clicking on the "Education" link at the left to
view NEW and additional information on how to successfully participate in PQRI.
Letter to Medicare Beneficiaries. CMS has posted a letter to Medicare
beneficiaries with important information about the PQRI. The letter is from
Medicare to the patient explaining what the program is, and the implications for
the patient. Physicians may choose to provide a copy to their patients in support
of their PQRI participation. To obtain a copy of the letter, see the "Related Links
Inside CMS" section below.
8 attributes of management excellence:
Bias for action
Close to the customer
Autonomy and entrepreneurship
Productivity through people
Hands on, value driven
Stick to the basics
Simple form, lean staff, cross train when possible
Simultaneous loose-tight properties
www.iom.edu
institute of medicine, excellent source of top quality information
Open access scheduling, allows your practice to redesign scheduling to offer
same day appointments to all patients, with acute or chronic conditions.
Demand is predictable and independent of your scheduling system; patients
continue needing your services regardless of your schedule. ―See you in 4
weeks, really means ―see you in 26, 28 or 30 days‖.
A key caveat: do today's work today.
Open scheduling is accomplished by systematically reducing/eliminating the
preexisting backlog of patients from the schedule, then matching clinician supply
to patient demand. It is a big adjustment to look at tomorrow’s schedule and see
no appointments. Open access has been successfully implemented in thousands
of private, public, and academic medical practices. Open access improves
continuity of care, and improves practice financial viability.
Open access is one of the key aspects of a PCMH. Having in mind that your
office is the patient’s PCMH and knowing that you are access able reduces the
likelihood they will patronize urgent care centers, emergency rooms, independent
PAs, NPs. Wallmart, Etc.
Finally, there are the inevitable stories of how few domestic medical students
matched into a primary care slot. This year is no different. As Jacob Goldstein
notes, "Just over 42% of the family medicine residency slots in this year’s match
went to seniors receiving their M.D.s this year from U.S. med schools," compared
with anesthesiology, where "just under 84% of the first-year anesthesiology
residency slots went to [United States] seniors."
The average salary of a family physician is $180,000, versus $400,000 for an
anesthesiologist
But it may be more instructive to consider how President Lyndon Johnson
succeeded in passing the legislation that created Medicare and Medicaid, says
David Blumenthal, an Obama campaign adviser who teaches at Massachusetts
General Hospital and Harvard Medical School and David Blumenthal, MD; National
Coordinator for Health Information Technology.
Blumenthal listened to the scratchy tapes of Johnson's Oval Office phone calls.
In one, just moments after a bill to create Medicare got through a key House
committee in March of 1965, Johnson sounds like he's in no mood to celebrate.
He gets on the phone to demand that legislators keep the bill moving.
"You just tell them not to let it lay around. Do that," Johnson barks.
"They want to, but they might not," he continues. "Then that gets the doctors
organized, then they get the others organized. And that damn near killed my
education bill. Letting it lay around. It stinks. It's just like a dead cat on the door.
When a committee reports it you'd better either bury that cat or get some life in
it."
The bill did pass and today, Medicare, the health insurance for the elderly and
disabled, and Medicaid, the program for the poor, cover more than 90 million
people.
Blumenthal analyzed this and other tapes in an article in this week's New
England Journal of Medicine.
He argues that Johnson succeeded because he was willing to leave the details to
Congress, and even let others get credit, including the powerful Arkansas
Democrat Wilbur Mills, chairman of the House Ways and Means Committee.
"Johnson would make clear to Wilbur Mills that it was going to be the Mills bill,
Mills would get the credit in history, Mills would be able to control the details,"
Blumenthal says. "Johnson didn't care about the details."
LBJ Drives The Action
Historians have often given more credit to Mills for the passage of Medicare and
Medicaid. But Blumenthal says the tapes show that Johnson was always at the
center, pushing Mills.
Another lesson, Blumenthal says, is that Johnson was willing to ignore the high
costs of health care expansion.
In a conversation on March 6, 1965, he tells Vice President Hubert Humphrey he
could no more limit spending for health care, than tell his wife what groceries to
buy.
"I'll go a 100 million or billion on health or education," Johnson said. "I don't argue
about that any more than I argue about Lady Bird buying flour. You got to have
flour and coffee in your house. And education and health, I'll spend the xxxxxxxx
money."
Johnson, with years in the Senate, was a champion arm-twister. Blumenthal
describes what happened when Johnson summoned Democrat Sen. Harry Byrd
of Virginia to the White House, after he seemed ready to block the Medicare bill
in committee.
"Byrd went sort of chasing over to the White House," Blumenthal says. "And LBJ
no sooner invited him into the Oval Office then he ushered him through the Oval
Office into the next room where there was a press conference waiting. And with
cameras rolling, LBJ took his elbow and leaned into him and said, 'Harry is there
any reason why you can't move the Medicare legislation?'"
Byrd fudged. But Johnson persisted until he got Byrd to make a public
commitment right then and there.
"Harry Byrd must have realized that he had just been manhandled by a true
master," says Blumenthal.
Dr. Blumenthal is the executive director of the Commonwealth Fund Task Force
on Academic Health Centers. He is also the director of the Institute for Health
Policy at Massachusetts General Hospital and Partners Health System and
professor of medicine in health care policy at Harvard Medical School. President
Obama has long said he wants an IT revolution in healthcare, the idea being
making medical records electronic will result in better patient care with lower
costs. And already a whopping $19.5 billion in public moola has been allocated in
the stimulus package towards that goal. Companies like Microsoft (MSFT) and
IBM (IBM) have set up IT healthcare units, salivating over getting their piece of
the pie.
Now we know who's in charge of overseeing how that $19.5 billion gets spent:
March 20, 2009
Contact: Anthony Coley/Melissa Wagoner (202) 224-2633
STATEMENT OF SENATOR EDWARD M. KENNEDY ON THE SELECTION OF
DR. DAVID BLUMENTHAL TO LEAD HEALTH IT EFFORT
WASHINGTON, DC-- Senator Edward M. Kennedy, Chairman of the Senate
Health Committee, today released the following statement in response to
President Obama's selection of David Blumenthal as coordinator for health
information technology:
"President Obama has made an inspired choice in selecting David Blumenthal to
lead the Administration's effort to bring health care into the digital age. David is
the right person to oversee this major initiative to reduce costs, avoid errors,
improve care, and save lives."
Dr. Blumenthal was a member of Senator Kennedy's health staff from 1977 to
1980. The recently enacted stimulus bill invested $19 billion for health
information technology.
There is not a more appropriate selection than Dr. David Blumenthal as National
Coordinator to lead America's Health Information Technology efforts through this
period of expansion and great promise. His selection by President Obama
illustrates the Administration's unqualified commitment to serious healthcare
reform and the vital role quality health information must play in this process. Dr.
Blumenthal brings to our challenge a unique depth of experience, an extremely
broad field of vision and, perhaps most important, an unquestionable
professional commitment to patient care and welfare -- the ultimate measurement
of successful reform.
"For these reasons especially, AHIMA looks forward to working with Dr.
Blumenthal and the ONC for HIT in the months and years ahead. And given our
shared commitment, health information management has never been more
certain of winning real reform -- including lower costs, better care and wider
coverage."
SOURCE American Health Information Management Association
Dr. Blumenthal underscores the need to prioritize health care reform and ―quiet
the inner economists‖ ─ not allowing the potential costs of reform to derail their
plans.
With Blumenthal’s perspective, look for Mr. Obama to apply some serious
political pressure on Congress to get through what he wants. This will likely
occur quickly, while there is plenty of political capital and will to ―get it done‖.
45 million on Medicare, 55 million on Medicaid, 50 (to 60) million uninsured in the
US.
FOR IMMEDIATE RELEASE
Wednesday, February 18, 2009
Contact: HHS Press Office
(202) 690-6343
CVS Pays $2.25 Million and Toughens Practices to Settle HIPAA
Privacy Case
The U.S. Department of Health and Human Services (HHS) and the Federal
Trade Commission (FTC) today announced that CVS, the nation’s largest retail
pharmacy chain, will pay the U.S. government a $2.25 million settlement and
take corrective action to ensure it does not violate the privacy of its millions of
patients when disposing of patient information such as identifying information on
pill bottle labels.
The settlement, which applies to all of CVS’s more than 6,000 retail pharmacies,
follows an extensive investigation by the HHS Office for Civil Rights (OCR) for
potential violations of the Health Insurance Portability and Accountability Act of
1996 (HIPAA) Privacy Rule.
In a coordinated action, CVS Caremark Corp., the parent company of the
pharmacy chain, also signed a consent order with the FTC to settle potential
violations of the FTC Act.
OCR, which enforces the Privacy Rule, opened its investigation of CVS
pharmacy compliance with the Privacy Rule after media reports alleged that
patient information maintained by the pharmacy chain was being disposed of in
industrial trash containers outside selected stores that were not secure and could
be accessed by the public. At the same time, the FTC opened an investigation of
CVS.
OCR and the FTC conducted their investigations jointly. This is the first instance
in which OCR has coordinated investigation and resolution of a case with the
FTC.
―OCR is committed to strong enforcement of the HIPAA Privacy Rule to protect
patients’ rights to privacy of their health information. We hope that this agreement
will spur other health organizations to examine and improve their privacy
protections for patient information during the disposal process,‖ said Robinsue
Frohboese, acting director of OCR. ―Such safeguards will benefit consumers
everywhere.‖
1. Tools for Decision Analysis
Decision making under risk is presented in the context of decision
analysis ... A Critical Panoramic View of Classical Decision Analysis ...
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'Medical home' concept embraced by IBM, other employers
Comprehensive, preventive medicine–rather than episodic care–paying off for early
adopters; return of the family doctor?
March 12, 2008 7:53 AM ET
When an IBM executive suddenly developed chest pain, he made an appointment with a
cardiologist, who performed a battery of tests that had inconclusive results except an
unidentifiable abnormality in the neck region.
The cardiologist referred the executive to a neck surgeon, who removed the abnormality. The
chest pain, however, persisted.
Several months later, the executive visited an IBM doctor to receive vaccinations prior to traveling
overseas and again reported the nagging pain. The company doctor pressed on the executive’s
chest, reproduced the pain and asked whether the executive had made any changes in his
routine before it started.
―It began when I started weed-whacking,‖ the executive said.
It turned out the executive was experiencing muscle soreness and inflammation due to
overexertion. But the correct diagnosis was not made until after $168,000 had been spent on
tests, surgery and several visits to specialists.
If that executive had a ―medical home,‖ a primary care doctor providing comprehensive, holistic
care, the cause of his pain may have been identified much earlier, said Dr. Paul Grundy, IBM’s
director of health care technology and strategic initiatives.
He said the hallmarks of a ―medical home‖ are an ongoing relationship with a doctor; a team
approach to delivering comprehensive, coordinated care that is integrated across the health care
system; the use of tools, such as electronic medical records, to ensure that care is delivered
safely and prevents redundancy and medical errors; and expanded access, including evening
and weekend office hours and the use of e-mail and telephone consultations (see story, page 10).
While in some ways the medical home sounds like the primary care physician in a closed-network
health maintenance organization, the medical home does not serve as a gatekeeper but rather as
a gateway to the health care system, Dr. Grundy said.
―A medical home is a real and virtual relationship with a doctor centered around a patient’s
needs,‖ he said.
Primary care system broken
IBM was one of the founders of the Patient-Centered Primary Care Collaborative, a coalition of
large employers and employer groups, consumer organizations and medical providers dedicated
to promoting the medical home concept to improve the quality of care and hopefully lower its cost.
―It started about three years ago with a discussion around my boss’ swimming pool,‖ Dr. Grundy
recounted. ―We were talking about the things large employers had done (to control health care
costs and improve quality) and realized that we were not addressing the fundamental issue�that
the primary care system is broken.‖
After that discussion, Dr. Grundy said IBM approached its health plans, asking to buy
comprehensive care for its employees, but the plans said they couldn’t do that.
―They said they could only sell what Medicare allows: episodic care based on code numbers,‖ Dr.
Grundy said.
For example, the current system compensates a surgeon for amputating the gangrenous limb of
a diabetic patient, but it doesn’t adequately compensate that patient’s doctor for managing the
care to prevent the amputation, Dr. Grundy said.
―So we reached out to primary care physicians and formed an organization that can change the
way we pay for care,‖ he said. ―It would make sense for buyers of care to pay more upfront if they
get the value on the back end. Companies like ours are committed to doing that.‖
Backers of the medical home model all agree that changing the provider compensation system is
essential to shifting the focus of medical delivery away from episodic care toward more
comprehensive, holistic care.
―There needs to be a re-emphasis on the importance of primary care,‖ said Dr. Bruce Bagley,
medical director for quality improvement at the American Academy of Family Physicians, which is
a member of the collaborative. ―The thing that’s wrong with the health care system is we value
high tech, impersonal care for some vs. primary care for all. This is the antidote.‖
Medical homes also could prevent an impending shortage of primary care physicians, Dr. Bagley
said.
Will doctors buy in?
Because the payment environment has undervalued primary care for the last decade, ―fewer
doctors are going into it. This is a way to reshape the payment environment to get a greater
proportion of health care dollars to flow to family physicians for these services,‖ Dr. Bagley said.
It also can help finance advances such as electronic medical records, he added.
―EMR and the medical homes are on parallel tracks,‖ Dr. Bagley said.
Bridges to Excellence, a coalition of employers devoted to improving the quality of patient care,
recently launched the BTE Medical Home Program to reward physicians who demonstrate they
have adopted good systems and processes of care and are using those systems to deliver
positive results in the management of their patients.
―These doctors will be compensated differently,‖ said Francois De Brantes, chief executive officer
of BTE. ―We believe very strongly�that these practices deserve somewhere around $125 per
patient per year in some form of additional incentive. How that incentive is distributed is up to
each plan or employer. Some plans are focusing more on fee schedule increases; others are
paying a basic capitation fee for care coordination.‖
In addition to capitation payments, ―providers will receive a bonus based on the quality of care
they deliver based on a set of standard performance measures,‖ Mr. De Brantes added.
But it is uncertain at this point whether payments such as the annual $125 per patient stipend
BTE provides will be enough to induce primary care doctors to serve as medical homes.
Paul Keckley, executive director of the Center for Health Solutions at Deloitte L.L.P. in
Washington, estimates it will cost at least $100,000 annually per practice to fully implement the
medical home model, based on a study the center published in February titled ―The Medical
Home: Disruptive Innovation for a New Primary Care Model.‖
To foster a transformation of the medical delivery system to emphasize primary care, the
Washington-based National Committee for Quality Assurance recently launched a new version of
its Physician Practice Connections program to evaluate medical homes.
The new Patient-Centered Medical Home designation program will emphasize the systematic use
of patient-centered, coordinated care management processes, said Margaret O’Kane, NCQA’s
president.
―It’s trying to assess whether you’re a 21st century practice,‖ Ms. O’Kane said. ―It’s much more
proactive than the old model of just thinking about you when you show up for an office visit. It’s
creating an ongoing relationship with the patient.‖ –Business Insurance
Write to the editors at [email protected].
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(ARA) - In what has been called the largest credit card fraud bust in American history, 11 people
were recently indicted for stealing up to 40 million credit card numbers. Could yours have been
one of the stolen numbers?
300,000,000 US population
300,000,000 Chinese users of the internet
PCMH
– Clinical pathways guide evidence based practice.
– Ongoing solicitation of patient input factors perceptions and
expectations
into care coordination, conveys clinically and
culturally relevant information to the physician.
– Enhanced access through open scheduling, telephone, e-mail and
other health information technology (HIT) synergize at point of care.
– Evidenced based outcomes and voluntary measurement analysis
drives quality improvement.
– Seamless integration of acute and well care with preventive
services
and chronic disease management.
Technology and the Law
THE LATEST LEGAL DEVELOPMENTS IN THE DIGITAL WORLD.
Stimulus Package Federalizes Health Information Breach
Notifications
Posted by: Aaron Titus in Privacy, HIPPA, HIPPA, HIPAA, Health
Information, Federal Legislation, Breach Notification Laws, Aaron Titus on Feb 2,
2009
Streamlining medical records has been a recurring theme of the Obama
administration. Tucked away in the pending economic stimulus legislation, known
as the American Recovery and Reinvestment Act (ARRA), is a provision which
would create a breach notification requirement for health information breaches.
Starting in Subtitle D, ARRA takes an unprecedented foray into federalizing data
breach notifications. Although ARRA regulates breaches of health information,
this legislation will no doubt be front and center of future debates about creating
a Federal Breach Notification Law.
Synopsis
Here is a quick analysis: ARRA mirrors most state breach notification laws, in
that it requires "covered entities" (i.e., Health Plans, Health Care Providers, and
Health Care Clearinghouses) to notify each individual if their "unsecured
protected health information has been, or is reasonably believed by the covered
entity to have been, accessed, acquired, or disclosed as a result of [a] breach."
Business Associates, or subcontractors, must alert the Health Care Provider of a
breach. The statute also places additional limits on how health information can
be sold and shared.
The statute dramatically broadens the ambiguous state-law concept of "data
owners," and applies to any HIPAA-covered entity that "accesses, maintains,
retains, modifies, records, stores, destroys, or otherwise holds, uses, or discloses
unsecured protected health information."
As expected, the Federal law takes a lowest-common-denominator approach to
duties. For example, although notifications must be made "without reasonable
delay," the statute allows up to 60 calendar days to comply. This is substantially
longer than the longest state requirement, which requires notification within 45
days.
Each state notification law requires direct (i.e. mail) notification to affected
individuals unless the person can't be found, and allows "Substitute Notice" in
cases of large breaches. "Substitute Notice" usually comprises posting an
announcement on the organization's website and notifying the media. Some
states do not permit Substitute Notice unless the breach is extremely large
(250,000+ in some cases). But ARRA allows substitute notice if the breach
involves just 500 people in a single state.
The statute also reaches well beyond traditional "covered entities" to any service
provider or vendor of personal health records. Presumably, this would include
data warehouses like Google or Microsoft, each of which has or has announced
plans to create online consumer health records warehouses. However, these
vendors need only report the breach to the FTC, which will treat it as a deceptive
trade practice. Individuals should not expect a letter from Google or Microsoft if
their health care records are breached.
On one hand, this federal legislation will plug holes in several states statutes by
regulating health information. Arizona, California, Hawaii, Michigan, Oregon, and
Rhode Island, for example, regulate health care providers and insurers differently
from other companies, and may even completely exempt them from notification
requirements.
This bill will no doubt spur the national discussion about breach notification laws.
But because they mimic existing state laws, the bill comes up short. Breach
Notification Laws were a step in the right direction when California passed the
first one almost seven years ago. But since that time, they have displayed
several shortcomings, which I critique here. Instead of fixing these problems,
ARRA will exacerbate many of them.
In Defense of Breach Notification
Laws (sort of)
Starting with California’s 2003 law, all but a hand full of states have now enacted
breach notification laws (BNLs). Though each is subtly different, all notification
laws recognize that a if your identity, or Data Self, is treated as mere chattel, it is
subject to fraud and abuse. These laws require data stewards to notify an
individual when his identity has been lost or kidnapped.
Your identity or Data Self is a digital alter-ego: a collection of personal facts
which has its own life, fallacies, and mortality. Data is Self, but data is also
treated like property. If Self is data, and data is property, then Self is
property. If your Self is the property of others, then it can be bought, sold,
traded, lost, stolen, or damaged like any other form of property. Identity Theft is
just that: Where a person’s Data Self is stolen and abused.
Measures of BNL Success
With five years of breach notification law experience, it is essential to ask, ―Are
they working?‖ My shorthand answer is ―yes, sort of.‖
I’ll be the first to admit that breach notifications are noisy, and contain a strong
element of political theater. Some contend that notification laws may even be
harmful, distracting and confusing consumers into thinking they aren’t at risk if
they don’t receive a notice. I agree that as currently written, breach notification
laws have several shortcomings. But their success or failure should be measured
in several ways:
1.
2.
3.
4.
Decreased Incidence of Identity Theft
Increased Awareness and Identity Control
Decreased Risk Behaviors and Incidence of Breach
Increased Victims’ Rights
1. Decreased Incidence of Identity Theft
Q: Do breach notification laws decrease identity theft?
A: Probably not. Several breach notification laws emphasize the need to protect
consumers from identity theft and other misuse of a person’s Data Self. However,
researchers Sasha Romanosky, Professor Rahul Telang, and Professor
Alessandro Acquisti presented a well-reviewed paper which measured the
change in the rate of reported identity thefts before and after data breach laws
went on the books. Though drawn from incomplete FTC data, the paper
convincingly demonstrates that breach notification laws have a negligible effect
on reported identity theft rates. Instead, they suggest that a state’s gross
domestic product and general fraud rate has a much stronger correlation with ID
theft.
2. Increased Awareness and Identity Control
Q: Do breach notification laws increase identity risk awareness? How
about consumers’ control over their identities?
A: Yes, to varying degrees. A cruel irony of data breaches is that the
responsible organization is the only one who knows exactly what happened, and
they have the strongest incentive to hide or skew the details. Many breaches go
under- or unreported, regardless of law. Even well-intentioned organizations
issue vague, incomplete, blame-shifting or liability-reducing press releases that
leave victims in the dark. In order to effectively empower consumers to conduct
their own risk analysis, breach notifications must contain the following elements:
Who: The class of victims affected by the breach.
What: A complete list of exposed information, not just the ones required
by law.
Where: Exposing entity’s contact information.
How and When: Sufficiently detailed information about the how and when
the breach occurred.
How Much: Total number affected, Sensitivity of information exposed,
Duration of exposure, and Distribution method (ie, stolen laptop, online
exposure, or dumpster).
What Now: A clear statement of consumer’s legal rights (or lack of rights);
Concrete actions taken by the organization to fix problems, mitigate risk,
or remedy harm; Suggested actions for the victim.
Of course, breach notification laws have much more lax reporting requirements
than these. And although I agree that the average breach announcement is
―noisy,‖ I think it would be a mischaracterization to label them as nothing more
than ―noise.‖ Even the least specific notifications build public awareness. For
better or worse, most public awareness of identity risks come from news bulletins
about data breaches. Although none of the announcements may put any
particular individual on notice of a personal risk, these ―noisy‖ notifications have a
net positive effect of educating the population at large.
3. Decreased Risk Behaviors and Incidence of Breach
Q: Do breach notification laws decrease individual risk behavior?
A: Probably Not, but they have the potential to. An effective notification must
contain actionable intelligence, which means Intelligence plus Action. For
example, imagine that you are in a life raft in the middle of the ocean, with no
hope of immediate rescue. You see bubbles. What do you do? You sink. You
were able to gather intelligence, but had no way to act upon it. Intelligence
without action breeds inaction.
However, imagine you’re on the same raft, and you see bubbles. But this time
you have a patch kit and a hand pump. This time you have actionable
intelligence, and you will likely attempt to patch the raft and pump it up.
An alert is only effective when it empowers a person to act. Typical breach
announcements usually do nothing to empower individuals. Effective breach
notifications require both intelligence and action. If either one of these elements
is missing (as is often the case), it will fail to empower victims, and may even
engender apathy.
Some suggest that in the current environment of data insecurity, consumers
should be on constant high alert for identity theft, even without notice of a breach.
After all, your Data Self is constantly being traded without your knowledge or
consent in IT and business environments of questionable reputes.
It’s a nice thought, but not very helpful. Being on high alert all the time is
essentially the same as not being on alert any of the time.
Q: Do breach notification laws encourage organizations to improve
behavior?
A: Probably yes. The Romanosky paper found that notification laws likely
encourage businesses to take more stringent safety precautions with personal
information, because of the economic incentive to avoid breaches. However, the
incentives to secure data do not appear to outweigh the market forces which
devalue privacy. Both the Privacy Rights Clearinghouse and the OSF Data Loss
Database show a steady, and perhaps even increasing number of breach
incidents and lost records each year. While part of this increase may be
attributable to better reporting, there is no solid indication that data breach
incidents are decreasing.
4. Increased Victims’ Rights
Q: Do Breach Notification Laws Create New Rights for Consumers?
A: Absolutely yes. While not the silver bullet to cure all ails, breach notification
laws are an important first step at creating rights for victims of breaches. Before
BNLs, nobody had the right to know whether their Data Self had been
compromised. Additional legislation will be necessary to address existing and
emerging identity threats. Especially as Data Selves are treated as property, our
society runs a risk that the unregulated trade of personal information could morph
into a new form of digital human trafficking.
Legislative Improvements
Breach notification laws are a first step in regulating the trade of Data Selves.
The right information at the right time, given to the right people, coupled with a
clear course of action will empower people and catalyze change. Here are six
legislative suggestions to effectively protect and empower consumers:
1. ―Stewards,‖ not ―Owners‖: Given the tenuous and dangerous legal
basis for ―owning‖ personal information, notification laws should replace
the concept of ―personal information owners‖ with ―personal information
stewards.‖ This change would help sharpen the distinction between Data
as Self versus Data as Property, and emphasize that third parties can’t
―own‖ a Data Self. When Self is Data and Data is Property, then we run
the risk that Self becomes Property.
2. Expand Reporting Requirements: Breach notifications should provide
actionable intelligence, including who, what, when, how, how much, and
―what now?‖ of each breach.
3. Standard Measures of Risk: I suggest using Size, Sensitivity, Duration,
and Distribution.
4. Presumptive Loss: In order to successfully sue for a breach, a consumer
must 1. Become an actual victim of identity theft, 2. Find the identity thief,
3. Prove that the thief’s copy of their SSN or other personal information
came from the breaching entity, and 4. Prove that the entity had a legal
obligation to keep that information private (a rare duty). This is an
unreasonable and often insurmountable burden of proof. Instead,
Tennessee has adopted a small presumptive ―ascertainable loss‖
whenever a breach occurs. These nominal damages would recognize
harm to reputation, apprehension, emotional distress, and violation of
selfhood. They would also help counteract the market’s failure to value
privacy
5. Require a Data Audit Trail: Stewards of personal information should
maintain standard inventory controls on personal information, recording
with whom and when the personal information was shared. This data trail
would be used for data audits and could help establish causation in the
case of a breach.
6. Automatic Credit Reporting: Consumers should get an automatic
notification at any activity on their credit.
Aaron Titus is the Privacy Director for the Liberty Coalition and runs National ID
Watch, and welcomes feedback.
Footnotes
Cal. Civ. Code §§ 1798.82-84.
See, e.g. N.H. Rev. Stat. § 359-C:2.
See, e.g. Ga. Code § 10-1-910(4),(7).
See, e.g. Cal. Civ. Code § 1798.81.5.(a).
Tenn. Code § 47-18-2102(1).
Posted by Aaron Titus on Thursday, December 18, 2008 at 12:25 am
Filed under Security Catalyst Contributors · Tagged with Breach Notification,
Identity Theft, security
Comments
7 Responses to ―In Defense of Breach Notification Laws (sort of)‖
1.
benjaminwright says:
December 18, 2008 at 3:06 PM
Aaron: You present a thoughtful argument. Still, you concede that ―none of
the announcements may put any particular individual on notice of a
personal risk‖. And you argue that the justification for mailing notices to
consumers is merely that ―notifications build [general] public awareness‖.
I argue that any specific notices mailed to consumers should be bluntly
accurate; otherwise they are misleading.
Let’s suppose that your rationale for sending notices to consumers is
correct. I would then I argue that notification laws should be changed so
that each specific notice mailed to a consumer start like this: ―This is a
general public service announcement mandated by the legislature. The
purpose of the specific information provided below is not to tell you
anything of any practical value to you. In fact, you are better off to just
ignore it and not read it. For all practical purposes applicable to you as an
individual, the information provided below is meaningless. . . . ‖
I argue that if legislature’s purpose is general public awareness, then it
should pursue that purpose directly (with public service announcements,
seminars etc.), and stop requiring the delivery of confusing notices to
individuals. -Ben http://legalbeagle.typepad.com/wrights_legal_beagle/2008/09/legal-liability-for-datasecurity-breach.html
2.
benjaminwright says:
December 18, 2008 at 3:30 PM
And, I argue a correct notice should say, ―The only information in this
notice that is of any value to you is this: All individuals should be on
absolute red alert for identity theft at all times, regardless of whether they
do or do not receive a notice like this.‖ -Ben http://hackigations.blogspot.com/2007/12/does-lost-tape-equate-to-lost-data.html
3.
aaron.titus says:
December 18, 2008 at 4:11 PM
Ben,
I agree with the substance of each of your statements. Specific notices
should be bluntly accurate (which is the premise of National ID Watch). All
individuals should be on red alert for identity theft at all times; but we
should also eat less and exercise more… and we don’t do that, either.
Breach Notifications (as currently required by law) are only marginally
effective, and should be improved. I like the idea of funding public
announcements, and I believe that the cost should be borne by the
breaching entities.
The question is, in my mind, ―How do we fix a broken system?‖ I tend to
take a glass-half-full approach, and view BNLs as an incomplete but
necessary first step in the effort to reduce identity theft, increase
accountability, improve consumer and organizational behavior, increase
awareness, and increase consumer rights. The next step is, exactly as
you suggest, to require bluntly accurate breach notifications, in
accordance with the principles in this article.
And in addition to notification, there are also other intended/unintended
benefits to BNLs.
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Check out what others are saying about this post...
1. Because I am Here » Blog Archive » In Defense of Breach Notification
Laws (sort of) says:
January 17, 2009 at 2:59 PM
[...] Note: This article was originally published on the Security Catalyst
Blog. [...]
2. The Top 5 Reasons You Won’t Hear About a Breach : The Security
Catalyst says:
January 23, 2009 at 7:21 AM
[...] have suggested solutions to some of these problems here and with the
creation of National ID [...]
3. Because I am Here » Blog Archive » The Top 5 Reasons You Won’t Hear
About a Breach says:
February 2, 2009 at 10:12 AM
[...] have suggested solutions to some of these problems here and with the
creation of National ID [...]
4. Because I am Here » Blog Archive » Stimulus Package Federalizes
Health Information Breach Notifications says:
March 6, 2009 at 9:49 AM
[...] one almost seven years ago. But since that time, they have displayed
several shortcomings, which I critique here. Instead of fixing these
problems, ARRA will exacerbate many of [...]
Newsroom
HHS HealthBeat (March 25, 2009)
What Diets Work
From the U.S. Department of Health and Human Services, I’m Ira Dreyfuss
with HHS HealthBeat.
There are low-protein diets, low-fat diets, and they all claim to work best.
So what approach works best? They all do, according to a study that looked at what
happened to dieters after a couple years. The researchers studied four varieties:
Low fat, average protein
Low fat, high-protein
High fat, average protein
And high fat, high protein
Researcher Frank Sacks of the Harvard School of Public Health:
"What surprised me, actually, is all the diets did the same. They were effective for
weight loss. And there was no advantage over the long run – or even over the short
run – in one diet over the other."
All the dieters kept off about 9 pounds over two years.
The study in the New England Journal of Medicine was supported by the National
Institutes of Health.
Learn more at hhs.gov.
HHS HealthBeat is a production of the U.S. Department of Health and Human
Services. I’m Ira Dreyfuss.
Last revised: March, 26 2009
Viagra Nascar Racing Jackets can be ordered on line
Googling Nascar will get to viagra for sale on line websites
Fish in U.S. Rivers Tainted With
Common Medications
THURSDAY, March 26 (HealthDay News) -- Fish from five U.S. rivers were
found to be tainted with traces of medications and common chemicals, according
to a new study from the U.S. Environmental Protection Agency and Baylor
University.
The common antihistamine diphenhydramine (Benadryl), an anticonvulsant and
two types of antidepressants were among the seven types of pharmaceuticals
found in the tissue and livers of fish from waterways in or near Chicago, Dallas,
Philadelphia, Phoenix and Orlando, Fla. Each river is considered "effluentdominated," because they receive large amounts of wastewater discharge from
nearby sewage treatment plants.
While federal standards exist for treated wastewater, they do not address
pharmaceuticals or most personal care products, and little is known about the
effects they have on the environment and wildlife. This study is part of a federal
strategy to address the issue.
Previous research has concluded that behavior vital for fish survival, such as
mating and fighting, can be affected if too much antidepressant residue collects
in their systems.
While other studies have found pharmaceuticals and personal care products in
wild river fish, this is the first time multiple compounds have been found in fish
from several different locations, co-lead investigator Bryan Brooks, an associate
professor of environmental sciences at Baylor, said in a news release issued by
the Texas-based university.
The medications and chemicals found from among the 36 tested for were, aside
from diphenhydramine:
the cholesterol drug gemfibrozil (Lopid), which researchers say had never
before been found in wild fish;
diltiazem (Cardizem), a medication that helps control high blood pressure;
carbamazepine (Tegretol), a drug used for epilepsy and bipolar disorder;
norfluoxetine, an active ingredient in the antidepressant fluoxetine
(Prozac);
the antidepressant sertraline (Zoloft);
galaxolide and tonalide, common odor-enhancing ingredients in soap and
other hygiene products.
Galaxolide and tonalide were found in the highest concentrations in the fish
tissue, while the others were more concentrated in the liver, which processes
foreign substances that enter the body.
The study was presented Wednesday at the American Chemical Society annual
meeting in Salt Lake City, while the results also are to be published in a special
online edition of Environmental Toxicology and Chemistry.
More information
The U.S. Geologic Survey has more about toxins in wastewater
occ-env-med-l] ProMED:
Gastroenteritis outbreak at "world's
best" restaurant, UK
Wednesday, March 25, 2009 10:32 AM
From:
"Gary Greenberg" <[email protected]>
Add sender to Contacts
To:
"Occ-Env-Med-L" <[email protected]>
UNDIAGNOSED GASTROENTERITIS, GOURMET RESTAURANT - UK (02):
(ENGLAND)
********************************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
Date: Fri 20 Mar 2009
Source: Health Protection Agency (HPA) press release [edited]
<http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1237535
658892?p=1231252394302>
Investigation at Fat Duck restaurant - update
--------------------------------------------[Norovirus is the most common cause of infectious gastroenteritis (diarrhoea and
vomiting) in England and Wales. The illness is generally mild and people usually
recover fully within 2-3 days; there are no long term effects that result from being
infected.
Noroviruses are named after the original strain "Norwalk virus," which caused an
outbreak of gastroenteritis in a school in Norwalk, Ohio, in 1968. Currently, there
are at least 4 norovirus genogroups affecting humans (GI, GII, GIII, and GIV),
which in turn are divided into at least 20 genetic clusters.
The incubation period for norovirus-associated gastroenteritis in humans is
usually between 24 and 48 hours, but cases can occur within 12 hours of
exposure. Norovirus infection usually presents as acute-onset vomiting, watery
non-bloody diarrhea with abdominal
cramps, and nausea. Noroviruses are transmitted primarily through the fecal-oral
route, either by consumption of fecally contaminated food or water or by direct
person-to-person spread.
Environmental and fomite contamination may also act as a source of infection.
No evidence suggests that infection occurs through the respiratory system.
The HealthMap/ProMED-mail interactive map locating the town of Bray in the
south east of England can be accessed at
<http://healthmap.org/promed/en?name=Bray,%20England,%20United%20Kingd
om&g=2654853&v=51.508,-0.701,10>
The final outcome of the HPA investigation is awaited. - Mod.CP]
Date: Fri 6 Mar 2009
Source: BBC News [edited]
<http://news.bbc.co.uk/2/hi/uk_news/england/berkshire/7927715.stm>
The number of people who have reported feeling ill after eating at Berkshire's
Michelin-starred restaurant "The Fat Duck" has risen to 400. Celebrity chef
Heston Blumenthal closed his restaurant in Bray more than a week ago after 40
customers fell ill. Mr Blumenthal said tests had ruled out food poisoning. In a
statement the Health Protection Agency (HPA) said cases reported to the
restaurant had risen since media coverage of the outbreak.
A boxing promoter said he fell ill after eating at the restaurant with friends and
would welcome an apology. "I really [did] enjoy the experience of it all," he said.
The people I was with, all of them are still suffering. Heston's obviously a very
talented guy, I watch his [TV] programs and I hope he gets it sorted out."
The HPA's Thames Valley Health Protection Unit is working with the Royal
Borough of Windsor and Maidenhead's environmental health department to
investigate the outbreak of vomiting and diarrhea. The restaurant remained shut
on Fri 6 Mar 2009.
Dr Graham Bickler, regional director of the HPA south east region, said: "This is
a very complex outbreak. We are working closely... to explain what happened
and to ensure that the risks of it happening again are reduced as much as
possible."
Samples have been taken from foodstuffs, people who have reported feeling ill,
and staff and work surfaces in the search for the cause of the illness. The chef
said the entire menu had been tested and all results had proved negative. Final
tests are being carried out to see if an airborne virus caused the sickness.
One diner went to the Fat Duck to celebrate his birthday in January 2009. His
brother and mother became ill and believes the cause could be a winter vomiting
bug [norovirus].
"While we all had a fantastic time, my brother and mother fell ill with diarrhea and
vomiting, for 5 days after," he added.
Diners at "The Fat Duck", 1 of only 3 restaurants in the UK with 3 Michelin stars,
can experience dishes such as snail porridge or scrambled-egg-and-bacon ice
cream. Opened in 1995, "The Fat Duck" was voted "the best place to eat on
Earth" by "Restaurant" magazine in 2005. [Taster menu begins at UKL 125 =
US$176 - Mod.JW]
-Communicated by:
ProMED-mail
<[email protected]>
[The epidemiology of this large cluster of illness, associated with a celebrity
chef's highly rated UK restaurant, must be known in order to be able to focus in
on the cause. The incubation period from dining to
onset of symptoms, length of illness, and the presence or absence of fever are 3
observations that can help distinguish a specific cause here. Norovirus is a
strong possibility -- see ProMED refs for 2000 & 2005 below.
Berkshire is a county in southern England. It is also often referred to as the Royal
County of Berkshire because of the presence of the royal residence of Windsor
Castle in the county. It can be found on a map at:
<http://en.wikipedia.org/wiki/Berkshire>. - Mod.LL]
[Photo of "The Fat Duck" restaurant at:
<http://upload.wikimedia.org/wikipedia/commons/4/4f/Fat_Duck.jpg>
Taster dish -- Snail Porridge with Jabugo ham & shaved fennel, accompanied by
a fine Austrian wine:
<http://farm2.static.flickr.com/1209/526512892_cd09b0cf92.jpg>
Photo of Windsor Castle at:
<http://www.bestvaluetours.co.uk/images/windsor-castle-christmas.jpg>
- Mod.JW
Gary N. Greenberg, MD MPH Sysop / Moderator Occ-Env-Med-L MailList
Univ. N. Carolina School Public Health
Medical Director http://www.UrbanMin.org
Urban Ministries of Wake County Open Door Clinic
http://www.OpenDoorDocs.org
[email protected]
http://occhealthnews.net
You are currently receiving Occ-Env-Med-L, a free discussion forum for clinical
and public health professionals (only) about topics in Occupational &
Environmental Medicine, housed at the University of N.Carolina School of Public
Health.
To broadcast to all readers, send your msg to [email protected]
Your messages are sent to: [email protected]
Center for Biosecurity
University of Pittsburg Medical Center
Clinicians Biosecurity Network
Third-generation Smallpox Vaccine LC16m8 Proven Safe and Immunogenic
By Amesh A. Adalja, MD, March 20, 2008
The Journal of the American Medical Association recently published a study
conducted by a team of Japanese researchers who vaccinated more than 3,000
Japanese military personnel from 2002-2005 with LC16m8, a tissue-cultured
third- generation smallpox vaccine. In the 1970s, LC16m8 was used in Japan to
immunize approximately 100,000 infants, with no reported adverse events
detected via passive surveillance.1 Third generation smallpox vaccines, as
discussed in a prior issue of the CBN Report, are attenuated vaccine strain
viruses that possess a reduced tendency to elicit adverse reactions, as
compared with first and second generation vaccines. They are thought to have
an improved safety profile in patients with HIV, atopic skin diseases, and other
immune system abnormalities that have historically precluded use of the earlier
generation vaccines. Since the third generation vaccines have been available
only since smallpox was eradicated, their efficacy in humans cannot be
definitively established.
Japanese Military Recruits Selected as Study Subjects
The objective of the current study was to assess the immunogenicity and safety
profile of LC16m8 in both vaccinated and unvaccinated adults. The study
subjects were recruits in the Japan Self Defense Forces during the years 20022005. Six selection rounds were performed, with 350 to 700 healthy adults aged
18 to 55 years recruited in each round. Immunosuppression (including the use of
immunosuppressive drugs) and current eczema were among the exclusion
criteria. Individuals with atopic dermatitis with stable skin lesions were
vaccinated.1
Stratification by Prior Smallpox Vaccination
The researchers stratified subjects based on age as a surrogate for vaccination
history. Given that routine smallpox vaccination with 3 inoculations with a first
generation vaccine stopped in 1976, different birth cohorts had different
vaccination histories. Four groups with varied vaccination histories ultimately
were identified: never vaccinated, vaccinated once, vaccinated twice, and fully
vaccinated with 3 doses.1
Study subjects were vaccinated with 1 dose of the LC16m8 vaccine and then
were monitored for 30 days. Appearance of a skin reaction (pustule, induration,
congestion) at the site of vaccination 10 to 14 days after inoculation indicated
success, that is, a clinical ―take.‖ Serum was also analyzed for neutralizing
antibody titers. General health interviews, electrocardiography (ECG), and
troponin assays at 30 days post-vaccination were also performed. The ECG and
troponin testing were administered to identify cases of myopericarditis, a known
complication of the vaccine currently licensed in the U.S.1
Primary Vaccinees Had Higher Take Rates and Seroconversion
In all, 3,221 individuals were vaccinated, 4 of whom had atopic dermatitis.
Approximately 50% had never been vaccinated, 98.4% were men, and all were
Asian. Clinical take rates were significantly increased in primary vaccinees as
compared with re-vaccinees (94.4% vs. 86.6%); however, primary vaccinee age
did not affect the likelihood of a clinical take. Re-vaccinees who had only 1 prior
vaccination displayed take rates higher than those who had received 2 or 3 prior
vaccinations. A higher propensity for seroconversion (4-fold titer increase) in
those who had not been previously vaccinated was found; however, titers of
neutralizing antibodies against LC16m8 were not significantly different between
primary vaccinees and revaccinees. Overall, the vaccine displayed high levels of
vaccine take in primary vaccinees and provoked an effective booster response in
some re-vaccinees.1
Naïve
Vaccine take in recipients
Seroconversion and/or
boost
in those with vaccine take
Revaccinees
1,443/1,529 1,465/1,692
(94.4%)
(86.6%)
37/41
(90.2%)
No Adverse Events Requiring VIG
93/155
(60%)
No severe adverse events were noted during the vaccination period, and there
was no need for vaccinia immuneglobulin (VIG) use. However, in the 30-day
post-vaccination follow-up, 2 possibly severe events occurred: 1 case of allergic
dermatitis and 1 case of erythema multiforme. No ECG abnormalities or
elevations of troponin levels were detected.1
Should the U.S. Diversify the Strategic National Stockpile to Include LC16m8?
The results of this study are important in light of the recent decisions by the U.S.
government to pursue third generation vaccines, as evidenced by the award of a
contract to Bavarian Nordic, the manufacturer of Imvamune (see CBN Report, 108-2009). While neither vaccine has been tested against human smallpox cases
in vivo, LC16m8 has been used without ill effect several times since the largescale use in the 1970s mentioned above.
While the advantages of one third generation vaccine over another have not
been elucidated, additional data on use in immunocompromised individuals may
be the deciding factor, given that 4% of Americans are immunocompromised and
10% to 15% have atopic skin disease. The first and second generation vaccines
are contraindicated in both groups.
While the safety data for LC16m8 are impressive, it is the case that in this study,
ECGs were performed only at 30 days post-vaccination, which means that
asymptomatic cases of myopericarditis that may have occurred within 7 to 14
days of vaccination would have been missed. However, the clinical significance
of detection of these asymptomatic cases is debatable.
Given the results of this study, it may be prudent to diversify the U.S. stockpile of
smallpox vaccines to include LC16m8.
References
1. Saito T, Fujii T, Kanatani Y, et al. Clinical and immunological response to
attenuated tissue-cultured smallpox vaccine LC16m8. JAMA 2009;301:10251033. http://jama.ama-assn.org/cgi/content/full/301/10/1025. Accessed March 16,
2009.
-Gary N. Greenberg, MD MPH Sysop / Moderator Occ-Env-Med-L MailList
Univ. N. Carolina School Public Health
Medical Director http://www.UrbanMin.org
Urban Ministries of Wake County Open Door Clinic
http://www.OpenDoorDocs.org
[email protected]
http://occhealthnews.net
March 16, 2009
http://www.jhsph.edu/publichealthnews/press_releases/2009/graham_flies.html
Flies May Spread Drug-Resistant Bacteria from Poultry Operations Researchers
at the Johns Hopkins Bloomberg School of Public Health found evidence that
houseflies collected near broiler poultry operations may contribute to the
dispersion of drug-resistant bacteria and thus increase the potential for human
exposure to drug-resistant bacteria. The findings demonstrate another potential
link between industrial food animal production and exposures to antibiotic
resistant pathogens. Previous studies have linked antibiotic use in poultry
production to antibiotic resistant bacteria in farm workers, consumer poultry
products and the environment surrounding confined
poultry operations, as well as releases from poultry transport.
―Flies are well-known vectors of disease and have been implicated in the spread
of various viral and bacterial infections affecting humans, including enteric fever,
cholera, salmonellosis, campylobacteriosis and shigellosis,‖ said lead author Jay
Graham, PhD, who conducted the study as a research fellow with Bloomberg
School’s Center for a Livable Future. Our study found similarities in the antibioticresistant bacteria in both the flies and poultry litter we sampled. The evidence is
another example of the risks associated with the inadequate treatment of animal
wastes.‖
―Although we did not directly quantify the contribution of flies to human exposure,
our results suggest that flies in intensive production areas could efficiently spread
resistant organisms over large distances,‖ said Ellen Silbergeld, PhD, senior
author of the study and
professor in the Bloomberg School of Public Health’s Department of
Environmental Health Sciences.
Graham and his colleagues collected flies and samples of poultry litter from
poultry houses along the Delmarva Peninsula—a coastal region shared by
Maryland, Delaware and Virginia, which has one of the highest densities of
broiler chickens per acre in the United States. The analysis by the research
team isolated antibiotic-resistant
enterococci and staphylococci bacteria from both flies and litter. The bacteria
isolated from flies had very similar resistance characteristics and resistance
genes to bacteria found in the poultry litter.
Flies have ready access to both stored poultry waste and to poultry houses. A
study by researchers in Denmark estimated that as many as 30,000 flies could
enter a poultry house over the course of six week period.
Additional authors of ―Antibiotic-resistant enterococci and
staphylococci isolated from flies collected near confined poultry feeding
operations‖ are Lance Price, Sean Evans and Thaddeaus Graczyk.
The study is published in the April 2009 issue of Science of the Total
Environment.
The research was funded by a grant from the Johns Hopkins Center for a Livable
Future.
According to Robert Lawrence, MD, director of the Center for a Livable Future,
confined animal feeding operations—where thousands of animals are crowded
together and are fed antibiotics for growth promotion—create the perfect
environment for selection of bacteria that are resistant to antibiotics.
―Antimicrobials are among the most important developments of the twentieth
century in managing infectious diseases in people. We can’t afford to squander
them by using them as growth promoters in industrial food animal production.
The increase in antibiotic-resistant bacteria is a major threat to the health of the
public, and policymakers should quickly phase out and ban the use of
antimicrobials for non-therapeutic use in food animal production,‖ said Lawrence.
Media contact for the Johns Hopkins Center for a Livable Future: Chris
Stevens at 410-502-2317 or [email protected].
Media contact for Johns Hopkins Bloomberg School of Public Health: Tim
Parsons at 410-955-7619 or [email protected].
I want to alert occ-env-med members to a case of criminal fraud by a drug
company affecting pretty much every self insured employer and workers
compensation insurer. If you work for or advise one of them, you should learn
about this case and know what to do.
In 2007 Purdue Pharma pled guilty to criminal charges that it mislead physicians
about the risks of addiction to Oxycontin. It paid a large fine to the Federal
government. Now, a federal court is in the process of implementing a class action
settlement, which enables any party that paid for Oxycontin between 1995 and
2008 to recover some of its payments.
This case is not just about Purdue misleading physicians to promote this drug. It
is also about using deception to increase the probability that thousands of
patients, many of them injured workers, will become psychologically and
physically dependent on pain medication
The settlement is not designed to recompense injured workers whose lives were
up-ended by addiction to Oxycontin. That would require another suit on behalf of
these workers.
At this moment, is it incumbent on self insured employers and workers comp
insurers (as well as health insurers) to file by May 19 in order to recover from
Purdue some of their Ozycontin outlays. Go to
www.oxycontintppsettlement.com. I’d appreciate your keeping in touch with me
on this matter.
Peter Rousmaniere
508 Woodstock Rd.
Woodstock VT 05091
802-457-9149 voice and fax
802-291-3843
[email protected]
professional website:
www.peterrousmaniere.com
River Po awash with 'cocaine'
Italian scientists have discovered that the river Po contains the remains of the
consumption of more than 4kg of cocaine daily - equivalent to an annual snow
festival of 1,500kg per year among the Po valley's five million inhabitants.
The point of all the numbers - published in the net's Environmental Health by a
team from the Institute for Pharmacological Research in Milan - is that
consumption of cocaine in the region is much higher than previously thought.
Indeed, the authorities had estimated the daily inhalation of nose candy at 27
doses (100mg) per 1,000 young adults.
These figures have now been literally blown out of the water by the test for
benzoylecgonine, a byproduct of the body metabolising cocaine which makes its
way into the sewer system in the normal way, and thence to the river Po.
The investigative team described the findings as "staggering", which comes as a
bit of a surprise since the river Po benefits from the presence of world fashion
capital Milan - generally considered to have the greatest percentage of anorexic
models among its population and therefore the planet's highest per capita
consumption of Bolivian marching powder.
weblog:
www.workingimmigrants.com
PROGRESSIVE INFLAMMATORY NEUROPATHY, PORK PLANT WORKERS USA: 2007-2008
************************************************************************
A ProMED-mail post <http://www.promedmail.org>
ProMED-mail is a program of the International Society for Infectious Diseases
<http://www.isid.org>
Date: Tue 3 Mar 2009
Source: Feedstuffs [edited}
<http://tinyurl.com/b92muo>
Workers at pork processing plants who developed a rare neurological disorder 2
years ago [2007] after being exposed to [organic] mist while removing brains
from pigs have improved but still display symptoms, according to a study by the
Mayo Clinic in Rochester, Minnesota (MN).
The workers at "heads tables" at Quality Pork Processors in Austin, MN, and at
another plant in Indiana had used compressed air to extract pig brains and
developed chronic inflammatory demyelinating polyneuropathy, which attacks
nerves and produces numbness, tingling and weakness in arms and legs.
An investigation by the Centers for Disease Control & Prevention found that only
3 USA pork plants used the compressed air process to remove pig brains: the
ones in Indiana and Minnesota and another in Nebraska.
All 3 voluntarily ceased using the process.
The Mayo study found that 16 of 17 of the workers who were treated with
immune therapies such as steroids improved with the treatment, 12 markedly so,
according to a report that has been prepared for a neurology meeting next month
[April 2009]; 6 workers who had no treatment also improved after they were no
longer exposed to the pig brain mist, according to the report.
[Byline: Rod Smith]
[Although the exact antigenic stimulus is not clear, the
pathophysiology appears to be exposure to a neural antigen such as myelin via
inhalation of the "pig brain mist". - Mod.LL]
-Gary N. Greenberg, MD MPH Sysop / Moderator Occ-Env-Med-L MailList
Univ. N. Carolina School Public Health
March 5, 2009
http://www.fda.gov/bbs/topics/NEWS/2009/NEW01967.html
Media Inquiries:
Karen Riley, 301-796-4674
Consumer Inquiries:
888-INFO-FDA
FDA Warns About Risk of Wearing Medicated Patches During MRIs
Certain adhesive patches that deliver medication through the skin have been
found to be a risk to patient safety. The patches, if worn while undergoing
magnetic resonance imaging scans or MRIs, can cause skin burns, says the U.S.
Food and Drug Administration today.
The patches of concern include both brand name and generic products and
patches purchased over the counter without a prescription.
The FDA issued the Public Health Advisory on transdermal drug patches after
learning that a warning was missing on some patches that contain aluminum or
other metals in their non-adhesive backing. The backing is the portion of the
patch not in direct contact with the skin. While not attracted to the magnetic field
of the MRI, the metal can conduct electricity, generating heat which can cause
burns. Users of the patches reported receiving skin burns at their patch site when
wearing the patch during an MRI scan.
"The risk of using a metallic patch during an MRI has been
well-established, but the FDA recently discovered that not all manufacturers
include a safety warning with their patches," said Janet Woodcock, M.D., director
of the FDA's Center for Drug Evaluation and Research. "Because the metal in
these patches may not be visible and the product labeling may not disclose the
presence of metal, patients
should tell both their health care professional and their MRI facility that they wear
a medicated adhesive patch."
The FDA was alerted to the missing MRI warning on Teva
Pharmaceutical's fentanyl transdermal system in January. The FDA investigated
and found that a similar warning was also missing on a variety of skin, or
transdermal, patches delivering medications.
The FDA is reviewing the labeling and composition of all medicated patches to
ensure that those made with materials containing metal provide a warning to
patients undergoing an MRI and will alert the public when this information has
been added. Until then, the agency recommends that people wearing medicated
skin patches, including nicotine patches, talk to a health care professional about
their patch at the time they receive their MRI referral. The professional will
advise the patient about when to remove the patch before the procedure and
about replacing it after the procedure.
Patients should also tell their MRI facility that they are using a patch when they
call to schedule their appointment and should repeat this information when filling
out their health history questionnaire after arriving for their appointment.
A ProMED-mail post <http://www.promedmail.org>
ProMED-mail is a program of the International Society for Infectious Diseases
<http://www.isid.org>
Date: Sun 15 Feb 2009
Source: Asia News Magazine. Yomiuri Shinbun report [edited]
<http://www.asianewsmagazine.com/world-today-news/pollution-afflicts-thaifarmers-toxic-cadmium-poisoning-symptoms-similar-to-itai-itai-disease.html>
Pollution afflicts Thai farmers. Toxic cadmium poisoning symptoms similar to 'itai
itai' disease
Farmers in a cadmium-polluted village in northern Thailand have been
complaining of symptoms similar to Japan's 'itai itai' disease, a type of cadmium
poisoning, and one of the 4 major pollution-related diseases in Japan.
In mid-January [2009], a group of 1128 Thai farmers filed a damages suit against
a local zinc-mining operator and a mine development firm, demanding 3.7 billion
baht (USD 105 million) in compensation. But the farmers are in a quandary, as
the legal battle is expected to be lengthy before any settlement.
In the Mae Ku district in the suburbs of Mae Sot, [Tak province in north western
Thailand], former rice paddies stretching over a gently sloping hilly area are now
covered with weeds, exposing cracks on the dry surface. "Only black rice grows
here," said [a farmer], 68, as she stood and looked at the tainted paddies. Having
devoted herself to
rice cultivation for the past 4 decades, [she] was proud of her rice crop, which
once won an award at an agricultural fair. However, the rice in her paddies began
turning dark around 2000.
The nonprofit International Water Management Institute (IWMI) concluded in
2004 that pollution of accumulated cadmium had changed the color of the rice in
the area. Upon the discovery, the Thai government banned farmers in the
polluted area from cultivating rice.
So [the farmer] began growing corn for fuel use and other vegetables in place of
rice, but in vain. "They didn't grow well, so I couldn't make enough money," she
said. That calamity was followed by her own health problems. "Recently, I've
been troubled with persistent pain, as if the bones in my arm are squeaking," she
said, adding that
calcium prescribed by her doctor was not helping. Her husband, 70, has been
bedridden for 2 years. She heard a rumor that 40 people had died in connection
with the tainted "black rice". "I was told my symptoms are similar to those of
Japan's 'itai itai' disease sufferers, whose
bones turned fragile. I don't want to die," she said, as tears welled in her eyes.
The IWMI survey showed that about 2000 hectares [4940 acres] in the Mae Ku
area and its vicinity had been polluted with cadmium. The amount of cadmium
detected in the tainted rice was more than 5 times the internationally permissible
level of 0.4 milligrams per kilogram.
Though the Thai government purchased polluted rice between 2004 and 2007, it
failed to take any measures to compensate for the farmers' financial losses.
Moreover, the source of the contamination has yet to be determined. A separate
survey by Mae Sot General Hospital and other groups found that about 7000
residents in the Mae Ku region and its
vicinity have complained of pains in their bones and of kidney disorders -symptoms believed to be caused by cadmium intake.
Although examinations by Japanese doctors and other experts showed that the
patients' symptoms at this stage were not as critical as those of 'itai itai' disease
sufferers, a local doctor expressed concern. "High levels of cadmium have
accumulated in the bodies of many elderly patients. We should take careful note
of the situation," said Pisit Limpatanachote, a doctor at Mae Sot General
Hospital,
adding that sufficient steps to address the situation have yet to be taken.
Farmers suspect the zinc-mining firm had released cadmium-contaminated
waste water into the river during the refining process. "I've lost my job, become
sick, and haven't received compensation. I can't stand this situation any longer,"
said [an individual] who represents the plaintiffs. But resolving the dispute likely
will take some time, as the company is set to contest its responsibility for the
cadmium contamination. "We believe the company has met required
environmental standards," said a company official in charge of general affairs.
[byline: Norimasa Tahara]
-- communicated by: ProMED-mail rapporteur Susan Baekeland
[The disease referred to 'itai-itai' literally translates to 'ouch-ouch' disease. The
disease is characterized by osteomalacia accompanied with osteoporosis, and
multiple proximal renal tubular dysfunctions. Cadmium causes a syndrome
described as softening of the bones, and it affects all bones and joints, including
those of the
spine. The bone pain and the kidney pain of those suffering from the disease
gave rise to the name of the disease.
In addition, victims of cadmium intoxication generally suffer with dry throat,
cough, headache, vomiting, chest pain, congestive lung conditions, pulmonary
edema, bronchospasm, wheezing, pneumonitis, muscle weakness, and severe
leg pain.
The situation for those suffering from cadmium disease is sad and made more
unfortunate by the inability to discover the source and for the people to receive
some type of compensation in order to live.
Supportive care is about the best treatment. EDTA has been added to
hemodialysis and has had some positive effect. - Mod.TG MENINGITIS,
MENINGOCOCCAL - USA: (PENNSYLVANIA)
***********************************************
A ProMED-mail post <http://www.promedmail.org>
ProMED-mail is a program of the International Society for Infectious Diseases
<http://www.isid.org>
Date: Tue 17 Feb 2009
Source: MSNBC [edited]
<http://www.msnbc.msn.com/id/29226512/>
The Philadelphia Health Department is investigating a 4th possible case of
meningococcal meningitis at the University of Pennsylvania, officials said
Monday [16 Feb 2009]. The university would not comment on the investigation
but did release a statement saying the 3 students who were hospitalized with the
disease last week are showing
improvement.
Two additional students who are from the same social circle were hospitalized
over the weekend with flu-like symptoms. Their conditions are also improving,
officials said. Doctors have been closely monitoring their conditions to ensure
they did not in fact contract meningitis.
Penn officials believe the disease has been spread through the university's
Greek [fraternity/sorority] system. As a precaution, all on and off-campus parties
were shut down this past weekend.
Meningitis is spread through close, prolonged contact like sharing toothbrushes
or utensils, kissing, or sexual contact. University officials say it is not uncommon
for more than one case to pop up on campuses. Early symptoms of infection
include fever, severe headache, stiff neck, nausea, vomiting, rash, lethargy and
sensitivity to bright
light.
More than 2100 students have received preventive antibiotics since the 1st report
of a meningitis outbreak was released.
[Byline: Vince Lattanzio]
-[Each year, up to 3000 people in the USA develop meningococcal disease. The
annual incidence generally ranges from 0.5 to 1.1 cases per 100 000. The
incidence peaks in late winter and early spring. Most cases are sporadic; less
than 2 percent occur in outbreaks
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5407a1.htm>. Outbreaks tend to
occur in semi-closed communities, such military recruit camps, college
dormitories, schools, and day-care centers. Community-based outbreaks in
towns, cities, and counties may also occur among persons who are not close
contacts of each other and who do not share a common affiliation.
Although the incidence of meningococcal disease in general is highest in children
less than 2 years of age
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5407a1.htm>, more cases arise
among the 5 to 19-year-old group during epidemics than during non-epidemic
periods. Currently, serogroups B, C and Y cause the majority of infections in the
USA; serogroup A is rare in the USA, and W-135 causes a very small proportion
of infections; serogroup B is the
most common serogroup in infants, while serogroup Y causes the majority of
cases in those aged 65 years and older
<http://www.nfid.org/pdf/meningitis/FINALChanging_Epidemiology_of_Meningoc
occal_Disease.pdf>.
An outbreak of meningococcal disease is defined as the occurrence of 3 or more
confirmed or probable cases during a period of less than or equal to 3 months,
resulting in a primary disease attack rate of at least 10 cases per 100 000
persons, which is approximately 10-fold greater than the normal occurrence
<http://www.cdc.gov/mmwr/preview/mmwrhtml/00046237.htm>.
Chemoprophylaxis is given to appropriate contacts whose risk for acquiring
meningococcal disease is 500-800 times greater than among the total population
<http://www.cdc.gov/mmwr/preview/mmwrhtml/00046237.htm>. Close contacts
of patients are household members, day care center contacts, and persons
directly exposed to the patient's oral secretions.
Administering chemoprophylaxis to persons who are not close contacts of
patients usually is not recommended. Neither oropharyngeal nor nasopharyngeal
cultures for _N. meningitidis_ are useful in deciding who should receive
chemoprophylaxis.
In an outbreak, the population at risk should be vaccinated with the
meningococcal vaccine appropriate for the serogroup causing the outbreak as
soon as possible after an outbreak has been declared
<http://www.cdc.gov/mmwr/preview/mmwrhtml/00046237.htm>. Mass
immunization campaigns are labor-intensive and costly. Meningococcal
polysaccharide vaccines do not protect very young children, do not protect
unvaccinated population groups, and only provide protection for up to 3 years. As
a result, repetitive meningitis outbreak responses can deplete a country's scarce
health care finances with
comparably little impact. A preventive strategy based on conjugate vaccines
could have a significantly larger and more enduring impact.
A quadrivalent A, C, Y and W-135 conjugate vaccine was licensed in the United
States in January 2005. The meningococcal conjugate vaccines induce a T-celldependent response, resulting in an improved immune response in infants,
providing long-lasting immunity and preventing
nasopharyngeal carriage of _N. meningitidis_and thus reducing bacterial
transmission of this microorganism
<http://www.nfid.org/pdf/publications/meningococcalepid.pdf>. The CDC in any
case now recommends the meningococcal conjugate vaccination for college
students and any persons aged 11 to 18 years, military recruits, microbiologists
who are routinely exposed to isolates of _N. meningitidis_, persons who travel to
Mecca during the annual Hajj or to countries in which _N. meningitidis_ is
hyperendemic or epidemic, particularly if contact with the local population will be
prolonged, persons who have terminal complement component deficiencies, and
persons who have anatomic or functional asplenia
<http://www.medscape.com/viewarticle/559807>,
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5407a1.htm>.
Dr. Caroline Johnson, Director of the Division of Disease Control for the
Philadelphia Department of Public Health reports: That the 3 culture-confirmed
cases were caused by meningococcus serogroup B, for which there is no
effective vaccine; that the 3 isolates were ciprofloxacin-susceptible (ciprofloxacinresistant meningococcal isolates have been reported in the past, see ProMEDmail Meningitis,
meningococcal, drug resistant - USA (MN, ND) 20080215.0601); and that the
population at risk is the student population of about 3000 involved in the campus
fraternity/sorority system. The attack rate of 3 confirmed cases and one case that
is probable in 3000 is over the
outbreak threshold of 10 per 100 000. Dr. Johnson also reports that the
fraternity/sorority campus population was given preventive ciprofloxacin and that
99 percent of University of Pennsylvania students were vaccinated against
meningococcal disease prior to admission, but serogroup B disease,
unfortunately, is not vaccine-preventable.
Philadelphia, Pennsylvania can be found on the HealthMap/ProMED-mail
interactive map of the USA at
<http://healthmap.org/promed?v=40,-97.6,4>. - Mod.ML] Recommendations and
Reports
Volume 58, No. RR-3
February 13, 2009
PDF of this issue
http://www.cdc.gov/mmwr/PDF/rr/rr5803.pdf
Plan to Combat Extensively Drug-Resistant Tuberculosis Recommendations of
the Federal Tuberculosis Task Force
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5803a1.htm?s_cid=rr5803a1_e
48 pages
Summary
An estimated one third of the world's population is infected with Mycobacterium
tuberculosis, and nearly 9 million persons develop disease caused by M.
tuberculosis each year. Although tuberculosis (TB) occurs predominantly in
resource-limited countries, it also occurs in the United States.
During 1985--1992, the United States was confronted with an
unprecedented TB resurgence. This resurgence was accompanied by a rise in
multidrug-resistant TB (MDR TB), which is defined as TB that is resistant to the
two most effective first-line therapeutic drugs, isoniazid and rifampin. In addition,
virtually untreatable strains of
M. tuberculosis are emerging globally. Extensively drug-resistant (XDR) TB is
defined as MDR TB that also is resistant to the most effective second-line
therapeutic drugs used commonly to treat MDR TB: fluoroquinolones and at least
one of three injectable second-line drugs used to treat TB (amikacin, kanamycin,
or capreomycin). XDR TB
has been identified in all regions of the world, including the United States.
In the United States, the cost of hospitalization for one XDR TB patient is
estimated to average $483,000, approximately twice the cost for MDR TB
patients. Because of the limited responsiveness of XDR TB to available
antibiotics, mortality rates among patients with XDR TB
are similar to those of TB patients in the preantibiotic era.
In January 1992, CDC convened a Federal TB Task Force to draft an action plan
to improve prevention and control of drug-resistant TB in the United States (CDC.
National action plan to combat multidrug-resistant tuberculosis. MMWR
1992;41([No. RR-11]). In November 2006, CDC reconvened the Task Force to
draft an updated action plan to address the issue of MDR TB and XDR TB. Task
Force members were divided into nine response areas and charged with
articulating the most pressing problems, identifying barriers to improvement, and
recommending specific action steps to improve prevention and control of XDR
TB within their respective areas.
Although the first priority of the Federal TB Task Force convened in 2006 was to
delineate objectives and action steps to address MDR TB and XDR TB
domestically, members recognized the necessity for TB experts in the United
States to work with the international community to help strengthen TB control
efforts globally. TB represents a
substantial public health problem in low- and middle-income countries, many of
which might benefit from assistance by the United States. In addition, the global
TB epidemic directly affects the United States because the majority of all cases
of TB and 80% of cases of MDR TB reported in the United States occur among
foreign-born persons. For these reasons, the Action Plan also outlines potential
steps that U.S. government agencies can take to help solve global XDR TB
problems. Unless the fundamental causes of MDR TB and XDR TB are
addressed in the US and internationally, the United States is likely to experience
a growing number of cases of MDR TB and XDR TB that will be difficult, if not
impossible, to treat or prevent.
The recommendations provided in this report include specific action steps and
new activities that will require additional funding and a renewed commitment by
government and nongovernment organizations involved in domestic and
international TB control efforts to be implemented effectively. The Federal TB
Task Force will coordinate
activities of various federal agencies and partner with state and local health
departments, nonprofit and TB advocacy organizations in implementing this plan
to control and prevent XDR TB in the United States and to contribute to global
efforts in the fight against this emerging public health crisis.
Introduction
Global Health Burden of Tuberculosis
Tuberculosis (TB) is among the most common infectious diseases and frequent
causes of death worldwide (1). TB is caused by Mycobacterium tuberculosis and
is spread most commonly by airborne transmission. M. tuberculosis can affect
any part of the body but is found most often in the lungs. Persons with pulmonary
TB generally have a cough that produces small airborne droplet nuclei containing
tubercle bacilli that can remain in the air for hours. Vulnerable persons exposed
to tubercle bacilli in airborne droplets might become infected. The majority of
persons who become infected remain noncontagious and without a cough or
other symptoms. These persons have latent M. tuberculosis infection (LTBI) and
can be treated with a single drug
(isoniazid) for 9 months to prevent disease.
Infected persons who do not have underlying medical problems and do not
receive LTBI treatment have a 5%--10% lifetime risk for progressing to TB
disease (2). However, the risk for disease progression increases substantially in
the presence of immunosuppression, such as that caused by the human
immunodeficiency virus (HIV) and immunosuppressive medications (2). Persons
with pulmonary TB can be cured with a 6-month course of antibiotics that
includes isoniazid, rifampin, pyrazinamide, and ethambutol during the first 2
months. In the United States, diagnosis and treatment for TB is accessible and
effective (3). However, many developing countries have limited resources to
diagnose TB illness and treat persons with TB. Worldwide, 2 billion persons (one
third of the world's population) are thought to have LTBI. Nearly 9 million persons
develop TB disease each year, and close to 2 million TB-related deaths occur
annually (1). In the United States, approximately 13,000 new cases of TB are
reported annually, and 650 persons die from TB each year (4). TB is
the leading cause of mortality among persons infected with HIV (5).
...
much more ...
MMWR: 09-02-13,
Coccidioidomycosis Increase - CA,
2000-7
Friday, February 13, 2009 11:37 PM
From:
"Gary Greenberg" <[email protected]>
Add sender to Contacts
To:
"Occ-Env-Med-L" <[email protected]>
February 13, 2009 / 58(05);105-109
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5805a1.htm?s_cid=mm5805a1
_e
Increase in Coccidioidomycosis --- California, 2000--2007
Coccidioidomycosis is an infection resulting from inhalation of airborne spores of
Coccidioides immitis or Coccidioides posadasii, soil-dwelling fungi endemic to
California's San Joaquin Valley; southern regions of Arizona, Utah, Nevada, and
New Mexico; western Texas; and regions of Mexico and Central and South
America (1). Of an
estimated 150,000 new infections annually in the United States (2),
approximately 60% are asymptomatic (1). Patients with symptoms usually
experience a self-limited influenza-like illness (ILI), although some develop
severe pneumonia. Fewer than 1% of patients develop disseminated disease.
Infection usually produces immunity to reinfection. During 1995--2000, the
number of reported
coccidioidomycosis cases in California averaged 2.5 per 100,000 population
annually. However, from 2000 to 2006, the incidence rate more than tripled,
increasing from 2.4 to 8.0 per 100,000 population.
To characterize this increase, the California Department of Public Health (CDPH)
analyzed case and hospitalization data for the period 2000--2007 and preliminary
case report data for 2008. The results indicated that, during 2000--2006, the
number of reported cases and hospitalizations for coccidioidomycosis in
California increased each year, before decreasing in 2007. Annual incidence
during 2000—2007 was highest in Kern County (150.0 cases per 100,000
population), and the hospitalization rate was highest among non-Hispanic blacks,
increasing from 3.0 to 7.5 per 100,000 population. Health-care providers should
maintain heightened suspicion for coccidioidomycosis in patients who live or
have traveled in areas where the disease is endemic and who have signs of ILI,
pneumonia, or disseminated
infection.
Coccidioidomycosis is a reportable disease in California, although laboratories
are not required to report. During 1991--1995, California experienced a large
epidemic of coccidioidomycosis in the San Joaquin Valley; since 1995, cases of
coccidioidomycosis have been reported
consistently to local health departments in California using Confidential Morbidity
Reports (CMRs). For the analysis summarized in this report, CDPH reviewed
case and hospitalization data for the period 2000--2007 using CMRs and
California Patient Discharge Data Set (CPDDS) data. Preliminary CMR case data
for 2008 also were analyzed.
CMRs include data on the patient's county of residence, sex, and dates of birth,
illness onset, diagnosis, and case report. CPDDS data include inpatient
discharge diagnoses from all California nonfederal hospitals. Cases with codes
for coccidioidomycosis (114--114.5 and 114.9) from the International
Classification of Diseases, Ninth
Edition were selected. Duplicate records were removed so that the CMR data set
retained only the first report of a case and the CPDDS retained only the first
report of a patient's hospitalization. For the 3% of reported CMR cases with no
date of illness onset or diagnosis, year of illness onset was presumed to be year
of case report. CMR data
were used to calculate incidence rates of reported cases overall and by age, sex,
region, and county. Because 34% of reported CMR cases had missing data on
race, incidence rates by race were not calculated.
CPDDS data were used to calculate rates of first hospitalization overall and by
age, sex, race/ethnicity, region, and county.
California Department of Finance population projections were used for
denominators (3). Negative binomial regression was used to test for statistical
significance of change in rates of reported cases and hospitalizations during
2000--2006, the period of annual increase in
reported cases and hospitalizations. Fatality rates among hospitalized patients
were calculated by using CPDDS data for 2000--2007.
After remaining stable since 1995, reported coccidioidomycosis cases in
California increased from 816 in 2000 (incidence rate: 2.4 per 100,000
population) to 2,981 in 2006 (8.0 per 100,000 population)
(p<0.001) (Figure 1), before decreasing in 2007 to 2,791 cases (7.4 per 100,000
population). Preliminary 2008 CMR data indicated that 1,718 cases were
reported in California during January 1--December 6, 2008, compared with 2,210
and 2,426 cases reported during the same period in 2006 and 2007, respectively.
During 2000--2007, estimated average annual incidence was highest among
adults aged 40--49 years (3,518 cases [8.0 per 100,000 population]) versus other
age groups (Table). A total of 10,909 (65%)cases were reported in male patients,
for an average annual rate of 7.6 per 100,000 population, compared with 5,848
cases in females (4.0 per 100,000 population) (Table). The greatest incidence
occurred in
the San Joaquin Valley region, where coccidioidomycosis is endemic. A total of
12,855 (76%) of California's 16,970 cases were reported from the San Joaquin
Valley during 2000--2007. Reported cases from this region increased from 490
(14.7 per 100,000 population) in 2000 to 2,135 (53.9 per 100,000 population) in
2007. Within the region, Kern
County reported the highest incidence every year. Rates of reported cases in
Kern County averaged 150.0 per 100,000 population during 2000--2007 (Figure
2), peaking in 2004 at 195.3 per 100,000 population.
In California, coccidioidomycosis cases requiring hospitalization increased from
611 in 2000 (1.8 per 100,000 population) to 1,587 in 2006 (4.3 per 100,000
population) (p<0.001), before decreasing to 1,368 (3.6 per 100,000 population) in
2007 (Figure 1).
Hospitalizations for coccidioidomycosis were highest among persons aged 60-79 years, averaging 5.8 per 100,000 population during 2000--2007 (Table). By
race/ethnicity, hospitalizations were highest among non-Hispanic blacks,
compared with non-Hispanic whites, Hispanics, and Asians/Pacific Islanders.
From 2000 to 2007,
hospitalizations among non-Hispanic blacks increased from 66 (3.0 per 100,000
population) to 169 (7.5 per 100,000 population).
Hospitalizations among non-Hispanic whites increased from 297 (1.9 per
100,000 population) in 2000 to 570 (3.5 per 100,000 population) in 2007;
hospitalizations among Hispanics increased from 182 (1.6 per 100,000
population) to 485 (3.6 per 100,000 population), and hospitalizations among
Asians/Pacific Islanders increased from 36 (0.9
per 100,000 population) to 86 (1.9 per 100,000 population).
By geographic region, hospitalizations for coccidioidomycosis in the San Joaquin
Valley increased from 230 (6.9 per 100,000 population) in 2000 to 701 (17.7 per
100,000 population) in 2007. Within the region, Kern County reported the highest
hospitalization rates, increasing
from 121 (18.2 per 100,000 population) in 2000 to 285 (34.9 per 100,000
population) in 2007, and peaking in 2005 at 353
hospitalizations (45.8 per 100,000 population). Overall in California, during 2000-2007, a total of 752 (8.7%) of the 8,657 persons hospitalized for
coccidioidomycosis died.
Reported by: DJ Vugia, MD, C Wheeler, MD, KC Cummings, MPH, California
Dept of Public Health. A Karon, DVM, EIS Officer, CDC.
Editorial Note:
This report describes increases in reported coccidioidomycosis cases and
hospitalizations during 2000--2007 and the highest incidence rate in California
since 1995, the first year that CMR data were available
consistently. The number of reported cases and hospitalizations decreased in
2007, and preliminary data indicate those decreases might have continued in
2008. However, rates of coccidioidomycosis in California remain substantially
higher than during 1995--2000. These
increased rates likely are real, rather than surveillance artifact, because no major
changes in diagnosis or reporting of coccidioidomycosis in California occurred
before or during the period studied.
Increases in coccidioidomycosis in California are similar to those observed in
neighboring Arizona and in the United States overall.
Arizona, which annually reports approximately 60% of all
coccidioidomycosis cases in the United States, reported a substantial increase in
coccidioidomycosis from 1,812 cases (37 per 100,000 population) in 1999 to
5,535 cases (91 per 100,000 population) in 2006 (4). In the United States overall,
the number of reported coccidioidomycosis cases increased from 1,697 (0.64 per
100,000 population) in 1996 to 8,917 (6.79 per 100,000 population in 2006) (5).
Reasons for these recent increases in reported coccidioidomycosis
are not fully understood. Some previous increases have been associated with
local environmental and climatic variations (6). Other hypothesized causes
include aerosolization of spores caused by soil disturbance during periods of
increased construction activity (4), growing numbers of persons who are
immunocompromised or have other risk factors for severe disease (7), and
immigration of previously unexposed persons from areas where
coccidioidomycosis is not endemic (2). Recent increases in coccidioidomycosis
in California are partially attributable to several hundred cases reported from two
San Joaquin Valley prisons (8) with inmates from areas where the disease is not
endemic. Multiple clusters also have been reported at California military bases,
where personnel often have intensive dust exposure (9). Such exposure is
hypothesized to increase the risk for infection; local outbreaks of
coccidioidomycosis have been noted after dust storms (1).
Coccidioidomycosis hospitalization rates in California were highest among
persons aged 60--79 years, which is consistent with previous reports that older
age might be a risk factor for severe coccidioidomycosis (7). Hospitalization rates
also were substantially higher among non-Hispanic blacks, compared with nonHispanic whites, Hispanics, and Asians/Pacific Islanders. Black race has been
associated previously with increased risk for coccidioidomycosis
hospitalization (7). In addition, blacks and persons of Filipino ancestry have been
found to have increased risk for disseminated coccidioidomycosis, possibly
because of underlying differences in susceptible host genetics (1,10).
Immunocompromised persons and women in their second and third trimesters of
pregnancy also have increased risk for disseminated disease (1).
The findings in this report are subject to at least three limitations.
First, because not all persons with coccidioidomycosis seek medical care and not
all diagnosed cases are reported to local health departments, this report likely
underestimates the actual rate of coccidioidomycosis in California. Second, for
cases in which patients were hospitalized, medical chart review was not
performed to confirm
laboratory diagnosis or cause of death from coccidioidomycosis, resulting in
possible overestimation of hospitalizations and deaths in persons with
coccidioidomycosis diagnosed. Finally, Kern County's
public health laboratory performs much of the coccidioidomycosis testing for
patients in that county and might be more likely to report cases routinely than
laboratories in most other counties in the San Joaquin Valley region where this is
not the practice. In 2009,
California plans to make coccidioidomycosis a laboratory-reportable disease to
improve completeness and timeliness of case reporting and delivery of targeted
public health recommendations during periods of increased disease.
Given the recent increases in coccidioidomycosis in California and Arizona,
heightened consideration of this disease is warranted in the differential diagnosis
of any patient with ILI, pneumonia, or signs of disseminated infection who has
lived or traveled in areas where
coccidioidomycosis is endemic. Because intensive dust exposure appears to
increase the risk for infection, CDC recommends that persons living or traveling
in regions where coccidioidomycosis is endemic who are at risk for severe or
disseminated disease (e.g., older persons, pregnant women,
immunocompromised persons, and persons of black race or Filipino ancestry)
should avoid exposure to outdoor dust as much as possible.* When such
exposure is unavoidable, measures to reduce inhalation of outdoor dust, such as
wetting soil and using respiratory protection when engaging in soil-disturbing
activities, might be
effective. However, options for environmental control of
coccidioidomycosis are limited, and no safe, effective vaccine for the disease
exists currently. Developing such a vaccine appears to be the best option for
preventing disease in those persons at risk for coccidioidomycosis (9).
Acknowledgments
The findings in this report are based, in part, on contributions by SR Bissell, MS,
California Department of Health; and EC Weiss, MD, Office of Workforce and
Career Development, CDC.
References
1. Chiller TM, Galgiani JN, Stevens DA. Coccidioidomycosis. Infect Dis Clin N
Am 2003;17:41--57.
2. Galgiani JN, Ampel NM, Blair JE, et al. Coccidioidomycosis. Clin Infect Dis
2005;41:1217--23.
3. State of California Department of Finance. Race/ethnic population with age
and sex detail, 1990--1999; 2000--2050. Sacramento, CA: State of California
Department of Finance; July 2007.
4. Sunenshine RH, Anderson S, Erhart L, et al. Public health surveillance for
coccidioidomycosis in Arizona. Ann NY Acad Sci 2007;1111:96--102.
5. CDC. Summary of notifiable diseases---United States, 2006. MMWR 2008;55.
6. Park BJ, Sigel K, Vaz V, et al. An epidemic of
coccidioidomycosis in Arizona associated with climatic changes,
1998--2001. J Infect Dis 2005;191:1981--7.
7. Flaherman V, Hector R, Rutherford G. Estimating severe
coccidioidomycosis in California. Emerg Infect Dis 2007;13:1087-9.
8. Pappagianis D. Coccidioidomycosis in California state
correctional institutions. Ann NY Acad Sci 2007;1111:103--11.
9. Crum N, Lamb C, Utz G, Amundson D, Wallace M.
Coccidioidomycosis outbreak among United States Navy SEALs
training in a Coccidioides immitis--endemic area---Coalinga,
California. J Infect Dis 2002;186:865--8.
10. Louie L, Ng S, Hajjeh R, et al. Influence of host genetics on
the severity of coccidioidomycosis. Emerg Infect Dis 1999;5:672-80.
* Additional information available at
http://wwwn.cdc.gov/travel/yellowbookch4coccidioidomycosis.aspx.
FIGURE 1. Rates* of reported cases of coccidioidomycosis and
first hospitalizations among persons with coccidioidomycosis
diagnosed — California, 1995–2007†
http://www.cdc.gov/mmwr/preview/mmwrhtml/figures/m805a1f1.gif
FIGURE 2. Average annual rate* of reported cases of
coccidioidomycosis, by county — California, 2000–2007†
http://www.cdc.gov/mmwr/preview/mmwrhtml/figures/m805a1f2.gif
TABLE. Total numbers and average annual rates* of reported
cases of coccidioidomycosis and first hospitalizations and deaths
among persons with coccidioidomycosis diagnosed, by selected
characteristics — California, 1995–1999 and 2000–2007 †
http://www.cdc.gov/mmwr/preview/mmwrhtml/figures/m805a1t.gif
-Gary N. Greenberg, MD MPH Sysop / Moderator Occ-Env-MedL MailList Univ. N. Carolina School Public Health
Medical Director
Briefing Webcast Available - Medicare 101
Please take a look at the webcast for the Alliance briefing below, and download the podcast if you like. You'll notice that videos o
the individual speakers are also available. A transcript of the briefing will be available soon. All are brought to you courtesy of
kaisernetwork.org.
Medicare 101
Medicare covers nearly 45 million beneficiaries, including 38 million seniors and 7 million younger adults with permanent
disabilities. The program is expected to cost the federal government approximately $477 billion in 2009, accounting for 13 percen
of federal spending and 19 percent of total national health expenditures. Whom does Medicare serve and what services does it
cover? What are Medicare Parts A, B, C and D? How is it structured and financed? What drives Medicare’s costs? How does
Medicare reimburse providers and hospitals? What future challenges face the program? To address these and related questions
the Alliance for Health Reform and the Kaiser Family Foundation sponsored a March 16 briefing.
for the webcast, podcast, individual speaker videos and resource materials, including
speakers' PowerPoint presentations.
Click here
(http://allhealth.org/briefing_detail.asp?bi=148)
The Alliance for Health Reform is a nonpartisan, not-for-profit health policy education group. We are committed to helping journalists, elected officials and other shapers of public opinion understand the roots of
nation's health care problems and the trade-offs posed by various proposals for change. Our aim is quality, affordable health coverage for all in the U.S., although we do not lobby or take positions on legislatio
Sen. Jay Rockefeller (D-W.Va.) is our Founder and Honorary Chairman; Sen. Susan Collins (R -ME.) is our Honorary Co-Chairman.
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main: (202) 789-2300
fax: (202) 789-2233
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Interesting that there are 45 million on Medicare. There are 50 million (or so)
uninsured in the US….
HEALTHCARE INDUSTRY
WEEKLY WATCH
Published by
Health Resources Publishing
March 16, 2009
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In This Issue
ADULT DAY, SENIOR SERVICES & HOSPICE: Hebrew
Community Services Adult Day Creates Greeting Cards For
Soldiers In Iraq HEALTHCARE INDUSTRY NEWS: Oncologists
And BCBSM Team In National Effort To Improve Cancer Care
End-of-Year And Forecast Survey: What are Your Predictions
For 2009? EMPLOYEE ASSISTANCE & WELLNESS: Survey
Highlights Ongoing Shift To Wellness To Manage Healthcare
Costs GRANTS AND FUNDING NEWS: Podcasting Provides
Name Recognition And Other Benefits To Organizations
ADULT DAY, SENIOR SERVICES & HOSPICE: Hebrew
Community Services Adult Day Creates Greeting Cards For
Soldiers In Iraq
Hebrew Community Services Adult Day Center, Hartford, Conn.,
develops a project each year for its clients to participate in.
Clients and children from a local elementary school are teaming up
to create greeting cards for the soldiers stationed in Iraq, Maureen
Toce, director of adult day services and president of the
Connecticut Association of Adult Day Centers told Adult Day
Services Letter.
The project culminated in a celebration with the adult day clients
and the children from the intergenerational program at Dr. Michael
D. Fox Elementary School of Ohio.
Read On ...
HEALTHCARE INDUSTRY NEWS: Oncologists And BCBSM
Team In National Effort To Improve Cancer Care
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requirements become more
challenging. While hospice
executive directors and
other senior administrators
are aware of what the
regulations are, hospice
staff may not always be
fully informed or compliant.
That's because staff
training and regulatory
compliance are the two
most difficult and laborintensive responsibilities for
administrators today.
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Bridging Adult Day
Services and
Hospice/Palliative Care
NEW 90-Minute LIVE Audio
Conference Thursday,
March 26 at 1:30-3:00 PM
EDT
The number of persons age
65 and older is estimated to
grow by 80 percent creating
an even more critical need
for direct services for
individuals approaching the
The oncologists are submitting information to a national database
end of their lives. This
established by the American Society of Clinical Oncology to help
interactive discussion will
physicians identify what works best in cancer care.
identify the benefits of
collaboration between ADS
BCBSM is providing funding to defray data collection costs and to
and hospice/palliative care,
encourage physician participation.
and enhancing end of life
care and support in the
Read On ...
ADS setting.
More than 180 oncologists in 11 physician groups across the state
are partnering with Blue Cross Blue Shield of Michigan (BCBSM) to
gather data to improve care for cancer patients in Michigan.
End-of-Year And Forecast Survey: What are Your Predictions
For 2009?
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EMPLOYEE ASSISTANCE & WELLNESS: Survey Highlights
Ongoing Shift To Wellness To Manage Healthcare Costs
Employers in Pennsylvania, West Virginia and Ohio believe the
future of managing healthcare costs lies in helping their employees
manage their health through wellness programs, according to a
survey by Cowden Associates Inc.
Cowden Associates, an independent human resources,
compensation and employee benefit consulting firm, compiled
results of its 2007-2008 survey from 274 employers throughout the
tri-state region.
Survey participants include for-profit, non-profit and governmental
employers. Size of employers ranged from less than 100
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GRANTS AND FUNDING NEWS: Podcasting Provides Name
Recognition And Other Benefits To Organizations
Podcasting offers organizations another medium for reaching
consumers, according to Elizabeth Tracey, director of electronic
media, media relations and public affairs at John Hopkins
University School of Medicine.
Keeping Score: A
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Insurers
Audio Conference CDROM Now Available
Pay-for-performance (P4P)
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largely because the
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Medicaid Services (CMS)
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Read On ...
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Issue #90, March 2009
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In this issue:
Are You in the Sprint?
Reengineering the Operating Room to Boost Efficiency and Quality
Triple Aim Gains Momentum as Initiative Expands
Engaging with Physicians in a Shared Quality Agenda
Knowing Is Not Enough
What's New at IHI.org
Opportunities to Get Involved
Are You in the Sprint?
April 1. That's the date by which we hope every hospital in the US will test the World Health Organization (WHO) Surgical Safety Checklist at least
once with at least one operating team. The Checklist is a powerful tool that has been shown to significantly reduce operating room mortality and harm.
A new interactive map on IHI's website shows hospitals that have tested it or plan to. Is your hospital on this map?
Learn more about the WHO Surgical Safety Checklist Sprint and see the map of participants
Reengineering the Operating Room to Boost Efficiency and Quality
Because the OR is a primary source of admissions, it is virtually impossible to streamline hospital-wide patient flow without first streamlining patient
flow through the OR. IHI is pleased to offer a two-day seminar addressing this challenge, based on fundamental tools of operations management and
variability theory.
Learn more about the April 23-24 seminar in Washington, DC
Triple Aim Gains Momentum as Initiative Expands
The Triple Aim strategy is resonating with increasing numbers of leaders, administrators, and providers across the health care spectrum
internationally. The initiative is based on an overarching agenda that seeks to optimize performance on three dimensions of care for populations of
patients: health, the experience of care, and the per capita cost. IHI is developing new projects on reducing avoidable ED visits and specialty care
overuse.
Read a new brochure outlining IHI's Triple Aim strategies and programs
Learn more about participating in new Triple Aim projects from Courtney Kaczmarsky at [email protected]
Engaging with Physicians in a Shared Quality Agenda
Health care executives know that physician support is crucial for improvement efforts to be successful. IHI invites you to join us for a two-day seminar
designed to help health care leaders learn and apply concrete practical strategies to bring physicians into the heart of their institution's quality and
safety work.
Learn more about the April 21-23 seminar in Chicago, Illinois
Knowing Is Not Enough
Health care leaders and educators are learning how to pass along quality principles to the next generation of providers. In a new article in Healthcare
Executive, Paul Batalden, David Leach, and Greg Ogrinc offer new thinking and strategies for engaging health professions students in improving
health care.
Read the article
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See the latest ideas, results, and resources recently added to our website
Opportunities To Get Involved
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Wal-Mart Says Will Sell E-Records to
Doctors
WASHINGTON (Reuters) Mar 11 - Wal-Mart Inc, which has moved into low-cost
healthcare with walk-in clinics and cheap prescriptions, said on Wednesday its
Sam's Club unit would sell a package including software and Dell computers
directly to doctors for electronic medical records.
"We are trying to help the small practice doctor have access to medical records
and practice management software re as well as the hardware at an affordable
cost," Sam's Club spokeswoman Susan Koehler said in a telephone interview.
The discount retail giant said it would offer a package deal with hardware,
software and installation for electronic medical records and e-prescribing.
"We will be a single point of contact to help with training, installation,
maintenance," Koehler said.
Koehler said Sam's Club already was marketing small business services to
healthcare professionals, with its pharmacies and opticians, as well as office
supplies and other merchandise.
"This will be an extension service of what we do already," she said. "We have
more than 200,000 medical practices that we are already serving."
Medical software company eClinicalworks will offer the software program,
Koehler said. She said the package would cost the first doctor in a practice about
$25,000, with each additional user costing around $10,000.
"We're not live yet. We are optimistic we are going to be able to launch shortly, I
guess early spring," Koehler said.
Wal-Mart also has walk-in medical clinics called "The Clinic at Wal-Mart" and
aims to open 2,000 nationwide in five to seven years.
"It is partially how we got that idea" for offering electronic health packages,
Koehler said.
IBM also offers electronic medical record software, an idea being pushed
strongly by the administration of President Barack Obama as a way to cut
healthcare costs, increase efficiency and reduce errors.
Wal-Mart also offers more than 1,000 over-the-counter items for $4 or less, a
move that forced retailers from Target Corp to grocery stores and stand-alone
pharmacies to offer similar discounts.
(Reporting by Maggie Fox, editing by Matthew Lewis)
Pay for Performance for Medical
Groups May Stimulate Practice
Changes
March 11, 2009 — California physicians given financial incentives to improve the
quality of healthcare have made important changes designed to achieve that
goal, according to the results of a RAND Corporation study reported in the
March/April issue of Health Affairs.
"Physician groups are responding to pay-for-performance programs by making
practice changes and altering how they compensate physicians to reward quality,
but health plans and purchasers say that those investments are not yet
translating into substantial gains in quality," lead author Cheryl L. Damberg, PhD,
a senior policy researcher at RAND in Santa Monica, California, said in a news
release. "The true benefits of these programs may take more time to be realized
and it is likely that investments in other quality efforts will be needed in addition to
performance-based pay."
Although pay-for-performance is already in widespread use and has grown
rapidly in recent years, the effects of this incentive system on physician response
and healthcare outcomes are still unclear. What types of financial incentive
strategies work best is also still undetermined.
This study looked at 7 major California health plans and 225 physician groups
enrolled in the California Integrated Healthcare Association's pay-forperformance program, which began in 2003. The 35,000 physicians employed in
these groups have a patient base of 6.2 million people enrolled in commercial
health maintenance organizations and point-of-service plans.
Between 2003 and 2007, participating health plans paid a total of $203 million in
incentives to participating physician groups. In turn, the groups provided some
payments of about $1500 to $2000 annually to individual physicians based on
quality measures. These included the number of patients with diabetes who
receive recommended blood tests, patient experience regarding access to care,
and adopting health information technology capabilities.
Surveys revealed that most of the medical groups felt that the financial incentives
were too small to stimulate significant change among most physicians and that
the payments should be 2 to 5 times higher to achieve quality improvements.
Although most physician organizations reported that they collected more in
financial incentives than they had spent to comply with the program, 6 reported
that their bonuses barely met their increased costs.
In response to this incentive system, physician-level performance rating,
feedback, and accountability increased; information technology such as use of
electronic medical records was more rapidly implemented; organizational focus
was clarified; and more support was generated for improvement. Twenty of the
medical groups surveyed reported positive changes in practice of their individual
physicians, such as more-intensive patient outreach.
"However, after three years of investment, these changes had not translated into
breakthrough quality improvements," the study authors write. "Continued
monitoring is required to determine whether early investments made by physician
organizations provide a basis for greater improvements in the future."
Despite the concern that pay for performance could result in physicians dropping
patients who did not follow prescribed recommendations, there were few reports
of such events. More than two thirds of the medical groups surveyed believed
that the pay-for-performance program yielded more benefits than harms.
Limitations of this study include a small, nonrandom sample of systematically
identified physician organizations, limiting generalizability; that data were based
on subjective self-assessments; weak incentives; and a limited number and
scope of measures.
"Physician organizations face a number of challenges that impede their ability to
move forward on quality, including difficulties in engaging and changing the
behavior of front-line physicians (particularly if an organization doesn't 'own' a
substantial fraction of the physician's practice) and lack of knowledge of what
specific improvement actions physicians should take," the study authors
conclude. "Meanwhile, purchasers and providers are challenged regarding how
to gauge the opportunity costs of investing in [pay for performance] versus
elsewhere, and how to expand performance accountabilities given limitations of
current performance measure sets and the data needed to generate measures."
The California HealthCare Foundation supported this study.
Health Affairs. 2009;28:517–525.
FACE OFF:
American Health Care in Crisis
FACE OFF: American Health Care in Crisis, is a new 3-part series in Medscape Physician Connect led
by Dr. Rick G. Kulkarni, Medical Director, WebMD and Editor-in-Chief of eMedicine. Dr. Kulkarni also
holds the post of Assistant Professor of Surgery at Yale University School of Medicine.
FACE OFF: American Health Care in Crisis - Part 1
Should President Obama Make Health Care Reform a Priority During Our Economic Crisis?
"The President has chosen to tie in health care
reform to the current economic crisis, declaring
the exploding costs of health care in America
today is 'one of the greatest threats, not just to the
well-being of our families and the prosperity of our
businesses, but to the very foundation of our
economy.'
PHYSICIAN POLL
Should President Obama be focusing on
health care reform at the expense of other
priorities?
(A) Yes
(B) No
(C) Other
VOTE »
Should President Obama be focusing on health
care reform right now? What should his priorities
be in health care reform? Should he tie in health care reform to the broader issue of
economic recovery?"
- Rick G. Kulkarni, MD
Read discussion and share insights in Physician Connect »
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Physician's First Watch for March 9, 2009
David G. Fairchild, MD, MPH, Editor-in-Chief
Google Health Offers Shareable Personal Health Records
Featured in Journal Watch: Benefits of Urgent Evaluation for TIA and Minor Stroke
Google Health Offers Shareable Personal Health Records
Google has launched a new feature on Google Health as part of its mission, it says, "to organize the world's information and make it universally
accessible and useful."
With the new feature, patients can share their health information securely with anyone they choose — their physicians, family members, and caregivers,
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Cleveland Clinic.)
One of the developers likens the system to "social networking for personal health records."
Google announcement (Free)
Dear William,
In reviewing our registration list, I noticed that you have not yet registered for
our webinar on March 18th, Physician Quality Reporting Initiative in 2009:
How To Avoid Submission Errors and Improve Reimbursement.
In 2008, CMS awarded more than $36 million in bonus payments to the more
than 56,700 health professionals who satisfactorily reported quality
information to Medicare under the 2007 Physician Quality Reporting
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During Physician Quality Reporting Initiative in 2009: How To Avoid
Submission Errors and Improve Reimbursement, a 90-minute webinar
on March 18, 2009, you'll hear from Dr. Bruce Bagley, medical director
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Betsy Nicoletti, consultant, Medical Practice Consulting, LLC, will
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hands-on PQRI coding and auditing strategies. You will get details on:
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Advice and lessons learned from practices participating in PQRI in 2007
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Executive Vice President
The Healthcare Intelligence Network
Flag this message
[occ-env-med-l] MMWR: 09-01-30,
MRSA among football team, NYC
2007
Friday, January 30, 2009 7:23 AM
From:
"Gary Greenberg" <[email protected]>
Add sender to Contacts
To:
"Occ-Env-Med-L" <[email protected]>
January 30, 2009 / 58(03);52-55
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5803a2.htm?s_cid=mm5803a2
_e
Methicillin-Resistant Staphylococcus aureus Among Players on a High School
Football Team --- New York City, 2007
On September 12, 2007, the New York City Department of Health and Mental
Hygiene (DOHMH) was notified of three players on a Brooklyn high school
football team with culture-confirmed methicillin-resistant Staphylococcus aureus
(MRSA) skin and soft tissue infections (SSTIs).
During August 19--24, the team had attended a preseason football training camp,
where all 59 players on the team lived together in the school gymnasium. An
investigation by DOHMH revealed four culture-confirmed and two suspected
cases of MRSA among 51 players interviewed (11.8% attack rate). Of the six
cases, three involved abscesses that required incision and drainage. The risk for
MRSA
infection was higher among those who shared towels during the training camp
than among those who did not (relative risk [RR] = 8.2). In addition, the six
players with MRSA infections had a mean body mass index (BMI) that was
significantly higher than the mean for those who were not infected. Multivariable
logistic modeling determined that
sharing towels during camp (adjusted odds ratio [AOR] = 15.7) and higher BMI
(AOR = 1.4) were associated independently with MRSA infection. Similar
outbreaks have been reported among football teams in which inadequate
hygiene, combined with skin injuries and living in
close quarters, contributed to the spread of MRSA infection. Such outbreaks
might be prevented by better educating players and coaches regarding SSTIs
and by better promoting proper player hygiene, particularly during training
camps.
Initial investigation by DOHMH began on September 12. Investigators learned
that all 59 players had attended a preseason training camp during August 19--24.
The players had lived together in the school gymnasium, slept on cots in close
proximity to each other, and showered in the school locker room, usually only
once at the end of
the day. The school had supplied antibacterial soap in pump dispensers in the
showers; however, several players brought their own soap.
Players supplied their own towels. Players reported that they usually left their
towels on their cots or on the floor when not in use. The school offered a daily
laundry service for uniforms and towels during the camp; however, most players
did not have their towels washed and wore their uniforms two or three times
between launderings. Players often remained in sweat-soaked clothes between
the morning and afternoon practices. The school did not have whirlpools or hot
tubs.
Investigators hypothesized that sharing facilities and equipment, previous skin
injuries, player position, inadequate player hygiene, and having a higher BMI
might be risk factors linked to MRSA infections (1--3). To find additional cases,
identify risk factors for infection, and implement infection control measures,
DOHMH conducted
face-to-face interviews on September 14 with 51 of the 59 players, using a closeended questionnaire; the eight remaining players could not be contacted. In
addition, a DOHMH physician further examined the five players reported by the
school nurse as potentially infected.
A confirmed MRSA case was defined as a clinically compatible SSTI with a
positive MRSA culture in a team member during August 5—September 14, a
period ranging from 2 weeks before to 3 weeks after the end of the training
camp. A suspected MRSA case was defined as a clinically
compatible SSTI or systemic infection with no culture confirmation.
Date of symptom onset was defined as the date an infected player reported first
noticing an infected wound.
Among the 51 players interviewed, four confirmed and two suspected MRSA
cases were identified (11.8% attack rate). Molecular typing with pulsed-field gel
electrophoresis revealed that three of the confirmed cases were USA300, a
strain usually considered to be a community-associated MRSA. An isolate from
the fourth player with confirmed MRSA was not available for typing. Symptom
onsets ranged from August 24, the last day of training camp, to September 6, a
total of 13 days after the camp (Figure 1).
In the four confirmed cases, infections initially appeared as a blister on the ankle,
calf, hip, or instep. One suspected case involved impetigo on the upper arm; the
other suspected case involved impetigo on the arms and eyebrow. Three players
reported their wounds to the school nurse or a physician only after blisters had
developed
into infections requiring medical attention. The six players with confirmed or
suspected MRSA infections were referred to their personal physicians for
treatment. Three of the players had abscesses that required incision and
drainage. Three of the players with confirmed cases were treated with Bactrim
and doxycycline, clindamycin and
mupirocin, and Bactrim and mupirocin, respectively. One of the players with
suspected MRSA infection was treated with ciprofloxacin.
Antibiotics used to treat the remaining two players were unknown.
Interviews with the players revealed that 33 (65%) had sustained at least one cut,
abrasion, or turf burn during the preseason camp or regular season. The players
reported that, unless the skin injuries were severe, they had cleaned, dressed, or
bandaged them by themselves. No players reported sharing towels or soap
during the
regular season, because players went home after practice to shower.
However, 10 (20%) had shared towels and six (12%) had shared soap during
training camp, when the players showered on site.
In a retrospective cohort analysis, after combining confirmed and suspected
MRSA cases, bivariate RRs and their 95% confidence intervals (CIs) were
calculated to identify risk factors associated with infection. Multivariable logistic
regression was used to evaluate the independent association of multiple risk
factors, including BMI, which
was modeled as a continuous variable because the small number of cases did
not allow for tests based on BMI categories (i.e., normal, overweight, and obese).
Sharing towels during training camp significantly increased the risk for MRSA
infection (RR = 8.2) (Table). Sharing protective pads, sharing soap, showering
less than once a day, having more than one skin injury, and washing uniforms
less than once a day were not significant risk factors for infection. Playing at
lineman or linebacker and wide receiver or cornerback positions (previously
shown
to be potential risk factors in football MRSA outbreaks [2,4]) also were not
significant risk factors (Table).
The six players with MRSA infection had a mean BMI of 29.1 (CI = 24.7--33.3),
which was significantly higher by t-test (t = 2.56; p=0.014) than the mean BMI of
23.8 (CI = 22.8--25.0) for the 45 players without infection. Using CDC's child and
teen BMI-for-age weight status categories,* five of the six (83%) players with
MRSA infection could be classified as overweight or obese, compared with 20
of the 45 (44%) players without infection (Figure 2). A bivariate analysis using
logistic regression revealed that higher BMI was associated with higher risk for
infection (OR = 1.3 per unit increase in BMI; CI = 1.1--1.7). A multivariable
logistic model confirmed that both sharing towels during training camp (AOR =
15.7; CI = 1.5--167.4)
and BMI (AOR = 1.4; CI = 1.1--1.9) were associated independently with MRSA
infection.
Reported by: P Kellner, MPH, A Yeung, MPH, HA Cook, MPH, J Kornblum, PhD,
M Wong, MPH, F Eniola, MPH, D Weiss, MD, New York City Dept of Health and
Mental Hygiene. HP Nair, PhD, EIS Officer, CDC.
Editorial Note:
Since 2000, outbreaks of MRSA SSTIs have been reported among players on
high school, college, and professional football teams with attack rates similar to
those described in this report (1--4). Despite education efforts by CDC and state
and local health departments, MRSA infections continue to be a problem among
football players. A 2007 CDC
survey of high school athletic trainers revealed that 53% had treated MRSA
infections in football players (1). The results of this investigation suggest that
sharing of towels among players at a preseason training camp was associated
with MRSA infection, a risk factor previously linked to football-related MRSA
outbreaks (1--3).
These results are also consistent with three previous reports that identified
MRSA infections in football teams temporally linked to training camps (2--4),
which might be a setting that increases risk behaviors for infection (4). Living in
close quarters for an extended period, a potential risk factor identified in other
settings (5),
might have further contributed to the outbreak.
The results also indicated that higher BMI among team players was associated
with higher risk for MRSA infection, independent of sharing towels. These results
are consistent with those of two other football-related outbreaks (5) and
published reports linking higher BMI with a range of infections, including skin
infections (6). The possibility that higher BMI is confounded by player positions
(e.g.,
lineman) involving heavier players and more frequent contact is not supported by
the data, which found no differences by player position.
Evaluating player position in general is statistically problematic because sample
sizes vary substantially by position on most football rosters.
The findings in this report are subject to at least two limitations. First, the small
number of cases reduced the precision of the point estimates, as reflected in the
wide CIs. Second, because players were not interviewed until 3 weeks after the
first reported symptom onsets, they might not have been able to accurately recall
events, leading to
misclassification of players by risk factor.
High school football programs might be able to reduce the risk for MRSA
outbreaks by improving their procedures and facilities to promote optimal player
hygiene, particularly during training camps.
Improvements might include providing a towel service and collecting used towels
from players on a daily basis. Skin injuries should be monitored closely by
coaches and trainers, rather than by players alone. Living arrangements might be
modified so that players are not living in close quarters for extended periods.
Education on SSTI
identification, prevention, and intervention might be included as a standard
component of football training camps.
Acknowledgments
This report is based, in part, on contributions by M Marx, PhD, J Nguyen, MPH,
M Layton, MD, Bur of Communicable Disease; L Thorpe, PhD, K Konty, PhD, Div
of Epidemiology; T Matte, MD, Div of Environmental Surveillance and Policy,
New York City Dept of Health and Mental Hygiene. J Magri, MD, Office of
Workforce and Career Development, CDC.
References
1. Brinsley-Rainisch K, Goding A, Sinkowitz-Cochran R, Pearson M, Hageman J,
the National Athletic Trainers' Association. MRSA infections in athletics:
perceptions and practices of certified athletic trainers [Poster]. Presented at the
Society for Healthcare Epidemiology of America 17th Annual Meeting, Baltimore
MD; April 15,
2007.
2. Begier EM, Frenette K, Barrett NL, et al. A high-morbidity outbreak of
methicillin-resistant Staphylococcus aureus among players on a college football
team, facilitated by cosmetic body shaving and turf burns. Clin Infect Dis
2004;39:1446--53.
3. Romano R, Lu D, Holtom P, et al. Outbreak of community-acquired methicillinresistant Staphylococcus aureus skin infections among a collegiate football team.
J Athl Train 2006;41:141--5.
4. Kazakova SV, Hageman JC, Matava M, et al. A clone of
methicillin-resistant Staphylococcus aureus among professional football players.
N Engl J Med 2005;352:468--75.
5. Campbell KM, Vaughn AF, Russell KL, et al. Risk factors for communityassociated methicillin-resistant staphylococcus aureus infections in an outbreak
of disease among military trainees in San Diego, California, in 2002. J Clin
Microbiol 2004;42:4050--3.
6. Falagas M, Kompoti M. Obesity and infection. Lancet Infect Dis 2006;6:438-46.
* Additional information available at
http://www.cdc.gov/nccdphp/dnpa/healthyweight/assessing/bmi/childrens_bmi/ab
out_childrens_bmi.htm.
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Exploit code sends Mozilla scrambling to fix Firefox
Ryan Naraine: Mozilla's security response team is scrambling to ready a patch for what appears to be a
serious security flaw affecting its flagship Firefox browser.
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Dancho Danchev: Scareware meets ransomware: 'Buy our fake product or else'
Ryan Naraine: Cisco IOS patch day covers multiple vulnerabilities
Ryan Naraine: Foxit PDF Reader being exploited in the wild
Jason D. O'Grady: Charlie Miller: Macs lacking in security
Study: IE8's SmartScreen leads in malware protection
Adam O'Donnell: 'No more free bugs'? There never were any free bugs
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Microsoft is facing another patent infringement suit, this time from BackWeb over the technology it uses
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TomTom joins Linux protection group
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Mary Jo Foley: Deadline looms for Windows XP, Office 2003
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Full-featured notebook shootout
Andrew Nusca: High-end thin-and-light laptops are still here for those of us who need portability and
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Gallery: In a presentation at last week's Mix 09 event in Las Vegas, Microsoft designer Stephan
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Larry Dignan: Wall Street analysts are betting that Pre demand - and the WebOS that rides shotgun will be strong enough to make Palm a player again. However, if you follow the money it's clear that Palm
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The Big Question: Why is opium
production rising in Afghanistan, and
can it be stopped?
Tuesday, 14 October 2008
NATO and the US are ramping up the war on drugs in Afghanistan. American
ground forces are set to help guard poppy eradication teams for the first time
later this year, while Nato's defence ministers agreed to let their 50,000-strong
force target heroin laboratories and smuggling networks.
Until now, going after drug lords and their labs was down to a small and secretive
band of Afghan commandos, known as Taskforce 333, and their mentors from
Britain's Special Boat Service. Eradicating poppy fields was the job of specially
trained, but poorly resourced, police left to protect themselves from angry
farmers. All that is set to change.
How big is the problem?
Afghanistan is by far and away the world's leading producer of opium. Opium is
made from poppies, and it is used to make heroin. Heroin from Afghanistan is
smuggled through Pakistan, Russia, iran and Turkey until it ends up on Europe's
streets.
In 2008, in Afghanistan, 157,000 hectares (610 square miles) were given over to
growing poppies and they produced 7,700 tonnes of opium. Production has
soared to such an extent in recent years that supply is outstripping demand.
Global demand is only about 4,000 tonnes of opium per year, which has meant
the price of opium has dropped. in Helmand alone, where most of Britain's 8,000
troops are based, 103,000 hectares were devoted to poppy crops. if the province
was a country, it would be the world's biggest opium producer.
In 2007, the UN calculated that Afghan opium farmers made about $1bn from
their poppy harvests. The total export value was $4bn – or 53 per cent of
Afghanistan's GDP.
Is it getting better or worse?
There was a 19 per cent drop in cultivation from 2007 to 2008, but bumper yields
meant opium production only fell by 6 per cent. Crucially, the drop was down to
farmers deciding not to plant poppies, and that was largely a result of a
successful pre-planting campaign, led by strong provincial governors, in parts of
the country that are relatively safe.
Only 3.5 per cent of the country's poppy fields were eradicated in 2008. High
wheat prices and low opium prices are also a factor in persuading some farmers
to switch to licit crops.
In Helmand, one of the most volatile parts of Afghanistan, production rose by 1
per cent as farmers invested opium profits in reclaiming tracts of desert with
expensive irrigation schemes. Opium production was actually at its lowest in
2001. The Taliban launched a highly effective counter-narcotics campaign during
their last year in power. They used a policy of summary execution to scare
farmers into not planting opium. Many analysts attribute their loss of popular
support in the south, which contributed to their defeat by US-led forces in late
2001, to this policy.
How are the drugs linked to the insurgency?
The Taliban control huge swaths of Afghanistan's countryside, where most of the
poppies are grown. They tax the farmers 10 per cent of the farm gate value of
their crops. Antonio Maria Costa, head of the UN Office on Drugs and Crime,
said the Taliban made about £50m from opium in 2007.
They also extort protection money from the drugs smugglers, for guarding
convoys and laboratories where opium is processed into heroin. The UN and
NATO believe the insurgents get roughly 60 per cent of their annual income from
drugs. The Taliban and the drug smugglers also share a vested interest in
undermining President Hamid Karzai's government, and fighting the international
forces, which have both vowed to try and wipe out the opium trade.
What about corruption?
The vast sums of drugs money sloshing around Afghanistan's economy mean it
is all too easy for the opium barons to buy off corrupt officials.
Most policemen earn about £80 a month. A heroin mule can earn £100 a day
carrying drugs out of Afghanistan. Most Afghans suspect the corruption reaches
the highest levels of government. President Karzai is reported to have called
eradication teams to halt operations at the last minute for no apparent reason.
When an Afghan counter-narcotics chief found nine tonnes of opium in a former
Helmand governor's compound, he was told not burn it by Kabul – but he claims
he ignored the order.
President Karzai's brother, Ahmed Wali Karzai, is widely rumoured to be involved
in the drugs trade – an allegation he denies. The New York Times claimed US
investigators found evidence that he had ordered a local security official to
release an "enormous cache of heroin" discovered in a tractor trailer in 2004.
Privately, Western security officials admit they suspect that a number of
government ministers are drug dealers.
Where does that leave the international community?
Right across Afghanistan, the government is corrupt and Afghans are fed up. The
police organise kidnappings. Justice is for sale. Violence is spreading and people
don't feel safe. The progress promised in 2001 hasn't been delivered.
Education is a rare success. There are now more than six million children at
school, including two million girls, compared with less than a million under the
Taliban.
But the roads which link the country's main cities aren't safe. Taliban roadblocks
are increasingly normal. UN convoys are getting hijacked.
A report published by 100 charities at the end of July warned violence has hit
record highs, fighting is spreading into parts of the country once thought safe,
and there have been an unprecedented number of civilian casualties this year.
General David McKiernan, the US commander of almost all the international
forces in Afghanistan, insited to journalists at a press conference on Sunday that
Nato isn't losing. The fact he had to say it suggest public perception is otherwise.
He also said that everywhere he goes, everyone he speaks to is "uniformly
positive" about the future. Those people must be cherry-picked.
Crime in the capital, Kabul, is rising. The Taliban broke 400 insurgents out of
Kandahar jail this summer, and they attacked the provincial capital in Helmand
last weekend. People are frustrated at the international community's failures and
scared that the Taliban are coming back.
What does that mean for the future?
President Karzai has touted peace talks with the Taliban through Saudi
intermediaries. The international community maintains it will support the Afghan
government in any negotiations, but privately diplomats admit that if they opened
talks tomorrow they would not start from a "perceived position of strength".
General David Petraeus is about to take command at CentCom, which includes
Afghanistan, and he is expected to focus on churning out more Afghan soldiers
and engaging tribes against the insurgents.
Meanwhile, in Pakistan, it remains to be seen whether Asif Ali Zardari will rein in
his intelligence service and crack down on the Taliban safe havens in the
Pakistani tribal areas, which they rely on to launch attacks in Afghanistan.
There are also elections on the horizon. The international community is
determined that they must go ahead, despite the obvious security challenges,
and anything the Afghan candidates do should be seen in the context of securing
people who can deliver votes.
Does the war on drugs undermine the war on terror?
Yes
*Working to eradicate poppies will remove farmers' best source of income and
turn them against Nato
*Using resources to fight against the entrenched poppy trade diverts them from
the war with the Taliban
*Corruption in government means that battling opium turns the mechanism of the
state against our forces
No
*In the end, an Afghanistan without opium production will be much less prone to
the influence of the Taliban
*Money from the international drugs trade may find its way to terrorists outside of
Afghanistan
*Removing the source of corruption will strengthen the country's institutions in the
long term
CLINICAL RESOURCE CENTERS
CME/CE
HEALTH LAW
TECHNOLOGY
TOOLS
TOP SEARCHES: iPhone // Health information exchange // Obama
MARCH 27, 2009
•
•
•
•
•
Questions for HHS
Online reputation protector
HHS not yet providing guidance on EHR implementation
funds
Federal officials are providing little guidance thus far on how physicians can access funds in the $787 billion federal stimulus
package to help offset the cost of buying and implementing electronic health record systems. More...
Prescribing errors
Maryland’s HIE
Decision-support tool
North Carolina firm protects physicians' reputations online
Doctors worried about patients trashing their reputations online can now ask them to sign a waiver promising they won't. More...
Prescribing errors can be caught by electronic tools, study
finds
Most medication errors in primary care practices are prescribing errors--many of which could be prevented by electronic tools,
according to a new study by the Agency for Healthcare Research and Quality. More...
Maryland to create health information exchange
Have e-prescribing
incentives changed your
prescribing habits?
A group of prominent Maryland healthcare institutions has submitted a plan to create a statewide health information exchange that
will allow hospitals to share electronic medical records. More...
Clinical support tool improves communication between
specialists and PCPs
A new computer decision-support tool for physicians can result in more recommendations from specialists being implemented
during a patient’s hospitalization, according to a study by its developers. More...
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Key Topic Updates
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Health information technology
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E-prescribing
E-prescribing systems cause "alert fatigue," study says
E-prescribing cuts drug costs, study says
E-Prescribing: Medicare offers 2 percent e-prescribing bonus in 2009
Internet
HHS launches HIT security education site for docs
Free online medical encyclopedia goes live
Behind doctors' social networking websites
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Part two
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Why is there such a big push for e-prescribing now?
Probably the biggest eason is the incentive being offered starting this year
through CMS (the Cneters for Medicare and Medicaid Services).
Because of MIPPA (Medicare Improvement for Patients and Providers Act of
2008) eligible e-prescribers will receive and incentive payment of 2% of their
Medicare Part B charges in 2009 and 2010. Those incentives will drop to 1% in
2011 and 2012, and to 0.5% in 2013. After 2013, there will be a decrease in
payments through Medicare.
You must submit claims no later than 2 months after the reporting period ends.
From Henry Schein’s MicroMD
Vitamin B 12
Foods
Vitamin B12 is naturally found in meat (especially liver and shellfish), milk and
eggs. Animals, in turn, must obtain it directly or indirectly from bacteria, and
these bacteria may inhabit a section of the gut which is posterior to the section
where B12 is absorbed. Thus, herbivorous animals must either obtain B12 from
bacteria in their rumens, or (if fermenting plant material in the hindgut) by
reingestion of cecotrope fæces. Eggs are often mentioned as a good B12 source,
but they also contain a factor that blocks absorption. Certain insects such as
termites contain B12 produced by their gut bacteria, in a manner analogous to
ruminant animals. An NIH Fact Sheet lists a variety of food sources of vitamin
B12.
According to the U.K. Vegan Society, the present consensus is that any B12
present in plant foods is likely to be unavailable to humans and so these foods
should not be relied upon as safe sources, as the B12 analogues can compete
with B12 and inhibit metabolism. Also, vegan humans who eat only plant based
foods must ordinarily take special care to supplement their diets accordingly. The
only reliable vegan sources of B12 are foods fortified with B12 (including some
soy products and some breakfast cereals), and B12 supplements.
While lacto-ovo vegetarians usually get enough B12 through consuming dairy
products, vitamin B12 may be found to be lacking in those practicing vegan diets
who do not use multivitamin supplements or eat B12 fortified foods. Examples of
fortified foods often consumed include fortified breakfast cereals, fortified soybased products, and fortified energy bars. Claimed sources of B12 that have
been shown through direct studies of vegans to be inadequate or unreliable
include, laver (a seaweed), barley grass, and human gut bacteria. People on a
vegan raw food diet are also susceptible to B12 deficiency if no supplementation
is used
Natural food sources of B12
Vitamin B12 is found in foods that come from animals, including fish, meat,
poultry, eggs, milk, and milk products. One half chicken breast, provides some .3
µg per serving or 6.0% of one's daily value (DV), 3 ounces of beef, 2.4 µg, or
40% of one's DV, one slice of liver 47.9 µg or 780% of DV, and 3 ounces of
Molluscs 84.1 µg, or 1,400 % of DV, while one egg provides .6 µg or 10% of DV.
[edit] Potential sources
The mushroom Agaricus bisporus could contain Vitamin B12. This can be seen
on some nutrition sites. Some sources say it is a form that is not usable as a
Vitamin B12 source.
Legumes have root nodules that contains Rhizobium bacteria. Rhizobium
bacteria can create Vitamin B12. It may not be a source of Vitamin B12 for
nutrition purposes.
Salt rising bread contains Clostridium perfringens which is known to create
Vitamin B12. It may not be available as nutrition.
[edit] Supplements
Vitamin B12 is provided as a supplement in many processed foods, and is also
available in vitamin pill form, including multi-vitamins. Vitamin B12 can be
supplemented in healthy subjects also by liquid, strip, nasal spray, or injection
and is available singly or in combination with other supplements.
Cyanocobalamin is converted to its active forms, first hydroxocobalamin and then
methylcobalamin and adenosylcobalamin in the liver.
The sublingual route, in which B12 is presumably or supposedly absorbed more
directly under the tongue, has not proven to be necessary or helpful. A 2003
study found no significant difference in absorption for serum levels from oral vs.
sublingual delivery of 500 µg (micrograms) of cobalamin.[33]
Injection is sometimes used in cases where digestive absorption is impaired, but
there is some evidence that this course of action may not be necessary with
modern high potency oral supplements (such as 500 to 1000 µg or more). Even
pernicious anemia can be treated entirely by the oral route.[34][35][36] These
supplements carry such large doses of the vitamin that 1% to 5% of high oral
doses of free crystalline B12 is absorbed along the entire intestine by passive
diffusion.
However, if the patient has inborn errors in the methyltransfer pathway
(cobalamin C disease, combined methylmalonic aciduria and homocystinuria),
treatment with intravenous or intramuscular hydroxocobalamin is
needed.[37][38][39][40][41]
Cyanocobalamin is also sometimes added to beverages including Diet Coke Plus
and many energy drinks (one example would be Chaser's Five Hour Energy
Drink, which contains 8333% of the Recommended Daily Value of Vitamin B12).
However, 500 µg would be needed to reverse biochemical signs of vitamin B12
deficiency in older adults.[42]
[edit] Recommendations
The Dietary Reference Intake for an adult ranges from 2 to 3 µg (micrograms)
per day.
Vitamin B12 is believed to be safe when used orally in amounts that do not
exceed the recommended dietary allowance (RDA). The RDA for vitamin B12 in
pregnant women is 2.6 µg per day and 2.8 µg during lactation periods. There is
insufficient reliable information available about the safety of consuming greater
amounts of Vitamin B12 during pregnancy.
The Vegan Society, the Vegetarian Resource Group, and the Physicians
Committee for Responsible Medicine, among others, recommend that vegans
either consistently eat foods fortified with B12 or take a daily or weekly B12
supplement.[29][43][44] Fortified breakfast cereals are a particularly valuable source
of vitamin B12 for vegetarians and vegans. In addition, adults age 51 and older
are recommended to consume B12 fortified food or supplements to meet the
RDA, because they are a population at an increased risk of deficiency [45].
[edit] Allergies
Vitamin B12 supplements in theory should be avoided in people sensitive or
allergic to cobalamin, cobalt, or any other product ingredients. However, direct
allergy to a vitamin or nutrient is extremely rare, and if reported, other causes
should be sought.
[edit] Side effects, contraindications, and warnings
Dermatologic: Itching, rash, transitory exanthema, and urticaria have been
reported. Vitamin B12 (20 micrograms/day) and pyridoxine (80mg/day)
has been associated with cases of rosacea fulminans, characterized by
intense erythema with nodules, papules, and pustules. Symptoms may
persist for up to 4 months after the supplement is stopped, and may
require treatment with systemic corticosteroids and topical therapy.
Gastrointestinal: Diarrhea has been reported.
Hematologic: Peripheral vascular thrombosis has been reported.
Treatment of vitamin B12 deficiency can unmask polycythemia vera,
which is characterized by an increase in blood volume and the number of
red blood cells. The correction of megaloblastic anemia with vitamin B12
can result in fatal hypokalemia and gout in susceptible individuals, and it
can obscure folate deficiency in megaloblastic anemia. Caution is
warranted.
Leber's disease: Vitamin B12 in the form of cyanocobalamin is
contraindicated in early Leber's disease, which is hereditary optic nerve
atrophy. Cyanocobalamin can cause severe and swift optic atrophy, but
other forms of vitamin B12 are available.[citation needed] However, the sources
of this statement are not clear, while an opposing view[46] concludes: "The
clinical picture of optic neuropathy associated with vitamin B12 deficiency
shows similarity to that of Leber's disease optic neuropathy. Both involve
the nerve fibres of the papillomacular bundle. The present case reports
suggest that optic neuropathy in patients carrying a primary LHON mtDNA
mutation may be precipitated by vitamin B12 deficiency. Therefore, known
carriers should take care to have an adequate dietary intake of vitamin
B12 and malabsorption syndromes like those occurring in familial
pernicious anaemia or after gastric surgery should be excluded."
[edit] Other medical uses
Hydroxycobalamin, or hydoxocobalamin, also known as Vitamin B12a, is used in
Europe both for vitamin B12 deficiency and as a treatment for cyanide poisoning,
sometimes with a large amount (5-10 g) given intravenously, and sometimes in
combination with sodium thiosulfate.[47] The mechanism of action is
straightforward: the hydroxycobalamin hydroxide ligand is displaced by the toxic
cyanide ion, and the resulting harmless B12 complex is excreted in urine. In the
United States, the Food and Drug Administration approved (in 2006) the use of
hydroxocobalamin for acute treatment of cyanide poisoning.
High vitamin B12 level in elderly individuals may protect against brain atrophy or
shrinkage, associated with Alzheimer's disease and impaired cognitive
function.[48]
[edit] Interactions
[edit] Interactions with drugs
Alcohol (ethanol): Excessive alcohol intake lasting longer than two weeks
can decrease vitamin B12 absorption from the gastrointestinal tract.
Aminosalicylic acid (para-aminosalicylic acid, PAS, Paser): Aminosalicylic
acid can reduce oral vitamin B12 absorption, possibly by as much as 55%,
as part of a general malabsorption syndrome. Megaloblastic changes, and
occasional cases of symptomatic anemia have occurred, usually after
doses of 8 to 12 grams/day for several months. Vitamin B12 levels should
be monitored in people taking aminosalicylic acid for more than one
month.
Antibiotics: An increased bacterial load can bind significant amounts of
vitamin B12 in the gut, preventing its absorption. In people with bacterial
overgrowth of the small bowel, antibiotics such as metronidazole (Flagyl)
can actually improve vitamin B12 status. The effects of most antibiotics on
gastrointestinal bacteria are unlikely to have clinically significant effects on
vitamin B12 levels.
Hormonal contraception: The data regarding the effects of oral
contraceptives on vitamin B12 serum levels are conflicting. Some studies
have found reduced serum levels in oral contraceptive users, but others
have found no effect despite use of oral contraceptives for up to 6 months.
When oral contraceptive use is stopped, normalization of vitamin B12
levels usually occurs. Lower vitamin B12 serum levels seen with oral
contraceptives probably are not clinically significant.
Chloramphenicol (Chloromycetin): Limited case reports suggest that
chloramphenicol can delay or interrupt the reticulocyte response to
supplemental vitamin B12 in some patients. Blood counts should be
monitored closely if this combination cannot be avoided.
Cobalt irradiation: Cobalt irradiation of the small bowel can decrease
gastrointestinal (GI) absorption of vitamin B12.
Colchicine: Colchicine in doses of 1.9 to 3.9mg/day can disrupt normal
intestinal mucosal function, leading to malabsorption of several nutrients,
including vitamin B12. Lower doses do not seem to have a significant
effect on vitamin B12 absorption after 3 years of colchicine therapy. The
significance of this interaction is unclear. Vitamin B12 levels should be
monitored in people taking large doses of colchicine for prolonged periods.
Colestipol (Colestid), Cholestyramine (Questran): These resins used for
sequestering bile acids in order to decrease cholesterol, can decrease
gastrointestinal (GI) absorption of vitamin B12. It is unlikely that this
interaction will deplete body stores of vitamin B12 unless there are other
factors contributing to deficiency. In a group of children treated with
cholestyramine for up to 2.5 years there was not any change in serum
vitamin B12 levels. Routine supplements are not necessary.
H2-receptor antagonists: include cimetidine (Tagamet), famotidine
(Pepcid), nizatidine (Axid), and ranitidine (Zantac). Reduced secretion of
gastric acid and pepsin produced by H2 blockers can reduce absorption of
protein-bound (dietary) vitamin B12, but not of supplemental vitamin B12.
Gastric acid is needed to release vitamin B12 from protein for absorption.
Clinically significant vitamin B12 deficiency and megaloblastic anemia are
unlikely, unless H2 blocker therapy is prolonged (2 years or more), or the
person's diet is poor. It is also more likely if the person is rendered
achlorhydric (with complete absence of gastric acid secretion), which
occurs more frequently with proton pump inhibitors than H2 blockers.
Vitamin B12 levels should be monitored in people taking high doses of H2
blockers for prolonged periods.
Metformin (Glucophage): Metformin may reduce serum folic acid and
vitamin B12 levels. These changes can lead to hyperhomocysteinemia,
adding to the risk of cardiovascular disease in people with diabetes.[citation
needed]
There are also rare reports of megaloblastic anemia in people who
have taken metformin for 5 years or more. Reduced serum levels of
vitamin B12 occur in up to 30% of people taking metformin
chronically.[49][50] However, clinically significant deficiency is not likely to
develop if dietary intake of vitamin B12 is adequate. Deficiency can be
corrected with vitamin B12 supplements even if metformin is continued.
The metformin-induced malabsorption of vitamin B12 is reversible by oral
calcium supplementation.[51] The general clinical significance of metformin
upon B12 levels is as yet unknown.[52]
Neomycin: Absorption of vitamin B12 can be reduced by neomycin, but
prolonged use of large doses is needed to induce pernicious anemia.
Supplements are not usually needed with normal doses.
Nicotine: Nicotine can reduce serum vitamin B12 levels. The need for
vitamin B12 supplementation in smokers has not been adequately studied.
Nitrous oxide: Nitrous oxide inactivates the cobalamin form of vitamin B12
by oxidation. Symptoms of vitamin B12 deficiency, including sensory
neuropathy, myelopathy, and encephalopathy, can occur within days or
weeks of exposure to nitrous oxide anesthesia in people with subclinical
vitamin B12 deficiency. Symptoms are treated with high doses of vitamin
B12, but recovery can be slow and incomplete. People with normal vitamin
B12 levels have sufficient vitamin B12 stores to make the effects of nitrous
oxide insignificant, unless exposure is repeated and prolonged (such as
recreational use). Vitamin B12 levels should be checked in people with
risk factors for vitamin B12 deficiency prior to using nitrous oxide
anesthesia. Chronic nitrous oxide B12 poisoning (usually from use of
nitrous oxide as a recreational drug), however, may result in B12
functional deficiency even with normal measured blood levels of B12. [53]
Phenytoin (Dilantin), phenobarbital, primidone (Mysoline): These
anticonvulsants have been associated with reduced vitamin B12
absorption, and reduced serum and cerebrospinal fluid levels in some
patients. This may contribute to the megaloblastic anemia, primarily
caused by folate deficiency, associated with these drugs. It is also
suggested that reduced vitamin B12 levels may contribute to the
neuropsychiatric side effects of these drugs. Patients should be
encouraged to maintain adequate dietary vitamin B12 intake. Folate and
vitamin B12 status should be checked if symptoms of anemia develop.
Proton pump inhibitors (PPIs): The PPIs include omeprazole (Prilosec,
Losec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole
(Protonix, Pantoloc), and esomeprazole (Nexium). The reduced secretion
of gastric acid and pepsin produced by PPIs can reduce absorption of
protein-bound (dietary) vitamin B12, but not supplemental vitamin B12.
Gastric acid is needed to release vitamin B12 from protein for absorption.
Reduced vitamin B12 levels may be more common with PPIs than with
H2-blockers, because they are more likely to produce achlorhydria
(complete absence of gastric acid secretion). However, clinically
significant vitamin B12 deficiency is unlikely, unless PPI therapy is
prolonged (2 years or more) or dietary vitamin intake is low. Vitamin B12
levels should be monitored in people taking high doses of PPIs for
prolonged periods.
Zidovudine (AZT, Combivir, Retrovir): Reduced serum vitamin B12 levels
may occur when zidovudine therapy is started. This adds to other factors
that cause low vitamin B12 levels in people with HIV, and might contribute
to the hematological toxicity associated with zidovudine. However, data
suggests vitamin B12 supplements are not helpful for people taking
zidovudine.
[edit] Interactions with herbs and dietary supplements
Folic acid: Folic acid, particularly in large doses, can mask vitamin B12
deficiency by completely correcting hematological abnormalities. In
vitamin B12 deficiency, folic acid can produce complete resolution of the
characteristic megaloblastic anemia, while allowing potentially irreversible
neurological damage (from continued inactivity of methylmalonyl mutase)
to progress. Thus, vitamin B12 status should be determined before folic
acid is given as monotherapy.
Potassium: Potassium supplements can reduce absorption of vitamin B12
in some people. This effect has been reported with potassium chloride
and, to a lesser extent, with potassium citrate. Potassium might contribute
to vitamin B12 deficiency in some people with other risk factors, but
routine supplements are not necessary.[54]
Vitamin B12 Deficiency
ROBERT C. OH, CPT, MC, USA, U.S. Army Health Clinic, Darmstadt, Germany
DAVID L. BROWN, MAJ, MC, USA, Madigan Army Medical Center, Fort Lewis,
Washington
Vitamin B12 (cobalamin) deficiency is a common cause
of macrocytic anemia and has been implicated in a
spectrum of neuropsychiatric disorders. The role of B12
deficiency in hyperhomocysteinemia and the promotion
of atherosclerosis is only now being explored.
Diagnosis of vitamin B12 deficiency is typically based on
measurement of serum vitamin B12 levels; however,
about 50 percent of patients with subclinical disease
have normal B12 levels. A more sensitive method of
screening for vitamin B12 deficiency is measurement of
serum methylmalonic acid and homocysteine levels,
which are increased early in vitamin B12 deficiency. Use
of the Schilling test for detection of pernicious anemia
has been supplanted for the most part by serologic
testing for parietal cell and intrinsic factor antibodies.
Contrary to prevailing medical practice, studies show
that supplementation with oral vitamin B12 is a safe and
effective treatment for the B12 deficiency state. Even
when intrinsic factor is not present to aid in the
A patient
information handout
on vitamin B12
deficiency, written
by the authors of
this article, is
provided on page
993.
A PDF version
of this document is
available. Download
PDF now (8 pages
/148 KB). More
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absorption of vitamin B12 (pernicious anemia) or in other
diseases that affect the usual absorption sites in the
terminal ileum, oral therapy remains effective. (Am Fam
Physician 2003;67:979-86,993-4. Copyright© 2003
American Academy of Family Physicians.)
Vitamin B12 (cobalamin) plays an important role in DNA synthesis and neurologic
function. Deficiency can lead to a wide spectrum of hematologic and
neuropsychiatric disorders that can often be reversed by early diagnosis and
prompt treatment.
The true prevalence of vitamin B12
deficiency in the general population is
unknown. The incidence, however,
appears to increase with age. In one
study,1 15 percent of adults older than
65 years had laboratory evidence of
vitamin B12 deficiency. The nearly
ubiquitous use of gastric acidblocking
agents, which can lead to decreased
vitamin B12 levels,2 may have an
underappreciated role in the
development of vitamin B12 deficiency.
Taking the widespread use of these
agents and the aging of the U.S.
population into consideration, the actual
prevalence of vitamin B12 deficiency
may be even higher than statistics
indicate. Despite these facts, the need
for universal screening in older adults
remains a matter of controversy.3,4
Clinical Manifestations
TABLE 1
Clinical Manifestations of
Vitamin B12 Deficiency
Hematologic
Megaloblastic anemia
Pancytopenia (leukopenia,
thrombocytopenia)
Neurologic
Paresthesias
Peripheral neuropathy
Combined systems disease
(demyelination of dorsal columns
and corticospinal tract)
Psychiatric
Irritability, personality change
Mild memory impairment, dementia
Depression
Psychosis
Cardiovascular
Possible increased risk of
myocardial infarction and stroke
Vitamin B12 deficiency is associated
with hematologic, neurologic, and
psychiatric manifestations (Table 1). It is
a common cause of macrocytic
(megaloblastic) anemia and, in
advanced cases, pancytopenia.
Neurologic sequelae from vitamin B12
deficiency include paresthesias, peripheral neuropathy, and demyelination of the
corticospinal tract and dorsal columns (subacute combined systems disease).
Vitamin B12 deficiency also has been linked to psychiatric disorders, including
impaired memory, irritability, depression, dementia and, rarely, psychosis. 5,6
In addition to hematologic and neuropsychiatric manifestations, vitamin B12
deficiency may exert indirect cardiovascular effects. Similar to folic acid
deficiency, vitamin B12 deficiency produces hyperhomocysteinemia, which is an
independent risk factor for atherosclerotic disease.7 Although the role of folic acid
supplementation in reducing homocysteine levels as a method for preventing
coronary artery disease and stroke continues to be a subject of great interest,
there has been little emphasis on the potential role of vitamin B12 deficiency as a
contributing factor in the development of cardiovascular disease. This possibility
becomes especially important when considering vitamin replacement therapy.
Folic acid supplementation may mask an occult vitamin B12 deficiency and further
exacerbate or initiate neurologic disease. Therefore, clinicians should consider
ruling out vitamin B12 deficiency before initiating folic acid therapy.8
Normal Absorption of Vitamin B12
In humans, only two enzymatic reactions are known to be dependent on vitamin
B12. In the first reaction, methylmalonic acid is converted to succinyl-CoA using
vitamin B12 as a cofactor (Figure 1). Vitamin B12 deficiency, therefore, can lead to
increased levels of serum methylmalonic acid. In the second reaction,
homocysteine is converted to methionine by using vitamin B12 and folic acid as
cofactors. In this reaction, a deficiency of vitamin B12 or folic acid may lead to
increased homocysteine levels.
An understanding of the vitamin B12 absorption cycle helps illuminate the
potential causes of deficiency. The acidic environment of the stomach facilitates
the breakdown of vitamin B12 that is bound to food. Intrinsic factor, which is
released by parietal cells in the stomach, binds to vitamin B12 in the duodenum.
This vitamin B12intrinsic factor complex subsequently aids in the absorption of
vitamin B12 in the terminal ileum.
In addition to this method of absorption, evidence supports the existence of an
alternate system that is independent of intrinsic factor or even an intact terminal
ileum. Approximately 1 percent of a large oral dose of vitamin B 12 is absorbed by
this second mechanism.9 This pathway is important in relation to oral
replacement. Once absorbed, vitamin B12 binds to transcobalamin II and is
transported throughout the body. The interruption of one or any combination of
these steps places a person at risk of developing deficiency (Figure 2).
FIGURE 2. Vitamin B12 absorption and transport.
Diagnosis of Vitamin B12 Deficiency
The diagnosis of vitamin B12 deficiency has traditionally been based on low
serum vitamin B12 levels, usually less than 200 pg per mL (150 pmol per L),
along with clinical evidence of disease. However, studies indicate that older
patients tend to present with neuropsychiatric disease in the absence of
hematologic findings.5,6 Furthermore, measurements of metabolites such as
methylmalonic acid and homocysteine have been shown to be more sensitive in
the diagnosis of vitamin B12 deficiency than measurement of serum B12 levels
alone.3,10-14
In a large study10 of 406 patients with
known vitamin B12 deficiency, 98.4
percent had elevated serum
Elevated levels of methylmalonic acid
methylmalonic acid levels, and 95.9
and homocysteine are a much more
percent had elevated serum
sensitive diagnostic clue than a low
homocysteine levels (defined as three serum B12 level in the diagnosis of
standard deviations above the mean). vitamin B12 deficiency.
Only one patient out of 406 had
normal levels of both metabolites,
resulting in a sensitivity of 99.8 percent
when methylmalonic acid and homocysteine levels are used for diagnosis.
Interestingly, 28 percent of the patients in this study had normal hematocrit
levels, and 17 percent had normal mean corpuscular volumes.
In another study13 of patients with known pernicious anemia who had not
received maintenance vitamin B12 injections for months to years, the rise of
methylmalonic acid and homocysteine levels was found to precede the decrease
in serum vitamin B12 and the decline in hematocrit. This finding suggests that
methylmalonic acid and homocysteine levels can be early markers for tissue
vitamin B12 deficiency, even before hematologic manifestations occur.
Use of methylmalonic acid and homocysteine levels in the diagnosis of vitamin
B12 deficiency has led to some surprising findings. If increased homocysteine or
methylmalonic acid levels and a normalization of these metabolites in response
to replacement therapy are used as diagnostic criteria for vitamin B12 deficiency,
approximately 50 percent of these patients have serum vitamin B 12 levels above
200 pg per mL.1 This observation suggests that use of a low serum vitamin B12
level as the sole means of diagnosis may miss up to one half of patients with
actual tissue B12 deficiency. Other studies have shown similar findings, with the
rate of missed diagnosis ranging from 10 to 26 percent when diagnosis is based
on low serum vitamin B12 levels alone.3
There are, however, a few caveats to keep in mind. Looking at the reactions that
use vitamin B12 (Figure 1),3 an elevated methylmalonic acid level is clearly more
specific for vitamin B12 deficiency than an elevated homocysteine level. Vitamin
B12 or folic acid deficiency can cause the homocysteine level to rise, so folic acid
levels also should be checked in patients with isolated hyperhomocysteinemia.
In addition, folic acid deficiency can cause falsely low serum vitamin B12 levels.
One study14 revealed that approximately one third of patients with folic acid
deficiency had low serum vitamin B12 levels--less than 100 pg per mL (74 pmol
per L) in some patients. Also, methylmalonic acid levels can be elevated in
patients with renal disease (the result of decreased urinary excretion); thus,
elevated levels must be interpreted with caution.10
An algorithm for the diagnosis of vitamin B12 deficiency is provided in Figure 3.3,14
Suspected Vitamin B12 Deficiency
*--If levels of metabolites normalize with vitamin B12 supplementation.
FIGURE 3. Suggested approach to the patient with suspected vitamin B12
deficiency.
Information from Stabler SP. Screening the older population for cobalamin
(vitamin B12) deficiency. J Am Geriatr Soc 1995:43:1295, and Snow CF.
Laboratory diagnosis of vitamin B12 and folate deficiency. Arch Intern Med
1999;159:1297.
Causes of Vitamin B12 Deficiency States
Once vitamin B12 deficiency is confirmed, a search for the etiology should be
initiated. Causes of vitamin B12 deficiency can be divided into three classes:
nutritional deficiency, malabsorption syndromes, and other gastrointestinal
causes (Table 2).14
NUTRITIONAL DEFICIENCY
Dietary sources of vitamin B12 are
primarily meats and dairy products. In
a typical Western diet, a person
Any process that interferes with gastric
obtains approximately 5 to 15 mcg of
acid production, such as prolonged
vitamin B12 daily, much more than the
use of acid-suppressing medications,
recommended daily allowance of
can lead to vitamin B12 deficiency.
2 mcg. Normally, humans maintain a
large vitamin B12 reserve, which can
last two to five years even in the
presence of severe malabsorption.14 Nevertheless, nutritional deficiency can
occur in specific populations. Elderly patients with "tea and toast" diets and
chronic alcoholics are at especially high risk. The dietary limitations of strict
vegans make them another, less common at-risk population.
MALABSORPTION SYNDROMES
The classic disorder of malabsorption is pernicious anemia, an autoimmune
disease that affects the gastric parietal cells. Destruction of these cells curtails
the production of intrinsic factor and subsequently limits vitamin B12 absorption.
Laboratory evidence of parietal cell antibodies is approximately 85 to 90 percent
sensitive for the diagnosis of pernicious anemia. However, the presence of
parietal cell antibodies is nonspecific and occurs in other autoimmune states.
Intrinsic factor antibody is only 50 percent sensitive, but it is far more specific for
the diagnosis of pernicious anemia.
A Schilling test, which distinguishes intrinsic factor-related malabsorption, can be
used to diagnose pernicious anemia (Table 3).14 Specifically, Schilling test results
were once used to determine whether a patient required parenteral or oral
vitamin B12 supplementation. This distinction is now unnecessary, because
evidence points to a B12 absorption pathway independent of intrinsic factor, and
studies have proved that oral replacement is equal in efficacy to intramuscular
therapy.9 Regardless of the test result, successful treatment can still be achieved
with oral replacement therapy.
TABLE 2
Etiologies of Vitamin B12
Deficiency
TABLE 3
Interpretation of the Schilling
Test
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Thus, the utility of the Schilling test has been brought into question.3 The
Schilling test also has fallen out of favor because it is complicated to perform, the
radiolabeled vitamin B12 is difficult to obtain, and interpretation of test results can
be problematic in patients with renal insufficiency.
The phenomenon of food-bound malabsorption occurs when vitamin B12 bound
to protein in foods cannot be cleaved and released. Any process that interferes
with gastric acid production can lead to this impairment. Atrophic gastritis, with
resulting hypochlorhydria, is a major cause, especially in the elderly.3 Subtotal
gastrectomy, once common before the availability of effective medical therapy for
peptic ulcer disease, also can lead to vitamin B12 deficiency by this mechanism.
As mentioned previously, the widespread and prolonged use of histamine H 2receptor blockers and proton pump inhibitors for ulcer disease also may cause
impaired breakdown of vitamin B12 from food, causing malabsorption and
eventual depletion of B12 stores. Recent studies have confirmed that long-term
use of omeprazole can lead to lower serum vitamin B12 levels.15,16 While more
studies are needed to identify the incidence and prevalence of vitamin B 12
deficiency in this subset of patients, screening for subclinical B12 deficiency
should be a consideration in patients who have received long-term acidsuppression therapy.2
OTHER CAUSES
Other etiologies of vitamin B12 deficiency, although less common, deserve
mention. Patients with evidence of vitamin B12 deficiency and chronic
gastrointestinal symptoms such as dyspepsia, recurrent peptic ulcer disease, or
diarrhea may warrant evaluation for such entities as Whipple's disease (a rare
bacterial infection that impairs absorption), Zollinger-Ellison syndrome
(gastrinoma causing peptic ulcer and diarrhea), or Crohn's disease. Patients with
a history of intestinal surgery, strictures, or blind loops may have bacterial
overgrowth that can compete for dietary vitamin B12 in the small bowel, as can
infestation with tapeworms or other intestinal parasites. Congenital transportprotein deficiencies, including transcobalamin II deficiency, are another rare
cause of vitamin B12 deficiency.
Oral vs. Parenteral Therapy
Because most clinicians are generally
unaware that oral vitamin B12 therapy
is effective,17 the traditional treatment
Oral vitamin B12 replacement is as
for B12 deficiency has been
effective as intramuscular injections,
intramuscular injections. However,
even in patients with pernicious
since as early as 1968, oral vitamin
anemia or ileal disease.
B12 has been shown to have an
efficacy equal to that of injections in
the treatment of pernicious anemia
and other B12 deficiency states.9,17-19 Although the majority of dietary vitamin B12
is absorbed in the terminal ileum through a complex with intrinsic factor, evidence
for the previously mentioned alternate transport system is mounting.
In one study,18 38 patients with vitamin B12 deficiency were randomized to
receive oral or parenteral therapy. Patients in the parenteral therapy group
received 1,000 mcg of vitamin B12 intramuscularly on days 1, 3, 7, 10, 14, 21, 30,
60, and 90, while those in the oral treatment group received 2,000 mcg daily for
120 days. At the end of 120 days, patients who received oral therapy had
significantly higher serum vitamin B12 levels and lower methylmalonic acid levels
than those in the parenteral therapy group. The actual transport mechanism used
in this pathway remains unproved, but vitamin B12 is thought to be absorbed "en
masse" in high doses. Surprisingly, one study20 showed that even in patients who
had undergone gastrectomy, vitamin B12 deficiency could be easily reversed with
oral supplementation.
Intramuscular injections, although safe and inexpensive, have several
drawbacks. Injections are painful, medical personnel giving the injections are
placed at risk of needlestick injuries, and administration of intramuscular
injections often adds to the cost of therapy. Treatment schedules for
intramuscular administration vary widely but usually consist of initial loading
doses followed by monthly maintenance injections. One regimen consists of daily
injections of 1,000 mcg for one to two weeks, then a maintenance dose of 1,000
mcg every one to three months.
Although the daily requirement of vitamin B12 is approximately 2 mcg, the initial
oral replacement dosage consists of a single daily dose of 1,000 to 2,000 mcg
(Table 4). This high dose is required because of the variable absorption of oral
vitamin B12 in doses of 500 mcg or less.19 This regimen has been shown to be
safe, cost-effective, and well tolerated by patients.19
TABLE 4
Schedule for Vitamin B12 Therapy
Route of
administration
Initial dosage
Maintenance dosage
Oral
1,000 to 2,000 mcg per 1,000 mcg per day
day for one to two
for life
weeks
Intramuscular
100 to 1,000 mcg
every day or every
other day for one to
two weeks
100 to 1,000 mcg
every one to three
months
Follow-Up
After the diagnosis of vitamin B12 deficiency has been made and a treatment plan
has been initiated, follow-up is important to determine the patient's response to
therapy. If vitamin B12 deficiency is associated with severe anemia, correction of
the deficiency state should lead to a marked reticulocytosis in one to two weeks.
In mild vitamin B12 deficiency, we recommend repeat measurements of serum
vitamin B12, homocysteine, and methylmalonic acid levels two to three months
after initiating treatment.
The authors thank Linda L. Brown, M.D., Department of Internal Medicine, Walter
Reed Army Medical Center, Washington, D.C., for review of the manuscript.
The authors indicate that they do not have any conflicts of interest. Sources of
funding: none reported.
The opinions and assertions contained herein are the private views of the
authors and are not to be construed as official or as reflecting the views of the
U.S. Army Medical Department or the U.S. Army Service at large.
The Authors
ROBERT C. OH, CPT, MC, USA, is a staff family physician at U.S. Army Health
Clinic in Darmstadt, Germany. Dr. Oh received his medical degree from Boston
University School of Medicine and completed residency training in family practice
at DeWitt Army Community Hospital in Fort Belvoir, Va.
DAVID L. BROWN, MAJ, MC, USA, is director of primary care sports medicine at
Madigan Army Medical Center, Fort Lewis, Wash. He received his medical
degree from the Uniformed Services University of the Health Sciences F. Edward
Hébert School of Medicine, Bethesda, Md. He completed a residency in family
practice at Tripler Army Medical Center, Honolulu, and a fellowship in primary
care sports medicine at the Uniformed Services University of Health Sciences.
Address correspondence to Robert C. Oh, CPT, MC, USA, CMR 431, Box 284,
APO AE 09175 (e-mail: [email protected]). Reprints are not available from
the authors.
REFERENCES
1. Pennypacker LC, Allen RH, Kelly JP, Matthews LM, Grigsby J, Kaye K, et
al. High prevalence of cobalamin deficiency in elderly outpatients. J Am
Geriatr Soc 1992;40:1197-204.
2. Bradford GS, Taylor CT. Omeprazole and vitamin B12 deficiency. Ann
Pharmacother 1999;33:641-3.
3. Stabler SP. Screening the older population for cobalamin (vitamin B12)
deficiency. J Am Geriatr Soc 1995;43:1290-7.
4. Green R. Screening for vitamin B12 deficiency: caveat emptor [Editorial].
Ann Intern Med 1996; 124:509-11.
5. Lee GR. Pernicious anemia and other causes of vitamin B12 (cobalamin)
deficiency. In: Lee GR, et al., eds. Wintrobe's Clinical hematology. 10th
ed. Baltimore: Williams & Wilkins, 1999:941-64.
6. Lindenbaum J, Healton EB, Savage DG, Brust JC, Garrett TJ, Podell ER,
et al. Neuropsychiatric disorders caused by cobalamin deficiency in the
absence of anemia or macrocytosis. N Engl J Med 1988; 318:1720-8.
7. Nygard O, Nordrehaug JE, Refsum H, Ueland PM, Farstad M, Vollset SE.
Plasma homocysteine levels and mortality in patients with coronary artery
disease. N Engl J Med 1997;337:230-6.
8. Tucker KL, Mahnken B, Wilson PW, Jacques P, Selhub J. Folic acid
fortification of the food supply. Potential benefits and risks for the elderly
population. JAMA 1996;276:1879-85.
9. Elia M. Oral or parenteral therapy for B12 deficiency. Lancet
1998;352:1721-2.
10. Savage DG, Lindenbaum J, Stabler SP, Allen RH. Sensitivity of serum
methylmalonic acid and total homocysteine derterminations for diagnosing
cobalamin and folate deficiencies. Am J Med 1994;96:239-46.
11. Sumner AE, Chin MM, Abrahm JL, Berry GT, Gracely EJ, Allen RH, et al.
Elevated methylmalonic acid and total homocysteine levels show high
prevalence of vitamin B12 deficiency after gastric surgery. Ann Intern Med
1996;124:469-76.
12. Frenkel EP, Yardley DA. Clinical and laboratory features and sequelae of
deficiency of folic acid (folate) and vitamin B12 (cobalamin) in pregnancy
and gynecology. Hematol Oncol Clin North Am 2000;14:1079-100.
13. Lindenbaum J, Savage DG, Stabler SP, Allen RH. Diagnosis of cobalamin
deficiency: II. Relative sensitivities of serum cobalamin, methylmalonic
acid, and total homocysteine concentrations. Am J Hematol 1990;34:99107.
14. Snow CF. Laboratory diagnosis of vitamin B12 and folate deficiency: a
guide for the primary care physician. Arch Intern Med 1999;159:1289-98.
15. Marcuard SP, Albernaz L, Khazanie PG. Omeprazole therapy causes
malabsorption of cyanocobalamin (vitamin B12). Ann Intern Med
1994;120:211-5.
16. Termanini B, Gibril F, Sutliff VE, Yu F, Venzon DJ, Jensen RT. Effect of
long-term gastric acid suppressive therapy on serum vitamin B12 levels in
patients with Zollinger-Ellison syndrome. Am J Med 1998; 104:422-30.
17. Lederle FA. Oral cobalamin for pernicious anemia: back from the verge of
extinction. J Am Geriatr Soc 1998;46:1125-7.
18. Kuzminski AM, Del Giacco EJ, Allen RH, Stabler SP, Lindenbaum J.
Effective treatment of cobalamin deficiency with oral cobalamin. Blood
1998;92: 1191-8.
19. Lederle FA. Oral cobalamin for pernicious anemia. Medicine's best kept
secret? JAMA 1991;265:94-5.
20. Adachi S, Kawamoto T, Otsuka M, Fukao K. Enteral vitamin B12
supplements reverse postgastrectomy B12 deficiency. Ann Surg
2000;232:199-201.
American Academy of Family Physicians 2003
Vitamin D
Vitamin D3 is made in the skin when 7-dehydrocholesterol reacts with UVB
ultraviolet light at wavelengths between 270–300 nm, with peak synthesis
occurring between 295-297 nm.[12][13] These wavelengths are present in sunlight
when the UV index is greater than 3. At this solar elevation, which occurs daily
within the tropics, daily during the spring and summer seasons in temperate
regions, and almost never within the arctic circles, adequate amounts of vitamin
D3 can be made in the skin after only ten to fifteen minutes of sun exposure at
least two times per week to the face, arms, hands, or back without sunscreen.
With longer exposure to UVB rays, an equilibrium is achieved in the skin, and the
vitamin simply degrades as fast as it is generated.
Walgreens giving free care to jobless
and uninsured
AP – March 23, 2009.
NEW YORK – Drugstore operator Walgreens will offer free clinic visits to the
unemployed and uninsured for the rest of the year, providing tests and routine
treatment for minor ailments through its walk-in clinics — though patients will still
pay for precriptions.
Walgreens said patients who lose their job and health insurance after March 31
will be able to get free treatment at its in-store Take Care clinics for respiratory
problems, allergies, infections and skin conditions, among other ailments.
Typically those treatments cost $59 or more for patients with no insurance.
Hal Rosenbluth, chairman of the Take Care Health Systems division, described
the plan as something close to an experiment: He said Walgreens isn't sure of
patient demand or how much providing the services might cost the company.
It's likely to generate more attention for the clinics, however. Rosenbluth said a
typical Take Care patient tells eight other people about his or her experience. So
far, about 30 percent of Take Care patients were new customers to Walgreens.
The program is expected to last through the end of 2009. Walgreens runs 341
Take Care clinics in 35 markets around the country, including Chicago, Atlanta,
Miami and Cleveland.
Free services will be offered only from 11 a.m. to 3 p.m. Monday through Friday.
Walgreens said it will not offer free checkups, vaccinations or other injections
because it is focusing on providing services patients might otherwise get at an
urgent-care center or even an emergency room.
Patients must present proof they are unemployed, including a federal or state
unemployment determination letter and an unemployment check stub. They will
have to sign a form at the clinic saying they have lost their jobs and health
benefits. If they find a new job or get new health insurance, they will no longer be
eligible for free care.
Spouses and children are also eligible for free services if they don't have
insurance of their own.
Medical lab operator Quest Diagnostics is participating in the program by offering
free tests for step throat and urinary tract infections.
Walgreens bought the Take Care clinics in May 2007. Take Care says it has
seen about 1.2 million patients since its launch in November 2005 and estimates
that up to 30 percent of them were uninsured.
A Case of Ascending Paralysis: the
Signs and Symptoms of Tick
Paralysis
Posted 03/26/2009
Menyoli Malafa, MSII; Veronica Tucci, JD, MS IV; Albert Vincent, PhD; Sajeel
Chowdhary, MD
Author Information
Summary and Case
Summary
Tick paralysis (TP), a response to the neurotoxic effects of the salivary secretions
produced by attached hard ticks (Ixodidae), is a syndrome that mimics a large
number of better known neurological disorders. TP is a sporadic, seasonal, rural
disorder in which acute ataxia often develops five to six days following a history
of walking in grass or low brush, followed by ascending flaccid paralysis.
Recognition and timely removal of the tick usually leads to complete resolution of
symptoms, whereas continued feeding can lead to respiratory arrest and death.
Follow-up includes species determination and patient surveillance for tick-borne
infectious disease.
Case
A 42 year-old man was hiking in Colorado for one week in July. Upon returning to
his home in Tampa, Florida, he felt flu-like symptoms and fatigue but no fever or
rash was noted. Two days later, he developed global muscle weakness and
presented to the emergency room. Upon physical exam, a tick was found under
the hair of the right occipital area.
Question: The patient likely has which of the following diagnoses:
a) Lyme Disease
b) Guillain-Barre Syndrome (GBS)
c) Colorado Tick Fever
d) Tick Paralysis
e) Babesiosis
Further Case History
The patient underwent extensive workup. All laboratory testing including CBC,
CMP and Lyme titers were within normal limits. Neurology was consulted given
the concern of possible Guillan-Barre Syndrome (GBS). After the tick was
removed, the patient improved, indicating a diagnosis of tick paralysis (TP).
Discussion
TP is a worldwide disease, occurring in Australia, Europe, South Africa and
throughout North America. In the United States, most cases occur in the Rocky
Mountain states and the Pacific Northwest, including Washington, Montana,
Oregon, Idaho, Wyoming, Nevada, Utah, Colorado and the northern parts of
Arizona, New Mexico and California. However, cases have also been reported in
central, southern and eastern states, including Texas, Oklahoma, Mississippi,
Florida, Georgia, North Carolina, South Carolina, Virginia, Washington, D.C.,
Pennsylvania and New York. In Canada, most cases are encountered in the
western part of the country, primarily southern British Columbia.[1,2]
More than 60 species of ticks are known to cause paralysis, but only a handful
are responsible for most cases. In North America, the disease is associated
primarily with six species: Dermacentor andersoni (―Rocky Mountain wood tick'),
D. variabilis (―American dog tick'), Amblyomma americanum (―Lone Star tick'), A.
maculatum (Gulf Coast tick), Ixodes scapularis (formerly I. dammini,
―Blacklegged tick') and I. pacificus (―Western Black-legged tick'). Peak incidence
occurs between April and June when nymphs and mature adults abound in low
vegetation and climb upward, questing for their next host by extending their
anterior pairs of legs.[1,3,4] Paralysis is a response to a neurotoxin secreted by the
salivary glands of the arachnid.[1,5] The biochemistry and pharmacology of the
specific paralysis- inducing toxins produced in North American ticks are yet to be
fully elucidated, but current evidence points to a mechanism by which the toxins
inhibit presynaptic acetylcholine release at the neuromuscular junction.[1,3,6] TP
presents more often and more severely in children, suggesting a concentrationdependent relationship between toxin levels and symptom expression. [1,4]
Signs and symptoms of TP begin about five to six days after the parasite has
attached, when neurotoxin is secreted at its peak levels. These prodromal
symptoms include restlessness, irritability, fatigue, nausea, paresthesias and
possibly ataxia. Over the next 24-48 hours, the patient develops ascending
symmetrical flaccid paralysis and weakness in the lower extremities. Over the
course of the next day or two, paralysis and weakness may ascend to involve the
trunk, axial and upper limb muscles. Cranial nerves may also become involved in
an ascending pattern, resulting in bulbar, facial and/or extraocular paralysis.
Patients demonstrate diminished or absent deep tendon and superficial reflexes
while, aside from occasional paresthesias, their sensory exam remains normal.
Pain and fever are absent. Death ensues following paralysis of the respiratory
muscles.[1,5,7,8,9]
Atypical presentations reflect variations in the site of tick attachment. There may
be ataxia and associated cerebellar deficits without accompanying muscle
weakness. The disorder may also present as an isolated facial paralysis without
trunk or limb involvement. Another group of atypical presentations is unilateral
paralysis and/or weakness, including isolated unilateral facial paralysis.[1,8]
Tick paralysis is treated by removal of the tick. Although the site of attachment is
most often the head and neck region, the entire body should be scrutinized,
including ear canals, nostrils and genitalia. Multiple ticks should be suspected,
and all must be removed.[1,4,7,10] Applications of petroleum jelly, nail polish,
alcohol, a needle and heat are inappropriate. These measures may result in
infection and cause the parasite to salivate or regurgitate more of its bodily fluids.
The tick should be grasped with blunt, angled forceps as close as possible to the
skin and to the embedded mouthparts (hypostome). Wearing protective gloves,
slowly pull the organism straight outward with a gentle and steady traction,
without twisting its body. Do not burst the tick. The hypostome is usually deeply
and firmly embedded and should be removed surgically should it come detached.
Antiseptic solution is then applied to the wound, and the recovered tick and
severed mouthparts may be preserved in 75% ethanol for identification. The
patient should be instructed to return in the event of additional illness and
educated on protective measures against ticks.
The symptoms of TP, at least those caused by North American species, typically
resolve rapidly following removal of all ticks from the patient. Improvement in the
condition of the patient subsequent to tick removal is confirmatory for the
diagnosis. Species found in some other parts of the world, notably Ixodes
holocyclus of Australia, produce a very potent neurotoxin and symptoms may not
subside as quickly, even worsening after removal.[5] The prognosis depends on
clinical presentation prior to removal. If all ticks were removed prior to the onset
of bulbar weakness, the patient often makes a full recovery within the first 24
hours. However, if onset of bulbar symptoms occurs during continued feeding,
the likelihood of fatal respiratory paralysis increases to 10%. Therefore, prompt of
diagnosis and tick removal are paramount.[1,5,7,8]
Because ticks are both vectors and reservoirs for various infectious diseases, it is
important to educate the patient about this added risk for possible concurrent
illnesses. Table 1 displays the geographical location and infectious diseases
associated with North American tick species which are also known to cause
TP.[1,8,11,12]
The list of differential diagnoses for ascending flaccid paralysis and acute ataxia
is extensive: 1) neuropathies such as Guillain-Barre syndrome, diptheric
polyneuropathy, porphyrias and meningoradiculopathies, 2) neuromuscular
junction disorders such as botulism and myasthenia gravis, 3) myopathies due to
electrolyte imbalance such as hypokalemia, hypophosphatemia,
hypomagnesemia, 4) heavy metal intoxication, 5) spinal cord disease and 6)
various CNS disorders such as rabies and poliomyelitis.[1,5,8,13] In addition to the
previously described symptoms of TP and the recent history of exposure to rural
tick-inhabited areas, there are other distinguishing clinical features of tick
paralysis. Neurophysiological studies reveal diminished compound muscle action
potential (CMAP) amplitudes, normal nerve conduction velocities and normal
response to repetitive stimulation. There are normal CSF findings and but an
absence of response to cholinergic drugs. Table 2 compares several of the major
differential diagnoses with hallmarks of TP.[1,5,6,13]
It is important for clinicians to include TP in the differential diagnosis of
ascending, flaccid paralysis with ataxia. The disease should be strongly
suspected when confronted by a bilateral ascending paralysis following a one
week history of hiking in tick-infested grasslands or brush during the spring or
summer. The entire skin should be scrutinized for embedded hard ticks, and all
must be promptly extracted by the appropriate technique to avoid potential
respiratory failure. Recovered specimens should be preserved in 75% ethanol for
identification*. The patient should be instructed to return in the event of additional
illness that may indicate a tick-borne infectious disease.
*Species indentification is offered by co-author
Albert L. Vincent Ph.D., Epidemiology Program
Hillsborough County Health Department
1105 E. Kennedy Blvd, Tampa, Fl 33602
Tel: (813) 307-8015 ext. 2910
Fax: (813) 276-2981 attn: Dr. Vincent
[email protected]
Every decision/pathway creates and orchestrates a cascade of highly evolved
reactions and consequences, some foreseen, other unforeseen. The decisions
you make concerning the complex workings of your office are of far reaching
beneficial effects over the next 4 to 8 years. You know your practice better than
anyone else, continuing to know it better in as many facets as possible is the key
to wise and appropriate decision making. Know the relevant metrics and move
forward with confidence.
Make a supersaturated solution of Epsom Salt, aka Magnesium Sulfate,
Magsulfate, MgSO4. Bring a pot of water to a fast boil, begin adding Epsom salt,
stirring with a wooden or plastic spoon. Continue adding until no more will go
into solution. If you accidently pour too much in, add some water and keep
stirring. When you have put in as much as possible take it off the heat and allow
it to cool undisturbed. Decant into clean jars and label. The resulting
liquid/paste/semisolid can be used as an osmotic agent to take swelling out of
sore body parts.
From
Clarification Document Regarding the
Patient-Centered Medical Home and
Specialty and Subspecialty Practices
Posted 03/26/2009
American College of Physicians Council of Subspecialty Societies PatientCentered Medical Home Workgroup
Author Information
Preface
The following document attempts to answer a number of questions regarding the
relationship of the Patient-Centered Medical Home (PCMH) care model to
specialist and subspecialist practices. The PCMH care model, while receiving
strong interest from providers, payers and patients, still requires substantial
development and testing. Much of this effort is taking place in demonstration
projects throughout the country. One particular area that requires further
development and testing is the integration of the care model with services
provided by specialty and subspecialty practices. This model development is
being addressed by the Council of Specialty Societies (CSS) PCMH Workgroup,
and through collaborative initiatives between the College and various specialty
and subspecialty societies. To learn more about the PCMH care model, please
go to the following American College of Physicians (ACP) site:
http://www.acponline.org/advocacy/where_we_stand/medical_home/
How Will the PCMH Healthcare Delivery and Payment Model
Affect Referrals to Specialists and Subspecialists?
The proposed incentives of the PCMH model are aligned to facilitate improved
communication and coordination of care between the personal physician and the
referred to specialist or subspecialist. The PCMH personal physician is the
patient's ally in facilitating treatment that is patient-centered, coordinated and of
high quality, and in navigating our complex system of care. The PCMH physician
should make referrals based upon their clinical judgment, while recognizing the
preferences and needs of the patient. It is also expected that the improved
physician-patient relationship promoted by the PCMH model will increase the
physician's knowledge of the patient and increase the likelihood that a patient will
follow the advice of their personal physician -- leading to a higher quality of
referral.
The PCMH model is not intended to limit appropriate referrals to specialists or
subspecialists by a patient's personal physician. The PCMH practitioner is not a
"gatekeeper" and there is no incentive tied to limiting access to specialists or
subspecialists. The general model does not prohibit the patient from choosing to
see a specialist or subspecialist of their choice when they desire.
Physicians practicing within a qualified PCMH setting would be expected to have
systems in place to communicate more effectively with their consultant and care
co-management colleagues and thereby improve the efficiency of the referral
process.
Since the suggested payment methodology under the PCMH model recognizes
the value of quality rather than only volume, PCMH physicians may complete
more of the preliminary evaluation of patients whom they previously would have
automatically referred for sake of ease and to increase service volume. This will
both decrease the likelihood of inappropriate, unnecessary referrals and provide
a more robust data base and documentation to accompany referrals that are
made. The model continues to recognize the importance of specialist and
subspecialist active participation in the evaluation, diagnosis and treatment of the
more complex medical conditions. In addition, a number of specialty and
subspecialty societies are in the process of developing or updating evidencebased best practice protocols to assist the PCMH personal physician in deciding
under what conditions to refer, and how best to treat if a referral is not necessary.
Furthermore, the PCMH model also emphasizes that the participating PCMH
practice accept accountability for continuous quality improvement. Thus, it would
be expected that the referring PCMH physician would make use of appropriate
clinical quality, efficiency and patient experience data in evaluating their referral
patterns as such valid data becomes available at the practice level. This refers to
the expectation that the PCMH physician would evaluate their own patterns of
referring or not referring patients with various conditions and complexities of
care, and consider the performance results of specialists and subspecialists
when making referrals.
Under What Circumstances Would Specialty or Subspecialty
Practices Qualify as a PCMH?
The PCMH healthcare delivery and payment model promotes the delivery of
patient-centered, longitudinal, integrated care. It offers the benefits of a personal
physician with a whole person orientation who accepts overall responsibility for
the first contact, continuous care of the patient and leads a team that provides
enhanced access to care, improved coordinated and integrated care, and
increased efforts to ensure safety and quality. It is viewed as appropriate for
practices providing primary or principal care to their patients that fulfill the
following criteria:
Meets the requirements of an approved third-party PCMH recognition
process (e.g. the NCQA PPC-PCMH recognition process available at
http://www.ncqa.org/tabid/631/Default.aspx) that ensures that the practice
has the structural capability and systems in place to provide care
consistent with the PCMH model.
Affirms the willingness to provide care consistent with the PCMH model as
reflected in the statement "Joint Principles of the Patient-Centered Medical
Home.[1]"
The PCMH model would be appropriate for the subgroup of patients in specialty
or subspecialty practices that are receiving long term, principal care for a
condition. Some examples include:
An endocrinology practice treating patients with Type 1 or Type 2
Diabetes who are on complex insulin regimes, multiple oral medications or
display significant complications.
A gastrointestinal practice treating patients with inflammatory bowel
disease or hepatitis.
An infectious disease practice caring for an HIV positive patient.
A rheumatology practice caring for patients with severe rheumatoid
arthritis.
A cardiology practice managing someone with advanced heart failure.
An oncology practice coordinating care for a person with a malignancy.
In all these situations, the personal physician within the designated PCMH
principal care practice would also be expected to be responsible for the more first
contact, whole person care (e.g., bronchitis, skin infections, urinary tract
infections, routine preventive health measures) required by the patient. The
presence of a personal physician engaged in a continuous professional
relationship with the patient is an important aspect of patient-centered care.
Potential models for a specialist or subspecialist who is providing principal care
to fulfill this responsibility include:
A principal care physician with appropriate training in primary care and
after discussion with the current primary care physician and patient,
directly provides for the routine first contact, whole person care of the
patient. Physicians practicing within a PCMH under this arrangement may
also benefit from attending the ACP Internal Medicine Update courses.
A principal care physician with appropriate training in primary care and
after discussion with the current primary care physician and patient hires a
nurse practitioner to provide for the routine first contact, whole person care
of the patient. The principal care physician will, however, still be medically
responsible for the overall care of the patient, and thus should remain upto-date on important clinical aspects of primary care medicine.
A principal care physician working in a multi-specialists practice
recognized as a PCMH can team-up with a primary care colleague to
provide the necessary routine first contact, whole person care of the
patient.
How Should the Decision Be Made and Transition Take Place
When a Patient Considers Changing Their PCMH Designation
From the Practice of Their Primary Care Physician to the
Practice of the Physician Providing Principal Care?
The answer to this question would be generally the same for any anticipated
change in a patient's PCMH. The PCMH care model emphasizes the importance
of the patient's active participation in all treatment decisions. The choice of which
practice to designate as the PCMH should be made by the patient after
consultation with both his or her primary care and their principal care physician.
Factors that should be considered by the patient when considering changing a
PCMH designation include the ability of the practice to provide first contact,
whole person, continuous, integrated care; the length of the expected course of
treatment provided by the principal care physician; and such personal
preferences as convenience and relationship with the physician. If a transition is
decided upon by the patient, the current primary care physician should supply the
new PCMH home with adequate information so that the new practice can
assume the role of providing care consistent with the PCMH model. As the
patient's clinical condition changes, the issue of the most appropriate PCMH
designation can be revisited.
How Does the PCMH Model Affect the Flow of Information
Between the Referring Personal Physician and the
Specialty/Subspecialty Practice? Who Is Responsible for What?
The PCMH is the central hub of care -- the location that is responsible for the
overall coordination of the patient's care. This function of the PCMH must be
recognized by all providers, including specialty and subspecialty physicians,
participating in the care of the patient and the patient.
The PCMH practice must have in place the structural capability and systems to
effectively assume the role of overall coordinator of care. This includes systems
to adequately track patient referrals and treatment provided by the other
professionals providing care to the patient; medications; and diagnostic tests and
laboratory results. Furthermore, the PCMH practice should have the capability to
communicate this tracked information, including un-summarized or uninterpreted
"raw" data, to other participating healthcare teams when appropriate and to the
patient.
The PCMH practice, in assuming the role of overall coordinator of care, is
expected to have formal or informal understandings and agreements with each
referred to or care co-managing specialty and subspecialty provider regarding
this coordination of care. These understandings and agreements should
minimally specify the expected form(s) of communication (e.g. faxed written
reports, reports sent by secure email, direct transfers from interoperable
electronic medical records), frequency or timeliness of communication, and the
specific information expected to be reported.
Specialists and subspecialists who choose not to become a PCMH should
determine appropriate practice management strategies to manage an increase in
communication (phone, e-mail, and fax) between PCMHs and their office. These
strategies may include:
Setting time requirements between PCMH and specialist/subspecialist to
communicate referral, consultant or treatment progress letters.
Setting time requirements between PCMH and specialist/subspecialist for
follow-up on lab and test results
Finally, the patient should be kept informed of communications taking place
between the PCMH practice and the referred to specialist or subspecialist.
It is also notable that the ACP has been involved in activities to improve the
general care coordination and transition between providers and settings. These
activities include participation in the "Stepping Up to the Plate Consortium"
organized by the American Board of Internal Medicine (ABIM) Foundation and
the "Transitions in Care" conference organized by the ACP in collaboration with
the Society of General Internal Medicine (SGIM), the Society of Hospital
Medicine (SHM), the American Geriatrics Society (AGS), the American College
of Emergency Physicians (ACEP) and the Society of Academic Emergency
Medicine (SAEM). Furthermore, guidelines or best practices regarding such
issues as transition procedures, information flow and responsibility protocols
specifically related to the PCMH-specialist/subspecialist interface are currently
being developed within the CSS PCMH Workgroup, and through direct
discussions between the College and various specialty and subspecialty groups.
How Are Physician Payments for the Additional Services
Provided Under the PCMH Care Model Expected to Be Funded?
The PCMH care model anticipates that most or all of the additional funding
required under this model will be funded through system-wide healthcare
savings. These savings directly relate to the provision of the patient-centered,
continuous, integrated care that is consistent with the PCMH care model.
Sources of savings include decreases in unnecessary or preventable use of
emergency departments or hospitals; decreases in unnecessary, duplicative care
and testing; and decreases in costs from improvements in overall clinical
outcomes resulting from such practices as population management, adhering to
evidence-based guidelines and providing patients with disease self-management
education. This assumption will be tested in both the Medicare Medical Home
demonstration project scheduled for implementation in 2009 and a number of
additional private or public-private multi-payer PCMH demonstration projects
being implemented throughout the country.
Does the American College of Physicians Support Improved
Payments for Specialty or Subspecialty Practices That Provide
Expanded Patient-Centered Care Coordination Services to Their
Patients Without Becoming a PCMH?
The American College of Physicians (ACP), in a 2007 policy paper "A System in
Need of Change: Restructuring Payment Policies to Support Patient-Centered
Care (available at http://www.acponline.org/hpp/statehc07_4.pdf), supported the
development of separate payments for services that facilitate patient-centered,
longitudinal, coordinated care. These "a la carte" payment codes would be used
by physicians in practices that cannot or choose not to provide all of the
attributes necessary to qualify as a PCMH. It is anticipated that the use of these
codes would be limited to specific treatment conditions or situations and would
require sufficient physician documentation within the medical record to ensure
that the defined service was delivered. There is currently precedence within
Medicare for the payment of care coordination or similar services that occur
primarily outside of the face-to-face visit. These payment codes include:
Care plan oversight for patients receiving home health care.
Care plan oversight for patients who have elected hospice coverage.
Ambulatory blood pressure monitoring.
Continuous glucose monitoring initiation.
Examples of possible new codes related to patient-centered, longitudinal,
coordinated care include:
Care plan oversight, for additional specified conditions, which would
include communication with other providers offering the patient treatment,
on-going review of patient medical status and lab reports, and care plan
modifications.
Physician email and telephonic consultation related to a care plan.
Disease self management training related to a care plan conducted by the
physician or nurse with related follow-up.
In addition, several subspecialty societies have suggested the development of
the concept of a "PCMH Neighbor" recognition process. It would reflect many of
the elements of the NCQA PPC-PCMH recognition tool currently being used in
most of the PCMH demonstration projects to identify PCMH practices. Required
elements for recognition would include the practice's ability to provide high levels
of care access, patient communication, focused care coordination, evidence
based care and efforts towards quality improvement. An important aspect of this
recognition would be validating practice's ability to communicate effectively with
the patient's PCMH. This form of recognition would also not require the
subspecialty practice to assume the first contact, whole person, primary care
responsibilities or be the major communication hub for the patient's treatment.
The College is working with NCQA and several payers to explore the possibility
of establishing this type of recognition that would provide subspecialty practices
with increased funding for this expanded level of service.
2008 STFM Annual Conference Theme: Strengthen Core
& Stimulate Progress: Assembling Patient-Centered
Medical Homes
From Annals of Family Medicine
Posted 12/19/2007
John Rogers, MD, MPH, MEd
Two plenary presentations at the 2007 Annual Spring Conference in Chicago
reinforced the choice of this theme, as have recent announcements about the
Patient-Centered Medical Home and the Patient-Centered Primary Care
Collaborative by the American Academy of Family Physicians (AAFP).[1,2]
In his plenary address at the 2007 Annual Spring Conference, Terry McGeeney
repeatedly said "Houston, we have a problem." He described the disheartening
state of family medicine clinical practice revealed by the TransforMED project.
Jim Mold, in his plenary presentation, presented an optimistic picture of a
statewide learning community that can lead to practice improvement, but his
data showed far from optimal performance. While family medicine may still have
a problem, there is a solution. By assembling patient-centered medical homes,
family medicine can strengthen the provision of its core clinical services and
stimulate progress toward optimal high quality care.
The AAFP is promoting the patient-centered medical home (PCMH) through the
TransforMED project, the Patient-Centered Primary Care Collaborative
(PCPCC), and advocacy in Congress. The American Board of Family Medicine
(ABFM) and the Association of Family Medicine Residency Directors (AFMRD)
are fostering the PCMH vision in residencies in the Preparing the Personal
Physician for Practice (P[4]) Project. STFM seeks to spread the PCMH model to
all teaching practices -- medical school faculty, residency program, and
community preceptor practices -- by promoting a teaching practice learning
community to help remodel the hundreds of teaching practices in family
medicine educational programs.
STFM joined the PCPCC[3] to advocate for this model of care. The Institute for
Family-Centered Care[4] and the New Health Partnerships[5] also advocate for
patient- and family-centered care. Attention to linkages around patient care is
consistent with STFM's mission statement and its responsibilities for the Future
of Family Medicine strategic priorities.
STFM is "dedicated to improving the health of all people through education,
research, patient care, and advocacy." Being involved in improving patient care
by joining the PCPCC and partnering with other organizations that advocate for
patient- and family-centered care is very consistent with STFM's mission.
STFM is charged with taking the lead on the Future of Family Medicine strategic
priority about recruiting and training a family physician workforce that will meet
the needs of the US population by practicing within the personal or patientcentered medical home.[6]
For recruitment, STFM has started FutureFamilyDocs.org and regular stories in
The STFM Messenger about efforts to recruit premedical students into medicine
who are likely to share the values we hold. The literature supports this strategy,
and also indicates that a required 3rd-year family medicine clinical experience is
directly related to the rate of recruitment of students into family medicine. [7] One
expected benefit of developing patient-centered medical homes in family
medicine is that this positive practice model would be attractive to clerkship
students. This strategy depends entirely on whether teaching practices for
students are patient-centered medical homes. Students rotate in medical school
faculty practices, residency programs, and community volunteer faculty
practices, so all of these teaching practices need to become patient-centered
medical homes.
For training, family medicine teachers need to prepare students and residents
for the PCMH practice model. A key step is to articulate the competencies
necessary for functioning well in a patient-centered medical home and to
develop curricula for providing learners with the knowledge-base required for
that environment. The STFM Special Task Force on the Future of Family
Medicine is developing competency-based curricula for the PCMH. The group
visit module is described as "a dynamic longitudinal way of teaching, whereby
the student learns by actively planning, conducting, and debriefing about each
visit with team members."[8]
This approach to education fits with the educational philosophy that students
learn what they do.[9] The importance of the clinical experience is supported by
the experiential learning cycle of abstract conceptualization, active
experimentation, concrete experience, and reflective observation. [10] Abstract
conceptualization and reflective observation, which are typical classroom
instruction activities, are important, but are incomplete without concrete
experience and active experimentation in clinical settings. Students and
residents continually note how the clinical experience compares with classroom
didactic instruction. Messages taught about medical home topics in class
settings will not stick unless learners experience the concepts in action in
clinical sites. Students must work in teaching practices with medical home
features or there is a risk that the PCMH initiative will be marginalized and lose
credibility.
Putting learners in teaching practices that are patient-centered medical homes
is a primary responsibility of family medicine educators. This implies that
educational leaders help remodel these teaching practices. This is a rather
ambitious agenda. There are over 100 medical school practices and over 450
residency program practices that need to become PCMH teaching practices. In
addition, estimating that each medical school has approximately 30 to 50
community practices in which it places students, there are roughly 3,000 to
5,000 community teaching practices that need to be remodeled into PCMHs.
Teachers of family medicine must be concerned about the types of clinical
practices where they place learners. The models of patient care that students
and residents experience in clinical settings exemplify Marshall McLuhan's
adage "The medium is the message."[9] The structure and process of patient
care provide the message of clinical education. This medium must model the
message of patient-centered care in medical homes. STFM's 2008 Annual
Conference theme underscores this fundamental point.
To read commentaries or to post a response to this article, see the online
version at
http://annfammed.org/cgi/eletter-submit/v/v/p.
John Rogers, MD, MPH, MEd, President, Society of Teachers of Family
Medicine
The Patient-centered Medical Home
Movement -- Promise and Peril for
Family Medicine
Posted 12/23/2008
John C. Rogers, MD, MPH, MEd
Author Information
Information from Industry
The Institute for Advances in Point-of-Care Testing
Keep up with emerging trends in glycemic control, anticoagulation management,
and other areas of point-of-care testing, to help reduce costs, enhance the
efficacy of healthcare management, and improve patient outcomes.
Introduction
"Strengthen the Core and Stimulate Progress: Assembling Patient-Centered
Medical Homes" was the theme of my year as the Society of Teachers of Family
Medicine President for 2007 to 2008. I advocated strongly for the patientcentered medical home (PCMH), especially its relevance to the educational
experiences in our teaching practices.[1-7] Realizing the risk of being accused of
"flip-flopping" on this issue, I do not think it would be prudent to continue to
enthusiastically embrace this movement without some reflection and analysis.
Although it is not a novel approach, I think an analysis of strengths, weaknesses,
opportunities, and threats is in order. Here I will review briefly what I consider
family medicine's internal strengths and weakness related to the PCMH and the
external opportunities and threats the PCMH movement presents to family
medicine. I will end with a general action agenda.
Strengths
It helps me to divide the Joint Principles of the Patient-Centered Medical Home[8]
into 2 categories: (1) the type of care we provide to patients and (2) the practice
infrastructure that supports our work.[3] The "care principles" are the personal
physician, physician-directed medical practice, whole person orientation, and that
care is coordinated and/or integrated. The "infrastructure principles" are that care
is coordinated and/or integrated, quality and safety, enhanced access, and
payment for added value. Note that coordination and integration of care is a care
principle in that we strive to do this for individual patients, but it is an
infrastructure principle when it requires registries, information technology, and
health information exchange.
We have been striving and succeeding for decades to practice in ways that are
consistent with the care principles. We also have a long history of teaching
students and residents about this type of care with accreditation standards that
enforce achievement of the principles in resident training. We also have
considerable scholarship and research documenting our provision of this care
and its value to patients and community health, as illustrated in part by
Rosenthal's article in this issue of the Journal of the American Board of Family
Medicine.[9]
Our strength with the infrastructure principles is our commitment to evidencebased clinical guidelines, quality improvement, and information technology and
our efforts to apply these to our routine medical care. We have well-developed
approaches for bringing the best information to the point of care and have
growing experience with enhanced access through open scheduling, expanded
hours, and electronic communication.
There is also strength in understanding the process of change in clinical
practices and how to facilitate that process. We have a solid scholarship base in
this area and practical experience with the TransforMED and P[4] projects.[10]
Strengths in the care and infrastructure principles and the change process are a
foundation for further progress.
Weaknesses
One of our weaknesses regarding the care principles is less than universal
provision of desired communication skills and shared decision making, as
observed by DeVoe et al in this issue of the Journal of the American Board of
Family Medicine.[11] Another is that, although we may be providing continuous,
team-based care that meets many patients' health needs, we do not have
systems that allow us to readily document (1) that each patient has an ongoing
relationship with a personal physician trained to provide first contact and
continuous and comprehensive care (personal physician); (2) that a personal
physician leads a team of individuals at the practice level who collectively take
responsibility for the ongoing care of patients (physician-directed medical
practice); (3) that a personal physician is responsible for providing for all of the
patient's health care needs or takes responsibility for appropriately arranging
care with other qualified professionals (whole person orientation); and (4) that
care is coordinated and/or integrated across all elements of the complex health
care system and the patient's community.[1] Furthermore, although we believe in
patient involvement in care, few of us are in practices that can boast that we use
a formal care planning process between physicians and patients, that we
regularly seek feedback to ensure patients' expectations are being met, and that
we involve patients and families in quality improvement activities at the practice
level (quality and safety principle).
These deficiencies underscore the fact that our greatest weakness is in the
infrastructure principles. We have few practices that have adequate resources
(capital and time) for these other elements of the care coordination and quality
and safety principles:
registries, information technology, health information exchange;
evidence-based medicine and clinical decision-support tools;
continuous quality improvement through performance measurement and
improvement;
information technology to support patient care, performance
measurement, patient education, and enhanced communication; and
demonstration that the practice has the capabilities to provide patientcentered services consistent with the medical home model.
The TransforMED National Demonstration Project has identified the difficulties in
changing practices to become patient-centered medical homes:
"Creating a PCMH is much more than a sum of implementing discrete model
components. Such transformation is exceedingly difficult, and those who attempt
it are heroic. To achieve transformation, full engagement of critical members of
the practice is needed. At the same time the practice needs to remain in charge
of its own destiny. They may need assistance in making the changes, but the
decision what to change needs to be theirs. They also need to remain full
partners in their learning and development process."[12]
Our weaknesses in the change process include the paucity of resources—time
and money—to support practice transformation, the limited diffusion of the
knowledge and skills necessary for change management, and where many of us
are in the stages of change related to the PCMH (precontemplation or
contemplation). Family medicine is rather weak on being able to document the
care it provides, supporting the cost and effort of implementing the infrastructure
elements in the PCMH principles, and supporting and managing the change
process.
From Family Practice Management
Out With the Old, In With the New
Posted 03/25/2009
Cindy Hughes, CPC
Author Information
A New Injection Code and Newborn Codes are Among This Year's
Most Notable CPT Changes.
When the new CPT book arrives each year, it may seem like change simply for
the sake of change. However, most CPT changes happen for valid reasons, such
as to address payment issues, to make codes easier to locate or to more
specifically identify a service. Not all of this year's CPT changes will affect you,
but the following additions, revisions and deletions should be noteworthy to
family physicians and other primary care specialists.
Injections - Don't Miss This Change!
To help physicians and coders select proper injection and infusion codes, the
hydration and injection codes have been changed to make them numerically
closer to the administration codes for chemotherapy and highly complex drug or
biological agents. That's right; the injection code, which was changed two years
ago, has been changed again! Add code 90772 to your list of deleted codes. The
code to remember for 2009 is 96372, "Therapeutic, prophylactic, or diagnostic
injection (specify substance or drug); subcutaneous or intramuscular."
Other hydration, nonchemotherapy and noncomplex drug injection and infusion
codes have also been moved to the 96360-96379 code series.
Newborn Evaluation and Management
New codes are sometimes added in awkward places in CPT because a limited
number of codes are available in the more logical spot. This occurred in 2008
with the code for initial hospital care of a neonate who requires intensive
observation, frequent interventions and other intensive care services. The lack of
an available code in the pediatric E/M subsections caused this service to be
placed under "Other Evaluation and Management Services." To correct this and
allow for future changes, codes related to newborn care and pediatric critical care
have been revised and can now be found in the 99460-99480 range. (See page
9 for a cross-reference of 2008 to 2009 newborn E/M codes.)
Important note: The instruction below code 99465, "Delivery/birthing room
resuscitation, provision of positive pressure ventilation and/or chest
compressions in the presence of acute inadequate ventilation and/or cardiac
output," incorrectly indicates that this code should not be reported in conjunction
with other newborn care services on the same date (99460, 99468 and 99477).
This is an error and has been added to the AMA's CPT errata (http://www.amaassn.org/ama/pub/category/3896.html). The correct instruction is that code
99465 should not be reported in conjunction with code 99464, "Attendance at
delivery (when requested by the delivering physician) and initial stabilization of
newborn."
Changes to Avoid Misinterpretation
Several of this year's CPT changes were simply to provide clearer descriptions of
what is included in the services represented by the code.
Preventive Medicine Services. The introductory language and code descriptors
for the preventive medicine services, 99381-99397, have been updated to more
specifically exclude the ordering of vaccine/toxoid products and screening tests
(e.g., vision, hearing and developmental testing). Those items should be reported
separately.
Wound Repairs. Codes 12031-12057 for intermediate wound repairs were
revised to avoid misinterpretations of the intent of these codes. The code
descriptors previously included the term "layer closure." Layer closure is replaced
with "intermediate repair" to clarify that single-layer closures of heavily
contaminated wounds that required extensive cleaning or removal of particulate
matter also constitute intermediate repair. For example, the descriptor for code
12031 now reads, "Repair, intermediate, wounds of scalp, axillae, trunk and/or
extremities (excluding hands and feet); 2.5 cm or less."
Lab Tests. The following lab test code descriptors were revised to indicate that
these codes are appropriately reported whether the testing platform utilizes
serum, plasma or whole blood specimens:
82040 Albumin; serum, plasma or whole blood,
84132 Potassium; serum, plasma or whole blood,
84155 Protein, total, except by refractometry; serum, plasma or whole
blood,
84295 Sodium; serum, plasma or whole blood.
New instructions in the microbiology section indicate that, when separate results
are reported for different species or strains of organisms, each result should be
coded separately. Use modifier 59 when separate results are reported for
different species or strains that are described by the same code. For most family
physicians, this may only be relevant in one instance: reporting codes 87804 and
87804-59 when testing for both Influenza A and B.
New codes
The following codes of note to primary care physicians have been added to CPT
for 2009:
Destruction of Hemorrhoids. A new code, 46930, has been added to report
various thermal energy destruction procedures for hemorrhoids including infrared
coagulation, cautery and radiofrequency. Note that no specific code is included in
CPT for destruction of hemorrhoids by cryosurgery. CPT now instructs
physicians to use 46999 to report this service. Codes for hemorrhoid injection,
ligation, incision, excision and repair remain unchanged. CPT codes 46934,
46935 and 46936 for destruction of hemorrhoids, any method, have been
deleted.
Lab Code. Code 87905, "Infectious agent enzymatic activity other than virus
(e.g., sialidase activity in vaginal fluid)," has been added for a test that allows
rapid diagnosis of bacterial vaginosis, such as BVBlue. This test would have
been reported with unlisted code 87999 before 2009. When testing by virus
isolation "including identification by non-immunologic method, other than by
cytopathic effect," physicians are instructed to report code 87255.
Vaccines. The CPT Editorial Panel has approved codes for some vaccines that
have not yet received FDA approval. These codes are marked with the ( )
symbol until approved. Updates on the FDA status of these codes are provided
on the AMA CPT Web site under "Category I Vaccine Codes" (http://www.amaassn.org/ama/pub/category/10902.html).
Code 90650 ( ) is currently pending FDA approval. This code will report a
human papilloma virus (HPV) vaccine that contains an adjuvant formulation and
is intended to protect against oncogenic types of cervical cancer (types 16 and
18). The existing HPV vaccine, 90649 (Gardasil), targets both oncogenic (types
16 and 18) and non-oncogenic (types 6 and 11) but does not contain the
adjuvant. Both vaccines have a three-dose schedule, but the current product is
administered at zero, two and six months, while the product reported with code
90650 is administered at zero, one and six months.
Code 90738 ( ) has been established to report an inactivated Japanese
encephalitis virus vaccine for intramuscular use that is also pending FDA
approval. The existing code, 90735 (Je-Vax), is also used to report an inactivated
Japanese encephalitis virus vaccine that is administered subcutaneously and
used primarily by the military. This vaccine is no longer supplied by the
manufacturer. The new vaccine is expected to replace the older vaccine when its
supply runs out and will be produced from Vero cell cultures without thiomersal
(mercury) and administered on a two-dose schedule.
The FDA approval-pending indicator ( ) was removed from code 90681,
attenuated human rotavirus vaccine for oral administration (Rotarix), which is
recommended for use in infants on a two-dose schedule. The other vaccine
product for rotavirus, reported with code 90680, is still valid and is identifiable by
a three-dose schedule.
Code 90696 has been established to report an FDA-approved, combination
vaccine to protect against diphtheria, tetanus, pertussis and poliomyelitis (DTaPIPV) in a single injection (Kinrix). This vaccine is intended to be administered as
a booster dose to healthy children four years old to six years old who completed
the recommended schedule for DTaP and polio virus as infants.
Code 90698 has been established to report the now-approved diphtheria, tetanus
toxoids, acellular pertussis vaccine, haemophilus influenza type B vaccine and
poliovirus vaccine, inactivated (DTaP-Hib-IVP), for intramuscular use (Pentacel).
Morton's Neuroma. For the treatment of patients with Morton's neuroma, new
codes have been added to report injection of a plantar common digital nerve
(64455) and destruction of a plantar common digital nerve by neurolytic agent
injection (64632). Regardless of the number of injections performed in a session,
report only one unit of service for code 64455. In addition, do not report 64455 in
conjunction with code 64632.
Just in Time for the New Year
So there you have it - a summary of coding changes across the spectrum of
family medicine intended to help you find and report codes in the most clear and
efficient manner possible. CPT isn't a perfect coding system, but hats off to those
who spend countless hours keeping it up-to-date. Here's wishing you health,
prosperity and no denials!
CPT 2009 Newborn Evaluation and Management Services
The following 2008 codes have been replaced with the codes listed in the righthand column.
Deleted 2008 codes and descriptors
2009 codes and descriptors
99431 History and examination of the
normal newborn infant, initiation of
diagnostic and treatment programs and
preparation of hospital records
99460 Initial hospital or birthing
center care, per day, for evaluation
and management of normal newborn
infant
99432 Normal newborn care in other than
hospital or birthing room setting, including
physical examination of baby and
conference(s) with parent(s)
99461 Initial care, per day, for
evaluation and management of
normal newborn infant seen in other
than hospital or birthing center
99433 Subsequent hospital care, for the
evaluation and management of a normal
newborn, per day
99462 Subsequent hospital care, per
day, for evaluation and management
of normal newborn
99435 History and examination of the
normal newborn infant, including
preparation of medical records (This code
should only be used for newborns
assessed and discharged from the
hospital or birthing room on the same
date.)
99463 Initial hospital or birthing
center care, per day, for evaluation
and management of a normal
newborn infant admitted and
discharged on the same date
99436 Attendance at delivery (when
requested by delivering physician) and
initial stabilization of newborn
99464 Attendance at delivery (when
requested by delivering physician)
and initial stabilization of newborn
99440 Newborn resuscitation; provision of
positive pressure ventilation and/or chest
compressions in the presence of acute
inadequate ventilation and/or cardiac
output
99465 Delivery/birthing room
resuscitation, provision of positive
pressure ventilation and/or chest
compressions in the presence of
acute inadequate ventilation and/or
cardiac output
The Patient-centered Medical Home
Movement -- Promise and Peril for
Family Medicine
Posted 12/23/2008
John C. Rogers, MD, MPH, MEd
Author Information
Introduction
"Strengthen the Core and Stimulate Progress: Assembling Patient-Centered
Medical Homes" was the theme of my year as the Society of Teachers of Family
Medicine President for 2007 to 2008. I advocated strongly for the patientcentered medical home (PCMH), especially its relevance to the educational
experiences in our teaching practices.[1-7] Realizing the risk of being accused of
"flip-flopping" on this issue, I do not think it would be prudent to continue to
enthusiastically embrace this movement without some reflection and analysis.
Although it is not a novel approach, I think an analysis of strengths, weaknesses,
opportunities, and threats is in order. Here I will review briefly what I consider
family medicine's internal strengths and weakness related to the PCMH and the
external opportunities and threats the PCMH movement presents to family
medicine. I will end with a general action agenda.
Strengths
It helps me to divide the Joint Principles of the Patient-Centered Medical Home[8]
into 2 categories: (1) the type of care we provide to patients and (2) the practice
infrastructure that supports our work.[3] The "care principles" are the personal
physician, physician-directed medical practice, whole person orientation, and that
care is coordinated and/or integrated. The "infrastructure principles" are that care
is coordinated and/or integrated, quality and safety, enhanced access, and
payment for added value. Note that coordination and integration of care is a care
principle in that we strive to do this for individual patients, but it is an
infrastructure principle when it requires registries, information technology, and
health information exchange.
We have been striving and succeeding for decades to practice in ways that are
consistent with the care principles. We also have a long history of teaching
students and residents about this type of care with accreditation standards that
enforce achievement of the principles in resident training. We also have
considerable scholarship and research documenting our provision of this care
and its value to patients and community health, as illustrated in part by
Rosenthal's article in this issue of the Journal of the American Board of Family
Medicine.[9]
Our strength with the infrastructure principles is our commitment to evidencebased clinical guidelines, quality improvement, and information technology and
our efforts to apply these to our routine medical care. We have well-developed
approaches for bringing the best information to the point of care and have
growing experience with enhanced access through open scheduling, expanded
hours, and electronic communication.
There is also strength in understanding the process of change in clinical
practices and how to facilitate that process. We have a solid scholarship base in
this area and practical experience with the TransforMED and P[4] projects.[10]
Strengths in the care and infrastructure principles and the change process are a
foundation for further progress.
Weaknesses
One of our weaknesses regarding the care principles is less than universal
provision of desired communication skills and shared decision making, as
observed by DeVoe et al in this issue of the Journal of the American Board of
Family Medicine.[11] Another is that, although we may be providing continuous,
team-based care that meets many patients' health needs, we do not have
systems that allow us to readily document (1) that each patient has an ongoing
relationship with a personal physician trained to provide first contact and
continuous and comprehensive care (personal physician); (2) that a personal
physician leads a team of individuals at the practice level who collectively take
responsibility for the ongoing care of patients (physician-directed medical
practice); (3) that a personal physician is responsible for providing for all of the
patient's health care needs or takes responsibility for appropriately arranging
care with other qualified professionals (whole person orientation); and (4) that
care is coordinated and/or integrated across all elements of the complex health
care system and the patient's community.[1] Furthermore, although we believe in
patient involvement in care, few of us are in practices that can boast that we use
a formal care planning process between physicians and patients, that we
regularly seek feedback to ensure patients' expectations are being met, and that
we involve patients and families in quality improvement activities at the practice
level (quality and safety principle).
These deficiencies underscore the fact that our greatest weakness is in the
infrastructure principles. We have few practices that have adequate resources
(capital and time) for these other elements of the care coordination and quality
and safety principles:
registries, information technology, health information exchange;
evidence-based medicine and clinical decision-support tools;
continuous quality improvement through performance measurement and
improvement;
information technology to support patient care, performance
measurement, patient education, and enhanced communication; and
demonstration that the practice has the capabilities to provide patientcentered services consistent with the medical home model.
The TransforMED National Demonstration Project has identified the difficulties in
changing practices to become patient-centered medical homes:
"Creating a PCMH is much more than a sum of implementing discrete model
components. Such transformation is exceedingly difficult, and those who attempt
it are heroic. To achieve transformation, full engagement of critical members of
the practice is needed. At the same time the practice needs to remain in charge
of its own destiny. They may need assistance in making the changes, but the
decision what to change needs to be theirs. They also need to remain full
partners in their learning and development process."[12]
Our weaknesses in the change process include the paucity of resources—time
and money—to support practice transformation, the limited diffusion of the
knowledge and skills necessary for change management, and where many of us
are in the stages of change related to the PCMH (precontemplation or
contemplation). Family medicine is rather weak on being able to document the
care it provides, supporting the cost and effort of implementing the infrastructure
elements in the PCMH principles, and supporting and managing the change
process.
Opportunities
The PCMH movement may bring recognition, reward, and support to family
medicine. Contrary to the negative recognition we received in the HMO/managed
care movement as gatekeepers who were to control access to other providers
and services, we are now receiving more positive recognition as gateways[13]
whose role is to coordinate and integrate access. This time the recognition
seems to be accompanied by an acknowledgment of both the health and
financial benefits to patients and communities of an available primary care base.
It is our intrinsic worth—just being present—that benefits the public, not our
control of access to other services. The reward and support may be increased
compensation to individual physicians and reimbursement that will fund
development of infrastructure provided that the payment system fulfills the stated
principles:
It should pay for services associated with coordination of care.
It should allow for separate fee-for-service payments.
It should allow for additional payments for achieving measurable quality
improvements.
It should support provision of enhanced communication access.
It should support use of health information technology for quality
improvement.
Recognition, reward, and support are sometimes viewed in terms of power and
prestige; an alternative view is to think of them in terms of equality and equity.
Either way, more appropriate levels may help with retention in practice of current
family physicians and enhance the recruitment of students to family medicine that
would be necessary to meet the goal of a personal medical home for every
person in the United States
Threats
The opportunity for enhanced reimbursement will probably depend on the
principle that practices go through a voluntary recognition process by an
appropriate nongovernmental entity to demonstrate that they have the
capabilities to provide patient-centered services consistent with the medical
home model.[1]
The National Committee for Quality Assurance's (NCQA) Physician Practice
Connections Patient-Centered Medical Home (PPC-PCMH) Recognition
Program[14] will be prominent. The TransforMED Medical Home IQ[10] instrument
shows practices how they would score on the NCQA PPC-PCMH Recognition
Program standards and identifies explicit changes necessary to achieve that
recognition. The threat is that the recognition criteria emphasize infrastructure
principles and provide little, if any weight, to care principles. This may distort
what is perceived as important in the PCMH movement. Focusing mostly on
implementing the infrastructure principles is a risk:
"Early analysis from the NDP [National Demonstration Project] (using both
qualitative data and the quantitative scores from 2 waves of patient outcome
surveys) does suggest that implementing components of the original
TransforMED model does not automatically lead to a patient-centered medical
home. A primary focus of the NDP has been implementation of the TransforMED
model components and to a certain extent, this focus on technical innovations
has competed with efforts to address relationship-centered patient care within the
practice."
"Successful implementation of new model components does not automatically
lead to the relationship-centered organization, necessary for sustained change
and learning. This is understandable, as the hard work of implementing
technology and revamping workflow means the difficult task of building practice
relationships retreat to the backburner. For the most part, the practices that are
relationship-centered were so in the beginning."[12]
The threat to family medicine is that a recognition program will emphasize
infrastructure and forget that relationship-centered care is the core of the PCMH
and that the purpose of infrastructure is to support patient-centered care, not
divert from it.
The Patient-Centered Primary Care Collaborative[8] has approximately 150
members representing every major stakeholder group in medical care, including
physician associations, health systems, patient organizations, insurance
companies, and business groups. A prominent motivation for many of these
groups advocating for the PCMH is the payment principle: "Payment
appropriately recognizes the added value provided to patients who have a
patient-centered medical home."[1] For patient organizations, "added value"
seems to mean improved quality of care, for insurance companies it seems to
mean cost savings, and for businesses it seems to mean more care for less
money. This "value" emphasis holds several threats for us, as raised by Fink in
this issue of the Journal.[15] One threat to family medicine is how quality of care is
measured. Any family medicine faculty member who has participated in quality
improvement efforts knows all too well that the indicators of quality and the data
systems for collecting these data can be flawed. Further, individual practices
could be penalized if the principle about payment ("It should recognize case mix
differences in the patient population being treated within the practice." [1]) is
ignored and "cherry-picking" of patients is allowed. A threat, and inequity, is if the
insurance companies ignore a powerful principle—"It should allow physicians to
share in savings from reduced hospitalizations associated with physician-guided
care management in the office setting."[1]—and pocket rather than share the
savings that family physicians create for them. Another threat is if these
stakeholders fail to realize that the PCMH is not a panacea for the rising costs of
health care and abandon the PCMH concept when health care costs continue to
rise and lead to continuing increases in insurance premiums for businesses.
I may be cynical, but I know that one threat to family medicine will be the PCMH
bandwagon where wannabes, lookalikes, and opportunists put out "PCMH"
shingles claiming they are a "medical home" and deserve the financial rewards
intended for the thousands of family physicians throughout this country who have
been unsung real medical homes for decades. The core principles of the PCMH
must be upheld to prevent it from becoming just another modification of disease
management or carve-out programs.
A most dangerous threat to family medicine will be those who co-op the vision of
the PCMH and distort the real meaning of what constitutes a medical home. Our
vision, and the vision our leaders have been articulating for just shy of 40 years,
is still in many ways a counter-culture vision of relationship-centered, patientcentered, family-centered care that integrates behavioral science into the fabric
of our continuing, comprehensive care of patients and families. This is the vision
that will realize the promise that the PCMH holds for the health and well-being of
our patients and communities.
The PCMH movement may threaten family medicine by the emphasis of the
recognition programs on infrastructure, the value orientation focus on cost
savings, PCMH imposters, and the possibility of a stolen vision. These threats
must not be minimized or ignored. Our general tendency in family medicine is to
be modest and to assume benign intent on the part of others. This is fundamental
to the power of our patient-centered, family-centered, relationship-centered care.
But to counter the real threats to the PCMH and our field, we must be alert,
diligent, and skeptical. Our advocacy is not self-centered but for the benefit of our
patients and communities whose health and well-being is enhanced by our
existence.
Action Agenda
I suggest a simple yet difficult and demanding action agenda.
Clinical Care
We move swiftly with wise, reasoned, and paced change toward the PCMH
principles in every one of our clinical practices. All of us must become change
agents advocating for advances in the care we provide. We must regularly
measure our practices against the external benchmarks provided by the
TransforMED Medical Home IQ and NCQA PPC-PCMH Recognition Program.
Research
We quickly identify the key questions regarding the effectiveness and
implementation of the PCMH principles. We must determine what is effective and
how to achieve it.
Education
We specify the teaching practices and teaching methods necessary to prepare
students, residents, and faculty for practice in PCMHs. Given vary rapidly
evolving medical care and the PCMH model, we also must identify the best
methods for rapid just-in-time skill acquisition.
Advocacy
We clearly, consistently, continuously and loudly articulate our vision for patientcentered, family-centered, relationship-centered care. We must stay "on
message" about the PCMH. We must not let others co-op the PCMH concept.
We must never forget, or let others forget, that care is what we do, and
infrastructure supports that role.
Conclusion
The PCMH movement offers us a defining moment in the development,
evolution, and even survival of our field. I think this opportunity blends our core
values of what we do in clinical care, our beliefs about equity and justice in health
care, and our self-image as counter-culture and change agents. Forty years ago
some visionaries saw clearly the needs of their patients and communities and
said there is a better way.[16] Today many other voices have joined our ancestors
to say that medical care can be better, it must be better. Let us honor our past,
stand strong for our beliefs, and help the system see the wisdom of the PCMH
and a strong primary care base, for the benefit of our patients and our
communities.
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John C. Rogers, MD, MPH, MEd, Baylor College of Medicine, Family and
Community Medicine, 3701 Kirby Dr., Suite 640, Houston, TX 77098. E-Mail:
[email protected]
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3. Rogers J. Assembling patient-centered medical homes-the care principles.
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4. Rogers J. Assembling patient-centered medical homes-the promise and
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5. Rogers J. Assembling patient-centered medical homes-teaching
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6. Rogers J. Assembling patient-centered medical homes-the clerkship
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7. Rogers J. Assembling patient-centered medical homes in teaching
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Medicine