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Friday, October 10, 2014

Population health: what might it look like?

Blue skies …
It is a beautiful day here in this little college town. The sun is shining and at 11 a.m. it is about 78 degrees with a barely perceptible breeze. People are out walking on Main Street and riding their bikes. The mountain nearby calls: I can go for a hike today with my dog and still be within 20 minutes or so of the hospital to respond to calls.

A mostly empty hospital
There are 2 patients on the hospitalist service in this fine critical access hospital. That is a tiny workload for my profession of hospitalists, who take care of patients in the hospital who have no primary care physician or whose doctor doesn’t manage their care while they are inpatients. Hospitalist usually don’t complain unless they are managing over 18 patients in a day. I am often quite busy, but not today. One of my 2 patients is going home later this morning. She is bright and cheerful, with progressive Alzheimer’s disease and chronic lung disease from a long gone habit of smoking 3 packs of cigarettes a day. She got a little perturbation of her lung bacteria with wheezing and a low oxygen level, and is now better on medications after an 18-hour hospital stay. Her daughter, who loves her and tells me about how she used to support herself selling the cherry pies she baked, will take her home to her house in the country where she will get along well, at least for a while, with her home nebulizer.

I just visited a former primary care patient of mine who is in the emergency room after a seizure and brief respiratory arrest. She is developmentally disabled and has a cancer which is finally going to take her life, and she will be going home to the group home where she has been scrupulously and lovingly taken care of for 28 years, with hospice. We have known this was coming. Medicare would have paid us to put her in the intensive care unit and support her breathing with a ventilator and her blood pressure with chemicals with the goal of postponing her death by a few days, but that isn’t what she or her family would want and it would be wrong to make her spend her last hours or days where the sounds and smells and people are unfamiliar.

A healthy community
The rest of the people in this town and outlying areas (those whose primary physicians don’t admit to the hospital) appear to be fine. At least fine enough to not require hospitalization. This is a good day, medically speaking. Drinks on the house!

But wait a second … it’s not that simple
Except, of course, financially for the hospital it is not so very rosy. They still have outpatients coming in for tests and treatments, but a major part of the positive side of the economic equation is payment for the treatment of inpatients. There are large fixed costs associated with a hospital being able to treat sick patients when they need it. Good nurses must be given adequate pay and adequate hours to support their families. Buildings and grounds must be maintained. Pharmacy staff and medications must be updated and ready for the huge variety of illness we see and the diverse ways we think of to treat it. Social workers and case worker nurses, who don’t bill anybody for their services, must receive salaries and continue to do what they do to make sure that patients discharged from the hospital are able to remain supported at home. Hospitalists must be paid so we can be on call 24 hours a day to treat the sometimes desperately ill patients who are admitted. The hospital creates new service lines for the mostly healthy, like a women’s imaging center with 3-D mammography (with questionable associated benefits) but a healthy population does not a healthy hospital make.

But we all want more days like today. Not every day, of course, or we will forget how to treat sick people, but a day like today is the holy grail of effective medical care. Today, while doing very little, I am doing a great job.

Population health—everybody healthy!
Population health is a term that I have been hearing for really only a few years, though the concept is not at all new. Population health is an approach to health which aims to improve the health of a whole population, not just to treat diseases, one patient at a time. Naturally we need to also treat diseases and the individual patients who have them, with special attention to who these people are and what will restore them most effectively to a fulfilling life. But population health is about making more days like today, where most people are doing just fine, without the need to bother themselves with doctors or hospitals. Since it is inevitable that there will always be some sort of ill health related misery to deal with, population health as a concept encourages us to focus on how doctors and hospitals can be most effective to minimize the time, energy and money people spend with us.

This week in JAMA, The Journal of the American Medical Association there were a couple of articles which brought home the importance of changing our attitudes and payment systems in ways that will actually promote population health.

Treat your own blood pressure
The first was a study out of the UK by Richard McManus and his primary care research group looking at giving patients the ability to monitor their own blood pressures and adjust their own medications, within certain parameters. In the U.S., in 2010, treatment of high blood pressure (hypertension) by physicians totaled $42.9 billion, and with that, it isn’t actually controlled very well. Depending on which group you look at, blood pressure is uncontrolled in maybe one third or up to half of people (worse if you are Hispanic, black, or uninsured) which translates to more strokes, heart attacks and kidney failure. When patients are given the ability to adjust their medications according to blood pressures they measure themselves, they control their blood pressure better than doctors do, without increased side effects. Home management of blood pressure will put a dent in that $42.9 billion and even more of a dent in the money spent for treatment of strokes, heart attacks and kidney failure, but some of us health care providers will be out of a job.

Happy teenagers (well, happier)
The other article, by Linda Richardson, MD, of the Children’s Research Institute in Seattle and colleagues, was more poignant. It looked at a collaborative model of treating adolescent depression, through Group Health Cooperative clinics in urban areas of Washington state. Depressed adolescents were assigned either to a “usual care” group who saw physicians and might have been prescribed medications or counseling based on their office visits, or a “collaborative care” group who decided, with their parents, whether they wanted medications, counseling or both, and had regular visits, in person and on the phone, with a master’s level clinician. Those who chose psychotherapy received a brief 4 session cognitive behavioral therapy intervention that had been designed for adolescents.

There were regular team meetings to discuss their progress and they were followed for a year, using a depression screening tool, with adjustment in treatment based on their response. In the usual care group only 34% responded to treatment, with 20% achieving remission, whereas the study group 67% responded and 50% were no longer depressed. This cost an average of a bit over $1,000 per patient over usual care. Adolescent depression is huge in the magnitude of distress it causes, from increased drug abuse and suicide to school failure and parental stress. The collaborative approach was possible in Group Health’s clinics because they treat whole patients, in fact whole families, so an intervention that improves health saves them money. This approach would be difficult in most healthcare settings.

Last week I treated a young person who was in the hospital with a chronic medical disease that was complicated by ongoing IV drug abuse. This was a sweet person, still had her teeth and her manners, but had been anxious and depressed since she was 16 and had found that injecting methamphetamine and heroin really helped. She will die if she doesn’t find another option, but she is in deep now, with a criminal record and hepatitis C and no job or insurance. I think that is why seeing this article about adolescent depression struck me so solidly. If something had actually worked at age 16 she wouldn’t be spending tens of thousands of dollars of county money in the hospital while heading unobstructed for early death or at least ignominious disability.

Basically this is what we want, but how do we get there?
I think it’s important to visualize population health, like visualizing world peace (or whirled peas, as the bumper sticker says). It doesn’t need to look like forcing everyone to eat broccoli or get colonoscopies or avoid butter. It can look like getting rid of health and resource disparities that make some people succeed and some people fail spectacularly. It can look like clever ways of using the health care knowledge and technology we already have to make people stronger and less dependent on us. It will also have to look like a different payment system that supports hospitals when they keep people healthy on beautiful days like today.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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