Wednesday, December 23, 2009

Half-hearted Atkins diet and cardiovascular disease

I would like to comment on a recent article comparing the Atkins, Ornish and South Beach diets (Miller et al., 2009; full reference at the end of this posting), which has been causing quite a lot of commotion among bloggers recently. Especially low carb. bloggers.

An excellent post by Michael Eades clarifies a number of issues with the study, including what one could argue is the study's main flaw. Apparently the study compared a half-hearted Atkins diet, with probably equally half-hearted Ornish and South Beach diets.

I refer to the study's Atkins diet as half-hearted because it seems to rely on a daily consumption of between 120 and 180 grams of carbohydrates. This is unlikely to lead to ketosis, the cornerstone of the Atkins diet, where the body uses ketone bodies (made from dietary as well as body fat) as a source of energy.

As I see it, the main findings of the study were that the participants in the half-hearted Atkins diet, after a period of 4 weeks on the diet, and when compared with the participants in the other diets, had: (a) greater levels of total cholesterol and LDL cholesterol, with only a small improvement in their HDL cholesterol and triglycerides levels; and (b) greater levels of markers for inflammation (e.g., C-reactive protein).

The participants were young and healthy. Their average age was 30.6 years, and their average body mass index was 22.6. On average, their total cholesterol was 184.9 mg/dL, triglycerides were 78.1 mg/dL, LDL cholesterol was 107.2 mg/dL, and HDL cholesterol was 62.2 mg/dL. These are arguably fairly healthy numbers; although quite a few doctors might want to put most of these folks preventively on statins because of their LDL being greater than 100.

What I find interesting about this study, and consistent with both my own experience and also a theory that I have, is that it suggests that a low carb. diet has to really be low carb. in order to bring about the benefits that one normally sees as a result of a diet that induces ketosis. A diet with, say, > 150 g of refined grains per day, is not really a low carb. diet.

Again, in my experience, and that of many other people, a truly low carb. diet (very low in, if not devoid of, refined carbs and sugars), will lead to an impressive increase in HDL cholesterol (especially for those who have low HDL to start with), an equally impressive decrease in triglycerides, increased insulin sensitivity, and possibly a decrease in LDL.

However, a half-hearted Atkins diet may actually lead to elevated LDL (of the small-dense type), and more inflammation, just like this study suggests it does, without the benefits regarding HDL and trigs. The reason is that the still relatively high level of carbohydrate intake, especially if it comes in the form of refined carbs. and sugars, will lead to higher levels of insulin being secreted into the bloodstream. This will promote increased body fat deposition. The extra saturated fat being consumed will be turned into body fat, and not used as energy, starving the cells and leading to increased hunger.

A diet rich in saturated fat may indeed be bad when it is also a diet even moderately rich in insulin-boosting, easily digestible carbs. This may be one of the main reasons why there have been so many studies in the past showing a correlation between saturated fat consumption and heart disease; studies that typically did not control for carbohydrate consumption.

In a recent interview on the Livin' La Vida Low-Carb Blog, Dr. John Salerno goes into more detail regarding this issue, recommending a much more rigid adoption of the Atkins diet than many think is okay. (In fact, I often talk to people who think that if they cut a very high carb. intake in half - e.g., from 400 to 200 grams per day - replacing the carbs with fat, they will be halfway into a full blown Atkins diet.) Dr. Salerno has worked in the past with Dr. Atkins. He calls his diet the Silver Cloud Diet. I am not sure I agree with all that Dr. Salerno had to say, but his argument in favor of a diet very low in carbs. does make sense to me.

Finally, I think that it is dangerous to extrapolate the results of any study, no matter how comprehensive, to the population in general. Each individual is unique in terms of his or her genetic makeup and life history; the latter also influences metabolic patterns. (Even identical twins raised together may display different metabolic patterns, because of their different life histories.)  So, while a low carb. diet may work well for a lot of people, it may have very negative effects on a few. Increases in inflammation markers and adverse effects on LDL cholesterol (especially when LDL is measured directly, accounting for particle numbers and sizes) are warning signs that any low carb. dieter should pay attention to.

Reference:

Miller, M. et al. (2009). Comparative effects of three popular diets on lipids, endothelial function, and c-reactive protein during weight maintenance. Journal of the American Dietetic Association, 109, 713-717.

Tuesday, December 22, 2009

Guest Commentary: Where are Nurse Practitioners in Health Care Reform?

Theresa Pluth Yeo, PhD, MPH, MSN, CRNP, AOCNP
Coordinator, Advanced Practice Oncology Nursing Program
Assistant Professor, Jefferson Schools of Nursing and Population Health
(Former President of the Nurse Practitioner Association of Maryland)

Cortese and Korsmo, in their September 23, 2009 article in the NEJM, observed that, “Americans do not consistently receive high-value health care. Collectively, our country spends more on health care than any other nation, but our people do not receive the best outcomes, safety, service, or access (to health care) in return.”

Our health care system is largely dominated by a plethora of specialists but deficient in primary care physicians. At a time when only 247 residency positions in primary care are available for graduating medical students per year (down 328 residency positions since 1999), over 6,000 nurse practitioners (NPs) are educated each year at more than 325 colleges and universities. Most of these NPs choose primary care or family practice settings for employment. (For the uninitiated, NPs are fully-trained and licensed registered nurses who complete a Master’s or doctoral degree as an advanced practice nurse and pass a certifying examination administered by a national board, which allows them to be licensed by state boards of nursing as a NP).

NP educational programs provide training in the diagnosis and treatment of acute minor illnesses, disease prevention, and management of stable chronic conditions. Nurse practitioners are part of the solution in health care reform and fill an important niche in providing access to a qualified health care provider for millions of Americans. NPs are a win-win for patients – NPs bring their education, compassion and experience as RNs to bear on patient care, yet they are paid less than physicians. An ever growing body of evidence points to comparable quality care – and often higher patient satisfaction – with NPs as primary health care providers. Currently there are 139,000 NPs practicing in the US.

So why is the AMA threatened by NPs? In October 2009 the AMA launched an offensive, targeting NP practice in a document entitled: AMA Scope of Practice Data Series – Nurse practitioners. The document states in part that: “The physician is responsible for the supervision of nurse practitioners and other advanced practice nurses in all settings and that the physician is responsible for managing the health care of patients in all practice settings.” This is blatantly untrue. Nursing has been a self-regulating and self-licensing profession for as long as medicine has. Why has the leadership of the AMA decided that physicians and only physicians have the “right” to assess, diagnose and treat ill persons and that all “non-physician providers” should be supervised by a physician?

The American Nurses’ Association recently issued a response to this AMA document, voicing its objection to the AMA’s attempts to change the public’s perception of NP practice as anything other than fully qualified professionals working within a legally established scope of practice. As America struggles to reconstruct its health care delivery “system,” it is unproductive for one profession to attempt to marginalize another. NPs stand ready to help meet the nation’s health care needs as collaborating partners, not as physician supervised providers. Health care reformers look our way!

Saturday, December 19, 2009

Total cholesterol and cardiovascular disease: A U-curve relationship

The hypothesis that blood cholesterol levels are positively correlated with heart disease (the lipid hypothesis) dates back to Rudolph Virchow in the mid-1800s.

One famous study that supported this hypothesis was Ancel Keys's Seven Countries Study, conducted between the 1950s and 1970s. This study eventually served as the foundation on which much of the advice that we receive today from doctors is based, even though several other studies have been published since that provide little support for the lipid hypothesis.

The graph below (source: canibaisereis.com, with many thanks to O Primitivo) shows the results of one study, involving many more countries than Key's Seven Countries Study, that actually suggests a NEGATIVE linear correlation between total cholesterol and cardiovascular disease.


Now, most relationships in nature are nonlinear, with quite a few following a pattern that looks like a U-curve (plain or inverted); sometimes called a J-curve pattern. The graph below (source also: canibaisereis.com) shows the U-curve relationship between total cholesterol and mortality, with cardiovascular disease mortality indicated through a dotted red line at the bottom.

This graph has been obtained through a nonlinear analysis, and I think it provides a better picture of the relationship between total cholesterol (TC) and mortality. Based on this graph, the best range of TC that one can be at is somewhere between 210, where cardiovascular disease mortality is minimized; and 220, where total mortality is minimized.

The total mortality curve is the one indicated through the full blue line at the top. In fact, it suggests that mortality increases sharply as TC decreases below 200.

Now, these graphs relate TC with disease and mortality, and say nothing about LDL cholesterol (LDL). In my own experience, and that of many people I know, a TC of about 200 will typically be associated with a slightly elevated LDL (e.g., 110 to 150), even if one has a high HDL cholesterol (i.e., greater than 60).

Yet, most people who have a LDL greater than 100 will be told by their doctors, usually with the best of the intentions, to take statins, so that they can "keep their LDL under control". (LDL levels are usually calculated, not measured directly, which itself creates a whole new set of problems.)

Alas, reducing LDL to 100 or less will typically reduce TC below 200. If we go by the graphs above, especially the one showing the U-curves, these folks' risk for cardiovascular disease and mortality will go up - exactly the opposite effect that they and their doctors expected. And that will cost them financially as well, as statin drugs are expensive, in part to pay for all those TV ads.

Friday, December 18, 2009

Stop Measuring and Start Thinking


Stop Measuring and Start Thinking

I recently wrote a paper suggesting that the arts might just offer us the most potent means of questioning the grotesque market-driven society that we live in, a society that insists on measuring everything in terms of cost-benefit-analysis.

In this paper that will be published shortly, I suggested that the arts not only offer us a means of questioning the world, and imposing some sort of order on the chaos that surrounds us; but that popular culture too, offers a potent part to play in the arts/health agenda. For those of you interested in popular culture and public health I’d like to recommend the writing of Mark Burns and his Sex and Drugs and Rock and Health, which can be found at www.sexanddrugsandrockandhealth.com

Since the global downturn, lots of economists have been talking of creative approaches to their work; whatever that might mean. To be honest; it makes me slightly nervous. Consumerism, to which we’re all in some way addicted, has infected all aspects of society. In the art world itself, the hyper-inflated egos and prices associated particularly with ‘Brit Art’ reflects elitism, consumerism and our obsession with celebrity culture.

Over the past thirty years, market forces have been the governing philosophy of how we live our lives, and over the last 12 months we’ve seen how imposing market values on all elements of human life has terrible consequences. The impact of mental illness in dominant, unequal societies offer some stark financial facts, with doctors in England in 2005 writing 29 million prescriptions for anti-depressant drugs, costing over £400 million to the NHS 1 and in 2003, the USA spent more than $100 billion on mental health treatments. 2

Across the North West I’ve experienced some amazing practice in the arts and seen the impact participating can have on people and yet I’m constantly asked for hard unequivocal evidence as to its value. In his Reith Lectures for the BBC this year Michael Sandel, Harvard Professor of Government, invites us to think of ourselves, less as consumers and more as citizens, and argues for politics of the common good where commodities of community, solidarity and trust are not commodities that deplete with use, like our finite environmental or economic resources, but are more like muscles, that grow stronger with exercise. These wonderful and relevant lectures can be listened to at www.bbc.co.uk/programmes/b00kt7sh

So, do we really need to weigh, measure and count everything we do to justify the arts?

After recently giving the paper in which I expanded on these themes, there followed a discussion that turned to the work I’m supporting around a National Forum for Arts and Health. This was about ‘strategy’ and ‘manifestos’ and I could feel the delegates’ eyes beginning to glaze.

Whatever statements and strategies we develop around the arts in relation to society and well-being, they’re going to date and stagnate on a thousand groaning shelves.

As a student, I always loved the pompous and extreme nature of artists’ manifestos (think Marinetti)…we have been discussing right up to the limits of logic and scrawling the paper with demented writing.’3

Perhaps when we look to manifestos and pamphleteering, we should take a slightly more provocative stance. I’d like to recommend two pieces of art that I put forward as manifestos in their own right.

The first is Jonathon Swift and his Modest Proposal,4 written in 1729. This was a stinging satire in the form of a pamphlet. In the guise of a well-intentioned economist, Swift proposed a solution to the poverty and inequity of the time, by suggesting the rich purchase and eat the children of the poor. Monstrous and politically loaded, this is as biting and as powerful as the written word gets. A manifesto? Perhaps not, but an artist at the height of his powers exploiting popular culture (pamphleteering) to attack and question the norms.

As a counter-blast to Swift’s, Modest Proposal, I’d like to offer Sam Taylor-Wood’s, Still Life5 , a 3 minute 44 second film. This film of a bowl of fruit slowly decomposing is very much in the lines of an elegant still life typical of 16th and 17th century painting of the Netherlands. As the fruit slowly transforms to a mass, a cheap and throwaway, plastic ballpoint pen in the foreground, remains static and unchanged

I urge you to try and see this work. There are 6 of them out there including one at Tate Modern. Of course youtube have a few, but they don’t do it justice. I shall leave you to form your own opinion of what the work’s about and what relevance it might have to our practice and the issues facing society. For me, this work speaks far more loudly than any strategy or conscious manifesto.


1. Hansard. Written answers to questions, (2005) 439:22 Nov. 2005: Column 1798w

2. Mark, T.L et al. Mental Health Treatment Expenditure Trends, 1986 – 2003, Psychiatric Services (2007) 58 (8): 1041 – 8.

3. F.T. Marinetti, The Futurist Manifesto, 1909

4. A Modest Proposal: For Preventing the Children of Poor People in Ireland from Being a Burden to Their Parents or Country, and for Making Them Beneficial to the Publick.

5. Sam Taylor-Wood, Still Life, 2001, Edition of 6, 35 mm Film/DVD

Monday, December 14, 2009

City Police Put the Squeeze on Lemonade Stand







Congrats to the entire JSPH team for our efforts to raise money for Alex's Lemonade Stand!! Together, we raised over $1,500 through today's bake sale and online donations.
Our web page remains open for JSPH members, friends, and family, who care to make a donation: http://www.alexslemonade.org/stands/20326
As you can see from the pics above, we had a little run-in with the good officers of this city who pointed out, rightly, that we did not have the requisite city permit required to peddle home baked goods outdoors to the public. As good stewards of population health, we removed the home baked stuff but continued to sell pre-packaged items and a variety of beverages.
Thanks to all who stopped by our table to make donations for a very worthy cause - we appreciate your tremendous enthusiasm and generosity!!

Friday, December 11, 2009

Guest Commentary: Healthcare Reform is Fiscal Reform

Eric Jutkowitz
Post-Baccalaureate Fellow
Jefferson School of Population Health

In last week’s New York Times opinion page, Paul Krugman wrote an excellent piece on the relationship between healthcare reform and budget reform. Although I agree with his analysis and opinion, he seems to be misunderstood by many in the media and politics.
His main thesis is that to reform healthcare is to reform the deficit problem.

Skyrocketing costs of healthcare services and the aging population are threatening not only the viability of Medicare but also the Federal budget. It may seem counterintuitive that passing health reform, which will insure more individuals and provide greater access to care, will actually help reduce the deficit. However, along with increasing access to care, the Senate healthcare proposal will enact cost-cutting measures to save money. Krugman and many other economists and health policy experts adamantly believe that the cost to insure the uninsured, coupled with cost savings, will result in a net savings to the system.

If these experts are right, that healthcare reform will reduce the budget deficit, then two key questions arise:
1) How are costs going to be cut? and
2) Why is this not being used as the primary selling point of health reform?

Cost will be controlled primarily through cuts to Medicare. From my understanding of the Senate health bill, this cost cutting will not be blind. Rather, the government will cut inefficient or ineffective programs and fund those interventions which are proven to work.

In theory, this is a good idea. However, for many health conditions and medical procedures, we don’t have all the answers as to what is the most efficient care. The government has started to fund projects which help to answer these questions, but much more research is required. Nevertheless, The Congressional Budget Office found that the proposed cost-cutting measures will result in a net savings to the healthcare system.

Why does a bill that increases access to healthcare for the uninsured, eliminates wasteful spending, and reduces the budget deficit, not easily pass through Congress? For one, there is considerable uncertainty about the types of cuts that will be made to Medicare. Aside from general fear of the unknown this has become, as Krugman points out, a key weapon of opposition and an easy way to stir up fear. However, I also believe that the President has done a poor job of making the connection between healthcare reform and the budget deficit. In every speech he gives, he should be talking about the looming budget deficit and how health care reform = budget reform. Not till this connection is made will Americans realize that healthcare reform is more than just increasing the number of insured.

Thursday, December 10, 2009

JSPH is Making Lemonade



Since the launch of our new School, we have been working hard to spread the word about the need to focus on population health. We’ve decided that there couldn’t be a better way to celebrate the holiday season than by supporting a true population health effort through hosting Alex’s Lemonade Stand.

Alexandra “Alex” Scott was just about one when she was diagnosed with neuroblastoma, a childhood cancer. Alex received treatment locally, close to her home near Philadelphia. She was determined, courageous and confident. Alex was a big dreamer, which was evident in her request to hold a lemonade stand to raise money to help her doctors find a cure for her cancer. Close to 4,500 lemonade stands have been held around the country and internationally to honor Alex and support her cause, raising over 7 million dollars.

On December 14th, JSPH will join the cause and host a lemonade stand at 11th and Walnut in front of Jefferson Foerderer Pavilion on Thomas Jefferson University’s campus. The stand will be open from 8am to 3pm, serving lemonade, hot chocolate, and sweet treats. We hope you will support our efforts by stopping by!

JSPH hosts: Alex’s Lemonade Stand

When: December 14, 2009 8am – 3pm

Where: 11th & Walnut (in front of Jefferson Foerderer Pavilion)

Wednesday, December 9, 2009

JSPH Health Policy Forum: Cultural Competency

Cultural Competency: Using A Case-Based Approach for Teaching and Learning was the title of today’s Health Policy Forum. The presenters, Lisa Hark, PhD, RD, Project Manager for Online Medical Education at Wills Eye Institute and Horace M. DeLisser, MD, Associate Dean, Spirituality and Cultural Competency at the University of Pennsylvania, used compelling real-life scenarios to illustrate cross-cultural issues that arise in clinical encounters. They discussed communication strategies for handling difficult situations and challenged the audience to examine their own perceptions.

Some Questions to Consider:

What does cultural competency mean to you and your work ?

What kinds of experiences have you had providing care to populations that you were unfamiliar with? How did you approach this? What kind of assistance did you need?

As a provider or patient do you feel that you had a negative interaction in a health care setting as a result of your culture, race, gender, language, age, sexual orientation, appearance, etc? How did you handle this?

Have you heard of any interesting programs or resources related to cultural competency?

Share your thoughts and keep the conversation going!

Tuesday, December 8, 2009

Guest Commentary: President Obama visits Pennsylvania


Photograph and Blog entry by
Patrick Monaghan
Director of Communications
Jefferson School of Population Health


There we sat, maybe a thousand of us, gathered in a small gymnasium on the campus of Lehigh Carbon Community College, nestled into a bucolic setting just outside of Allentown, Pa. The Pledge of Allegiance had been recited; the Star Spangled Banner sung. The Presidential Seal had been secured to the podium. An air of anticipation hung in the rafters that I have perhaps felt a handful of times.

Ticket holders had waited outside well over an hour, patiently filing through security as if boarding a flight home.

“Ladies and gentlemen, the President of the United States of America.” A modest roar and raucous applause from the crowd. Cameras flashing. I don’t recall hearing “Hail to the Chief,” but there he was, Barack Obama, probably the most recognizable person on the planet, walking to the stage. As he prepared to begin his remarks, he stood just a long jump shot from my seat in the bleachers.

I certainly didn’t expect to be here. Did anyone? An e-mail had been circulated earlier in the week notifying me and my colleagues at the Jefferson School of Population Health that there was an opportunity to see the President speak in our area. Six tickets – first come, first served. By the time I retrieved the message, an hour had passed. Opportunity missed, I thought.

I called anyway, and here I was, face-to-face with my first Presidential address. Regardless of your political leanings, it’s one of those events that makes you feel more connected to the Democratic Process. I’m a bit of a news junkie, and you didn’t have to be Walter Cronkite to know that this was going to make a few headlines. Welcome signs hung from businesses and schools leading to the college. Protestors at the entrance; “Don’t Tread on Me” flags; rows of news vans sprouting a small forest of satellite uplinks.

Given the setting, I had a feeling the President would focus his comments on jobs and the economy. As a JSPH staffer, I had come in hope of hearing some inside information on the health care bill. Would it come to a vote soon? Is the public option a deal breaker? What’s the story with Joe Lieberman?

As those of us vested in the health care debate understand, our nation’s fragile economy will only truly flourish when our dysfunctional health care system is mended. Health care expenses are bleeding our country dry – medical care now absorbs 18 percent of every dollar we earn.

It’s a connection that is not lost on Mr. Obama.

“What has happened is a lot of the debate in Washington has been around health care, so people think, well, I guess they must not be working on jobs,” Mr. Obama said. “No, we’ve been working on jobs the whole time. Health care is part and parcel with where we need to take our economy.”

The President began his remarks just before noon. His oratory skills are on full display in a live setting, but I was somewhat surprised by his reliance on a TelePrompTer for his formal comments. It forces him to look side-to-side (to the prompter panels) instead of straight ahead. Before concluding, he took a few questions from the audience, and it was during this unscripted segment that he seemed most at ease.

He worked the crowd on the way out, shaking hands and posing for the obligatory photo-with-a-baby. By 1 p.m. he had left the building.

We remained somewhat sequestered, momentarily suspended behind closed doors, presumably until the motorcade was out of sight. By the time we emerged from the gym, there was barely a trace he had been there.

Except for the protestors.

Refined carbs, sugar, and cholesterol: My own experience

A few years ago I went to the doctor for a routine appointment, and I was told that my LDL cholesterol was elevated. I was in my early 40s. My lipid profile was the following - LDL: 156, HDL: 38, triglycerides: 188. The LDL was calculated. I was weighing about 210 lbs, which was too high for my height (5 ft 8 in). My blood pressure was low, as it has always been - systolic: 109, diastolic: 68.

My doctor gave me the standard advice in these cases: exercise, lose weight, and, most importantly, reduce your intake of saturated fat. I was also told that I would probably have to take statins, as my high LDL likely had something to do with my genetic makeup. Again, this is quite standard, and we see it all over the place, particularly in commercials for statins.

I told my doctor that I would do some research on the topic, which I am going to save for other posts. Let me get to the point, by telling you what my lipid profile is today - LDL: 123, HDL: 66, triglycerides: 46. Again, the LDL value is calculated. I am weighing about 152 lbs now, with about 13 percent of body fat.

The HDL and triglycerides numbers above are shown in bold font because my research convinced me that these two numbers are the ones most people should really worry about when trying to address what is known as dyslipidemia. Here I am assuming that only standard lipid profiles are available; there are better alternatives, such as particle type analyses, which are not yet standard.

Many people who suffer from cardiovascular disease have low LDL cholesterol, but very few of those have high HDL cholesterol, which is one of the best predictors of cardiovascular disease among lipids. More specifically, if you have an HDL higher than 60, you have a very small chance of developing cardiovascular disease. (It can happen, but it is very unlikely, with a percentage chance in the single digits.)

Interestingly, low HDL cholesterol is also associated with the metabolic syndrome. This syndrome is characterized by the following:

- High fasting serum glucose (hyperglycemia), which is one of many signs of insulin resistance, a precursor to diabetes type 2;
- High blood pressure;
- Abdominal obesity (also known as pot or beer belly);
- Low HDL cholesterol; and
- Elevated triglycerides.

Now, you may ask, how did you increase your HDL? Well, I tried a number of things - diet and lifestyle changes - and had a blood test every 3 months. After a while I was able to put all of the measures in a spreadsheet table, and correlate them using a statistical software that I developed, to give me an idea of what was going on.

Weight was a big factor on LDL, and I was able to bring my weight down to 150 lbs and my LDL to below 100 at some point. For me, and many other people, body weight and LDL cholesterol are strongly and positively correlated (the higher the weight, the higher the LDL cholesterol - actually body fat seems to be the real culprit). Moreover, my LDL seemed to decrease more markedly when my weight was on the way down, and not as much when it was stable, even if low.

But the HDL would only increase if I increased my saturated fat intake. The problem is that every time I increased my saturated fat intake my LDL would go up; it reached 162 at one point, when my HDL went up to a modest but encouraging 47. That was my highest HDL until I eliminated refined carbs and sugars (e.g., bread, pasta, cereals, doughnuts, bagels, regular sodas) from my diet.

When I brought my intake of refined carbs and sugars down to zero, my intake of protein and saturated fat went up. Either that would happen, or I would starve, because you have to eat something. (I figured that I would not die by doing a low carb/high fat-protein experiment for 3 months to see what happened.) Also, I dramatically increased my dietary cholesterol - two to four eggs per day, organ meats, and seafood.

That is when my HDL shot up, to 66, and my LDL went down. Yes, my LDL levels seem to be negatively correlated with dietary saturated fat and cholesterol amounts, as long as I do not consume refined carbs and sugars. Moreover, it is very likely that my LDL particle size increased, and large LDL particles DO NOT cause atherosclerosis because they cannot penetrate the artery walls.

So, the bottom line is that, at least for me, an INCREASE in saturated fat and a DECREASE in refined carbs and sugars, happening together, seem to have taken me out of my previous path toward the metabolic syndrome.

Moreover, I feel a lot more energetic than before, my immune system seems to have gotten better at fighting disease, and even my pollen allergies are not as bad as they were before. Admittedly, these benefits may be strongly associated with the weight loss and the related reduction in body fat percentage.

I hope this post is helpful to others. The standard advice that people with high LDL cholesterol receive, which usually focuses on reducing saturated fat intake, has a big problem. When you reduce your intake of a type of food, you usually increase your intake of other types of food. Most people who try to reduce their saturated fat intake invariably increase their carb intake, usually with the wrong types of carb-rich foods (the man-made ones), simply because they go hungry.

Monday, November 23, 2009

New Breast Cancer Screening Guidelines and The Value of Breast Self Exams

Since their release earlier this week, there has been extensive controversy over the new US Preventive Services Task Force (USPSTF) recommendations against routine mammograms for women under 50. These new recommendations have raised the ire of women across the US and have been disputed by the American Cancer Society, the Susan G. Komen Foundation and other cancer information and services organizations. USPSTF also questioned the value of breast self examination (BSE), saying it was not recommended because it has led to a high number of false positive results. That recommendation has also been called into question from a wide range of women’s organizations and individuals who have found breast lumps as a result of a BSE.

This latter recommendation hits home for me as my wife was recently diagnosed with Breast Cancer and is being treated here at the Jefferson Breast Center. The cancer was not caught from a routine mammogram but rather through her own monthly breast self exam. As a result of that exam, she visited our family doctor immediately. After an ultrasound and additional tests confirmed her breast cancer, she started treatment.

Without her monthly breast self exam, who knows when she would have seen her doctor, received her diagnosis, and begun treatment? BSE is an important, individual personal health screening that can and should be done routinely. My wife is Hispanic. A study from the University of Arizona’s Zuckerman College of Public Health earlier this year reported that two-thirds of Hispanic women diagnosed with breast cancer discovered it through BSE and not from diagnostic services provided within the healthcare environment. The USPSTF recommendation against BSE, if applied nationwide, could adversely impact early detection of breast cancer, especially among diverse populations, many of whom do not routinely use our healthcare system.

Rob Simmons, DrPH, MPH, CHES, CPH
Director, MPH Program
Jefferson School of Population Health

Friday, November 13, 2009

Healthcare reform needs patient adherence -
http://ping.fm/Vi0Du

Healthcare Reform Needs Patient Adherence

While the debate rages on regarding Healthcare Insurance Reform, several key issues are either severely diminished or completely eliminated from the conversation. Many of the huge costs to the system are associated with the management of chronic illnesses, such as diabetes, asthma and heart disease. Patient compliance or adherence is one of the most critical elements of achieving improved outcomes for patients with chronic illnesses, helping to prevent costly complications and hospitalizations.

Unfortunately, the evidence regarding patient education, behavioral models, care coordinating infrastructure, and perhaps financial incentives to support patients with chronic illnesses lags behind treatment recommendations. While most health professionals are armed with myriad evidence-based clinical guidelines, little is understood or proven on how to engage patients to accept personal responsibility and become active participants in their health care.

Even a coordinated care model runs the risk of failing to achieve improved outcomes if patients do not adhere to recommendations. It is not enough for health professionals to counsel patients to stop smoking, eat a well balanced diet, get screened for markers of cancer and chronic illnesses, take their vaccines, statins, ACE inhibitors, check their blood sugar, etc. Unless there is a funding mechanism to provide the needed resources to support patients in their efforts to comply, we will continue to fail them and add to our ever-increasing cost burden to the system.

Until the system is geared up to support patients and caregivers with the best tools to accept more personal health responsibility and adhere to proper proven recommendations, we will continue to have sub-optimal outcomes no matter what we spend or recommend for healthcare reform changes.

Mike Toscani, PharmD
Project Director
Jefferson School of Population Health

Friday, November 6, 2009

The “S” Word in the Health Care Reform Debate

Like most of you, I have followed our country’s health care reform debate closely. Unfortunately, the conversation is confusing because the subject is complex and generally not presented in a logical and orderly fashion. The current approach to reform involves tweaking the current “system” rather than starting from scratch to design a rational one. Since the current system evolved in a haphazard fashion, attempts at reforming it will doubtless result in something equally complex.

Because the discussion involves strongly held beliefs about intensely personal and important issues, the discussions around health care reform have become quite heated. Emotions come into play, often vigorously, and can get to a point where objective discussion is no longer possible.

The word that seems to have triggered the most emotional response is socialism (the “S” word). It is used in almost a pejorative fashion, as if it is the worst thing that could possibly happen in America. Students of economics embrace capitalism strongly (others have different reasons) because it has proven unparalleled in raising standards of living for vast numbers of people and for providing innovation in our society.

The “S” word is commonly invoked when the discussion turns to a government-provided public insurance option. Simple definitions can help here. In capitalism, individuals own the means of production for goods and services. In socialism, the government owns them. Curiously, socialism is rarely used to describe Medicare, Medicaid, and the various other government-sponsored plans that account for roughly half of the health care dollars spent in this country, and are bona fide examples of “socialist” services.

My reaction to the use of this word has evolved from frustration to bemusement. First, most people cannot possibly have the facts concerning existing government-funded insurance plans in mind when they drop the “S” word in the context of health care reform. Second, for anyone looking at the matter objectively, it is clear that the United States is not a purely capitalistic country. We have many government-run services such as the military, highways, education, the postal service, social security, Medicare, etc. Thus, the United States contains elements of both capitalism and socialism, a so-called mixed economy.

As has become abundantly clear through our recent financial crisis and the government-sponsored rescue of our financial system, government spending when the private sector couldn’t (or wouldn’t) shortened what otherwise would have been an extended economic downturn. Having a little government (read socialism) mixed in with our capitalism can be a good thing. The flaw in the premise of most peoples’ assumption about capitalism is that free markets are inherently self-correcting. They are not. Simply having a capitalistic system does not guarantee a good outcome.

Similar reasoning can be applied to health care. Let’s examine the facts. The United States occupies 37th place in the World Health Organization’s ranking of healthcare quality in industrialized nations, despite the fact that we pay almost twice as much for health care. Perhaps our “capitalistic” healthcare system could use some “socialist” guidance, since it did not find an optimum outcome on its own. If not the government, who will provide guidance toward better outcomes in health care? As has occurred many other times in health care, the government (in the form of CMS) is leading the way to cost and quality reform through various demonstration projects and programs. Private insurance companies are following the government’s lead.

If we take the possibility of a government provided public insurance option to its extreme, is it so crazy to consider a government run health insurance system?
Let’s examine the premise of how insurance works. With a large number of people in a risk pool, the cost for any one individual is reduced. The larger the pool, the broader the risk is spread, the lower the cost.

How could we spread the risk as broadly as possible? A federal government provided public insurance option covering all Americans would do the trick. In point of fact, many Medicare services are administered by the Blues and other private insurance companies. Combining a single large insurance pool with private administration is a nice mixed economic insurance solution. Certainly not as crazy a scheme as what we endure now as a nation with regard to cost and quality…


Richard Jacoby, MD
Associate Professor
Jefferson School of Population Health

Thursday, October 29, 2009

Health Insurance Reform Options

October of 2009 has been an exciting month for health policy wonks. For those of us who enjoy the study of health policy, it doesn’t get much better than this. In this post we briefly describe some of the key health policy ideas still surviving the legislative process. This is not intended to be a thorough review of each measure. As always with complex legislation, the devil is in the details.

The “Mandate”: All the key bills making their way through the House and Senate include a mandate that everyone be required to have health insurance. A health insurance mandate is going to happen, one way or another. Now, for those of us without health insurance, there are provisions (tax credits or “subsidies”) to make insurance affordable. How much those tax credits will offset the cost of buying insurance for each income bracket is still being debated. Likewise, the size of the penalty for not buying insurance is also still being debated.

The “Public Option”: For all the attention this idea is getting from both inside and outside of the Washington beltway, it’s really less interesting to this student of health policy because it’s not as creative or innovative like the other tools being discussed e.g., health insurance exchanges, state-based high risk pools, payment reform, value-based purchasing initiatives… the list goes on. Yet, because the “public option” strikes at a historical, deep-rooted political ideal (the role of government in the private market), it has received the vast majority of attention from the media and the lay public. The audience should know that the “public option” is so fluid in meaning at this point that no one really knows what the “public option” will mean for healthcare. It could be national or state-based; states may be given the option to choose to participate; it might be tied to Medicare, it might negotiate with providers on its own. The point of having a public option is to make premiums affordable by keeping the insurance industry honest and competitive. Recent attention has been given to a maneuver that would create a pathway for the public option in the future only to be implemented (or “triggered”) if insurance companies fail to cover the desired percentage of the population. Votes are needed either way - look for compromises on this issue, not one extreme or the other.

Health Insurance Exchange(s): This is perhaps the most exciting part of health reform, yet few fully understand how important exchanges will be for this health system. For a whole lot of reasons, individuals purchasing insurance on their own have been at a massive disadvantage to those who receive insurance through their employer. An insurance exchange would create a clearinghouse of insurance plans for individuals and families to choose from. For the insurance industry, it also creates a massive pool of potential customers who otherwise might not seek insurance. Like the public option, the exact structure and functioning of the exchange or exchanges is not yet known, i.e., there could be one big national exchange or many “state-based” exchanges. Regardless of approach, there are a few things likely to be included in an individual market exchange. First, the government (either federal or state) will likely set the rules. For insurance companies to participate, the plans they offer would have to meet specific criteria for quality, cost, and access. Furthermore, the ratios by which they can increase or decrease premiums based on age, smoking status, and family size, will likely be fixed.

Subsidies: Finally, the most expensive piece of reform: premium subsidies. Every proposal creates subsidies to buy insurance – so regardless of plan, we will see subsidies. This is where the biggest chunk of the 800 billion to 1 trillion dollars will be spent. The core goal of every reform proposal is to get everyone insured, and health insurance is expensive. Therefore, based on percent of federal poverty level, individuals and families will receive some form of financial support from the federal government to offset the cost of purchasing insurance. The manner in which this financial support is distributed and the size of the subsidies based on income is still being debated.

The mandate, public option, insurance exchanges, and subsidies are 4 key ideas being debated this fall in Congress. There are many more ideas and changes to the system included within each proposal, however. Needless to say, it’s the golden years for health policy wonks – the months of November and December should be very exciting. Stay tuned.

Rich Toner, MS

Sunday, October 18, 2009

Health Insurance Reform---NOT REAL REFORM

I am struck that most of the national conversation about "health reform" has really been all about "insurance reform". Missing from the national conversation are the crucial issues that face our dysfunctional system----unexplained clinical variation, waste, the epidemic of medical errors, solving the tort crisis and much more. NONE of the proposals coming from the Senate or the House even begins to get at these critical issues. We need leaders in Washgington and elsewhere to confront what is really broken and begin the difficult process of self evaluation to fix these core issues. We spend the most and get the least. Sure, on a particular case by case basis we might be fortunate enough to have insurance and to get great medical care---this is not the issue. The issue remains as to how to create value, how to reorganize the system to promote coordination of care, how to realign the financial incentives and finally, how to make the whole thing patient centered. I don't know about you, but my patience is almost running out. I hope we can get the conversation back on track to address these issues that truly matter, and that can help us deliver real reform. DAVID NASH

Friday, October 16, 2009

End-of-Life Care for Patients with Dementia

As the United States population continues to age and the incidence of Alzheimer’s Disease and related disorders (ADRDs) increases, it is crucial that we examine end-of-life care in this patient population.

The prevalence of dementia in older adults is currently at 50% of the population over age 85. By 2030, approximately 8 million individuals will suffer from dementia. Unfortunately, end-of-life care for this population is less than adequate, and hospice care is too often underutilized. To explore this issue further, the Pennsylvania Hospice Network (PHN) developed a Task Force to survey Pennsylvania Hospice providers about barriers to and facilitators of hospice access for patients with dementia. PHN partnered with the Jefferson School of Population Health and the Delaware Valley Chapter of the Alzheimer’s Association to develop and refine the Survey instrument. The Survey link will be sent to hospice agencies via email this week with a request for response no later than October 31st.

In addition to hospice demographic data, the survey will illuminate providers’ access and quality concerns, such as the number of hospice enrollees with dementia and length of hospice stay in 2006-2008, trends in hospice admission for patients with dementia, perceived regulatory and other barriers to hospice care for this population, hospice capabilities in providing care to persons with dementia, and community outreach activities.

The Survey is a first step toward quantifying hospice access for persons with dementia. We expect that the findings will provide direction for further research and enhanced advocacy efforts, and data to inform policy direction. We will update you with more information in the near future.

If you have questions, please contact JoAnne Reifsnyder, PhD (joanne.reifsnyder@jefefrson.edu) or Laura Kimberly, MSW, MBE (laura.kimberly@jefferson.edu).

JoAnne Reifsnyder, PhD
Assistant Professor
Program Director, Chronic Care Management
Jefferson School of Population Health

Wednesday, October 7, 2009

What is Population Health?

The term “population health” is often misunderstood. So, what does it really mean? Is it public health? How does the population differ from the public? David Kindig, a Senior Advisor at the Population Health Institute at the University of Wisconsin has been working on improving population health in his quest to make Wisconsin the healthiest state and is regarded as an authority on the topic. Kindig defines population health as the distribution of health outcomes within a population, the health determinants that influence distribution and the policies and interventions that impact the determinants. Mention of health determinants and policy clearly indicate that public health is a large component of population health, but that is not where it ends. The key difference between public and population health is the focus on health outcomes, which entails a clinical component as Dr. Abatemarco indicated in the last blog post. While population health is NOT public health the two are intertwined.

Population health is holistic. It seeks to reveal patterns and connections within and between multiple systems that can be analyzed in order to respond to the needs of the population. It must be interdisciplinary, collaborative and transparent. We have set out to create a learning environment for students here at Jefferson to learn these key concepts and develop population health leaders of the future. Many of our students have diverse backgrounds and that is the greatest asset, in my opinion, to the learning community. While the need for population health management is evident in every newspaper you pick up, news story you hear or journal article you read, our role is providing students with practical knowledge to be real change agents. With all of this in mind, we have been working to create a text describing these key concepts, which will serve as a resource for both students and professionals. Population Health: Innovation, Strategy and Practice will be published by Jones and Bartlett, Sudbury, Massachusetts in August 2010. Dr. David Nash, Dr. JoAnne Reifsnyder and I are collaborating from JSPH with Dr. Ray Fabius to edit this multi-authored text. We have engaged 32 authors from various backgrounds; medicine, public health, policy disease management, education, and industry. Our goal is to create a text that describes innovative approaches to address population health needs, provides strategies to work toward those goals and advises readers on how to integrate these concepts into practice or their daily work. I hope that you will share your comments and thoughts about the often misunderstood “population health” concept and look for our new book in late summer 2010!

Valerie Pracilio
Project Manger for Quality Improvement
Jefferson School of Population Health

Thursday, October 1, 2009

Improving Population Health through the Integration of Public Health and Clinical Care

My name is Dr. Diane J. Abatemarco and I am energized by being here at the beginning of an exciting process – the creation of a school of population health that is cutting-edge in its science and its vision. I’d like to tell you a bit about my research. My primary areas of expertise include evaluation research methods, behavioral epidemiology and intervention science.

My primary research is focused on maternal and child health. I am the Co-Principal Investigator of Practicing Safety, a study to evaluate a pediatric-based practice change intervention to prevent child maltreatment of children age 0 to 3 years of age. The work is highlighted as an AHRQ Innovation http://www.innovations.ahrq.gov/content.aspx?id=1806, and can also be found on the American Academy of Pediatrics website http://www.aap.org/practicingsafety. The project is funded by the Doris Duke Charitable Foundation through the American Academy of Pediatrics. This work is important because a healthier start to life is necessary for a healthy life not only through childhood but into adulthood as well.

I’ve had several global health experiences; one is a US/Croatian Healthy Cities Partnership to delay the onset of alcohol use among adolescents in Split, Croatia. We implemented Project Northland, a U.S. intervention developed by Perry and Williams. My work in Croatia included the use of experimental design, qualitative and quantitative methods in implementation and evaluation. Working with the country of Croatia for more than four years was an incredible experience. Croatia has wonderful citizens who showed me how a country recently war torn could remain hopeful about life and their country.

The work I have done in social epidemiology has been to conduct a study of HIV infected pregnant women to determine their rates of treatment and to identify factors associated with receipt of treatment. I also conducted numerous survey research projects to determine tobacco prevalence among pregnant women, college students, and adults and surveyed prenatal providers about tobacco dependence treatment practices. Current and ongoing research includes the measurement of stress, anxiety, and socioeconomic factors as determinants of maternal health and birth outcomes, and an exploration of biomarkers that may inform us as to how anxiety affects gestation. We experience a great amount of stress in our lives and understanding how stress affects us biologically may lead to interventions that enhance the quality of our lives, thereby reducing stress, anxiety and depression.

Additionally, I am currently evaluating an obesity prevention program developed by a professor at Carnegie Mellon University. The project is called Fitwits - www.Fitwits.org. This exciting multidimensional intervention has received national attention from the Clinton Foundation. Watching the children interact with the Fitwits characters and seeing them digest (no pun intended) the nutritional knowledge shows that even our youth can make better eating choices with the right support.

All of my work is predicated on improving population health through the integration of public health and clinical care. As a key dimension of population health, each project promotes empowerment over one’s own health behavior. Join me in learning more about our new school as I begin to work with the faculty to develop doctoral programs in Population Health Sciences.


Diane J. Abatemarco, PhD, MSW Associate Professor, Director of Doctoral Programs
Jefferson School of Population Health

Monday, September 28, 2009

The Health Care Reform Dialogue Continues at JSPH

Speaker of the House Nancy Pelosi was on the Jefferson campus last week with a local Congressional delegation. She emphasized the need for reform of our broken system and campaigned for the house bill. She is committed to a public option and to universal coverage. Her comments were compelling and they attracted a good deal of local press attention too. Dr. Nash was fortunate enough to be interviewed by Jefferson’s local ABC affiliate in a story that aired just after the Speaker’s visit!

Last week the Jefferson School of Population Health (JSPH) also hosted a symposium on The Future of Health Care in Pennsylvania: Developing Leaders in Health Care Quality and Safety. Thomas Jefferson University (TJU)’s president, Dr. Bob Barchi, kicked off the event by speaking about the need to improve quality, outcomes and access to health insurance. He also highlighted TJU’s commitment to improving the health care crisis by founding JSPH. The event included two panel discussions, and Kim Taylor, President of Centocor Ortho Biotech Inc., announced the recipients of full scholarships for two JSPH Health Policy students.

Rosemarie Greco, Senior Advisor to the Governor’s Office of Health Care Reform, served as the featured speaker and talked about the need for cultural transformation within health care. According to Greco, everyone must be involved in this transformation, and everyone must ask and understand the “why” behind need for health care reform. Unless there is a common understanding of the “why,” meaningful reform cannot take place.

The first panel discussion, moderated by Josh Goldstein of the Philadelphia Inquirer, focused on the stimulus plan and its national impact on health care. Much of the conversation centered on stimulus dollars for Health Information Technology (HIT) and the use of HIT to improve outcomes. Panelists also called for research to build the evidence base for higher quality bedside care and better outcomes.

The second panel, moderated by Chris Satullo of WHYY, explored health care reform in Pennsylvania and how we can leverage our state resources. Significant takeaways from the panel included innovation and its role in health care reform, opportunities and obstacles in the greater Philadelphia region to encouraging and embracing innovation, and the lack of a regional start-up culture. The panel also touched on public medical education in Pennsylvania and the importance subsidizing the cost of medical education in this region in order to bring young, talented people into a setting where medical innovation thrives. Dr. Nash concluded the afternoon by announcing that he hopes everyone will continue to participate in local and regional dialogue about these key issues.

David B. Nash, MD, MBA
Dean, Jefferson School of Population Health

Laura Kimberly, MSW, MBE
Director of Special Projects, Jefferson School of Population Health

Wednesday, September 16, 2009

First Day of School at JSPH

Last week was quite a week at the Jefferson School of Population Health. On Tuesday we hosted our first Orientation to welcome our incoming students, and Wednesday – 09/09/09 – was the first day of classes for the new school. Appropriately enough, President Obama brought his case for health care reform before a joint session of Congress that very same evening.

It’s likely that the students we greeted last week – the inaugural class of the Jefferson School of Population Health – will have witnessed historic changes to the way we organize and deliver health care in the United States – all by the time they complete their first year as a JSPH student. I continue to be amazed at the synchronous path we at JSPH continue to follow with our nation’s top domestic agenda in passing meaningful health care reform. I know that our students are tuned into our national dialogue on health care reform and how it meshes with our mission of preparing leaders with global vision to develop, implement and evaluate health policies and systems that improve the health of populations, and thereby enhance the quality of life.

The healthcare industry plays an increasingly vital role in our national economy, as employer and generator of almost 20 percent of our Gross Domestic Product (GDP). The intensifying complexity of this industry in an era of heightened expectations and scrutiny means that there is both need and demand for professionals and researchers who are well versed and prepared to assume leadership roles in public health, health policy and healthcare quality and safety.

To the members of our inaugural class, we look forward to serving you, and wish you success in the 2009-2010 academic year as we work together to fulfill our mission. The future of the United States as a vibrant nation depends on the nation’s leaders bringing affordable, quality health care to all Americans, and we will play a significant role in training and equipping these leaders for the job.

- Caroline Golab, PhD
Associate Dean, Academic and Student Affairs
Jefferson School of Population Health


Wednesday, September 9, 2009

SHAPE THE FUTURE

SHAPE THE FUTURE---In a stirring and forceful speech, President Obama delivered a bipartisan centrist message that appealed to our character as a nation. Noting that we cannot fix the economy without fixing health care and promising not to increase the deficit he inherited, the President called for mandated insurance coverage for all Americans. Recognizing that the status quo is untenable, he called for the creation of an insurance exchange and for the so called "public option" to be created whereby those without insurance currently, could get coverage ----noting that it might take up to four years to implement. He also explicitly linked our need to reduce waste, improve quality, reduce hospital acquired infections and practice better team based care to the set of tools needed as part of the solution. From a policy perspective the speech clarified his own views and reinforced the notion that we have to build on the existing system. He did not disconnect insurance from the place of employment, he did not call for a major Medicare overhaul and he did not create major new federal bureaucracies to make his plan operational. Much more work needs to be done but I believe he effectively re--set the clock, re--set the arguments, and crafted a political umbrella under which lawmakers can now operate together. DAVID NASH MD MBA, Dean, Jefferson School of Population Health, Phila, PA

Monday, September 7, 2009

We Are Back and Ready to Go !!!!

This coming Wednesday is a watershed day for Thomas Jefferson University and the new Jefferson School of Population Health. The date is 9--9--09 !! and the significance is the first day of school for all of our students across our three degree programs---Public Health, Health Policy and Quality and Safety. As the founding Dean I am incredibly proud of our team and the nearly two years of work leading up to this momentous day. We are proud to report that the inaugural class numbers more than 115 persons from all across our region with a very heterogeneous set of skills and backgrounds. I want to thank again several key individuals including of course our university President, Dr Robert Barchi and our Senior Vice President for Academic Affairs, Dr Mike Vergare for their amazing support and encouragement. The Dean's staff including Caroline Golab, Alexis Skoufalos, Neil Goldfarb and David Glatter get special kudos for their tireless work. I am indebted to our faculty and staff who share my enthusiasm and are committed to helping to fix what is wrong with our broken health care system. No matter what happens in Washington DC in the next few weeks, our Jefferson School of Population Health is going to be a part of the solution, not just another part of the ongoing problems we all face!! Thanks again and I sure would like to hear about any similar programs and encourage persons to go to our school website at www.jefferson.edu/population_health DAVID NASH

Sunday, May 31, 2009

Main Line Health and Quality

I am very pleased to report that after one year on the Board of Governors of the Main Line Health hospital system in suburban Philadelphia, I have now been appointed the Chair of the Board Quality and Safety Committee and a member of the Board Executive Committee. MLH is a very successful system of five acute care hospitals and one rehab hospital. They are largely a private practice based physician culture with partially salaried chiefs of service across the hospitals. They have a consolidated medical staff and a robust quality and safety apparatus already in place. I hope to bring my ten year experience as a Board member of Catholic Healthcare Partners , in Cincinnati OH, to MLH. At Catholic Healthcare Partners we began the quality journey of the Board nearly seven years ago and now, CHP is a national leader in governance engagement in quality. MLH will one day share this distinction, I am sure. With health reform looming, with a less than stellar ten year effort post the IOM report "To Err is Human," MLH has a real governance challenge ahead. I am humbled and excited to be a part of this wonderful organization and I look forward to the work ahead. How is your system managing the governance challenges of qualitya and safety?? DAVID NASH

Sunday, May 17, 2009

What Health Reform Plan??

The Obama administration is working in overdrive to create a health reform package that could possibly be passed this summer. That is the headline we are all reading. The challenge, among many, is "what exactly is the proposed plan?"Like you, I am very concerned that the real work is being done in the basement of the White House by a very small number of non elected leaders. Sure, the press has been pretty good to date with a "down payment" on reform via the ARRA and lots of talk about the benefits of the infusion for information technology. However, the actual proposed legislation is leaking out in bits and pieces as the various interest groups inside the Beltway try hard to get their hands on real information. I hope we keep our eye on the four pillars of reform---create value, insure everyone, change the payment system and promote coordination. The pillars represent real reform, everything else is tinkering around the edges. At the Jefferson School of Population Health we are tracking these developments carefully but we need your help too. We must continue to press for transparency here and we must make sure that the four pillars are embodied in any legislative proposal. I am interested in your views too. DAVID NASH

Sunday, May 10, 2009

The 18th Annual Grandon Lecture

Each year for the past 18, we have sponsored a nationally prominent person in the broad field of health policy to come to Jefferson and deliver a talk on a timely topic. Past speakers have included persons such as John Iglehart, Peggy O'Kane, Jack Rowe, and others. This year, Dr Tom Nasca, the CEO of the ACGME in Chicago, delivered the address. He linked the work of the ACGME, the group that accredits every residency program in the nation, to the need for improved quality and safety in the delivery of health care. He demonstrated that professionalism today also means an awareness of these issues and an ability to allocate resources appropriately and furthermore, a deeper understanding of the "systems" nature of care. He also met with all of our residency program directors from our teaching hospital, nearly 80 individuals who represent almost 750 trainees across all disciplines, to discuss the challenges of accreditation such as limited duty hours and the like. Clearly, there are important links between accreditation, duty hours, professionalism and health care reform. We need to provide a health care work force ready to meet the challenges of a reformed system. The ACGME is a core component of meeting this challenge. What is your residency program doing to meet the challenges of health reform?? How are you working to promote accountability and a deeper understanding of the systems nature of care?? I am interested in your views, DAVID NASH

Sunday, May 3, 2009

OUTLIERS--The Story of Success

Malcolm Gladwell is one of my favorite authors. His last two books, the Tipping Point and Blink, became best sellers. I reviewed both books in our Jefferson Health Policy Newsletter in 2001 and 2005, respectively. His newest book, OUTLIERS-The Story of Success, is another hit!! I especially enjoyed chapter 7--The Ethnic Theory of Plane Crashes. This could serve as a primer on the basic tenets of Crew Resource Management--the study of improved cockpit communication and its connection to safer flights and fewer crashes. Essentially, CRM teaches pilots, copilots and other crew members a standardized form of communication that empowers everyone to participate in a safe flight. It reduces "mitigated speech" patterns and helps to preserve communication "against the authority gradient" with out punitive damages. I am convinced that healthcare teams could use a heafty dose of CRM and that training programs across most hospitals would benefit as well. Imagine for a moment a team making rounds that chooses to ignore the third year student who has a crucial piece of history, taken from the patient, that may dictate a change in therapy?? Would your team be willing to listen to the lowly third year student, especially if her information would contradict what the attending has already decided?? Think about it, and let me know!! DAVID NASH

Tuesday, April 21, 2009

Follow on Biologics

Earlier today, I moderated an all day meeting at the National Press Club in Washington DC on a key topic---the policy questions surrounding follow on biologics or FOBs. Biologic drugs, the so called big molecules, include some of the greatest scientific breakthroughs of the last decade. These drugs are giving hope to thousands of patients. They are expensive to create and they do cost more than small molecules or non biologic products. There is an industry out there interested in trying to create a type of "generic product", a FOB. The challenge here is that a FOB is not biologically equivalent to an original innovative product. In addition, the FDA does not have a pathway that makes sense to approve these FOBs. Our program today, with experts from around the nation, demonstrated the need for an urgent policy solution to these issues. We will create a special edition of our journal, Biotechnology Healthcare, that will highlight these findings. For now, pay attention to what happens on Capitol Hill as we struggle with the FOB question. Much more news to follow. Does your institution support the FOBs?? DAVID NASH

Sunday, April 19, 2009

The Non Stop Conversation

I feel as though we are in a non stop conversation about reforming our broken health care system and frankly, I think we might be generating more heat than light in the process!! Right now, the process has me perplexed. What is the best way to reach out to the broadest possible audience in order to reach our key stakeholders?? As we plan for and launch the Jefferson School of Population Health, I want our message to come through the cacaphony loud and clear. As a result, of course, I have my BLOG, but this is certainly not enough. You can now view my brand new video on YOU TUBE, you can send me a tweet on twitter (nashpophealth) and you can face book me too. A google search on "School of Population Health" will bring us up immediately and if you put in David B. Nash MD, Google does a good job tracking my publications. In short, we are doing everything we can to get out the message---the message that our system needs a new kind of leader and we are determined to create the educational programs to deliver on that promise. I look forward to hearing from you, DAVID NASH

Sunday, April 12, 2009

The Benevolent Perfect Storm

David Ellwood, the Dean of the Kennedy School of Government at Harvard has it right!! We are facing a potential benevolent perfect storm, which is steering students back to public service and to health care specifically. With billions of dollars in the American Recovery and Reinvestment Act, the Stimulus Bill, headed to health care, smart students are headed in the same direction. I am hopeful that the Jefferson School of Population Health will benefit from this newly developing social trend and that this storm will deposit interested and motivated students at our doorstep. We are ready!! We are working hard to organize our faculty and our considerable resources to prepare for this storm and we will be there on Nine Nine Zero Nine----the first day of class. I hope you will join me soon as we begin the journey of preparing a new generation of leaders for the health care industry. Happy Easter and Happy Passover too. I am interested in your views about the Benevolent Perfect Storm, DAVID NASH

Sunday, April 5, 2009

CHIME and HIMSS

Each year, the top information technology officers from hospitals around the nation gather for their annual meeting to learn about the latest trends in technology,and the role that technology plays in improving the quality and safety of medical care. The Saturday before the HIMSS meeting, the key leaders gather for their own meeting, the CHIMES conference. I just spoke at the April 4 CHIMES meeting at the giant McCormick Center in Chicago. I told the CIOS that they play a central role in reforming our ailing system. In a nutshell, I view the future of payment as follows---No Outcome--No Income!! That is, we will be paid if we produce the outcomes that are desired, based on the best available medical evidence. This is surely a tall order and I get it. The CIOS get it too, and they know that information about daily practice, readily available at the bedside and in the examining room, will be vital to seeing this vision of NO OUTCOME, NO INCOME come alive. I hope you'll share your views of this vision with me as we work together to reform our broken system. DAVID NASH

Saturday, March 21, 2009

NCQA Quality Awards

Every year, the NCQA hosts a major event in Washington D.C. called the Quality Awards Dinner. Typically, the NCQA gives out multiple awards to deserving politicians, providers, and others, who have contributed to the quality agenda at the national level. This year, the dinner was held on Wednesday night March 18th and I attended along with one of my key new faculty members, Dr Susan DesHarnais---she directs our Masters Degree Program in Quality and Safety. The attendees at the dinner, numbering nearly 500, come from all across our industry. I recognized key policy persons from many of the biggest managed care plans in the country, vendors who service the industry and of course, the phamrmaceutical companies too. I was lucky enough to sit at the MedAssurant table, a key firm involved in processing data from managed care companies and helping them to turn that data into useful information to measure and improve quality. For me, the highlight of the evening was the brief talk by Dr Peter Orszag, director of the OMB and a key player in health reform. He reiterated the Obama Administration key message ---create an agenda for Comparative Effectiveness Research, change provider incentives,promote health IT and finally, invest more in prevention and wellness----that sure all sounds good to me!! I am more convinced than ever that our new Jefferson School of Population Health could not have come along at a better, or more challenging time!! Kudos to NCQA on a great event and for their ongoing work in our field. Hope I see you there next year, DAVID NASH

Sunday, March 15, 2009

Medical Student Idealism

I just returned from making several presentations at the Annual Meeting of AMSA, the American Medical Student Association, in Washington D.C. Over 1,000 students from across the nation converged on DC for four days of seminars, lobbying, and networking. I feel recharged from the experience as I soaked up some of their idealism and energy!! Even the theme of the meeting ,Take Back our Profession,had a certain positive edginess to it. The students who met with me were focused on leadership, specifically, what are the skill sets necessary to become a leader. We agreed that medical education does not really provide leadership training, at exactly the time that we need it the most. We reviewed the many opportunities that now exist to get a second degree during medical school, such as an MPH or an MBA. Of course, I spent time talking about our new Jefferson School of Population Health and the unique opportunities to pursue a masters degree in health care quality and safety, as well as degrees in public health and health policy. They were intrigued and asked scores of questions about these new programs too. In the end, I came away with a great feeling that there is indeed hope for the future and that some medical students are still idealistic and willing to work for the greater good. I think our new programs will add to the options available and will enhance the leadership model for students.Good leaders prepare the leaders of tomorrow!! AMSA is a good example of this kind of positive role modeling behavior. We should do more to emulate these programs at every medical school. I hope some medical school deans are listening carefully. Thanks for your continued listening too. DAVID NASH

Saturday, March 7, 2009

Population Health Colloquium and then some!!

This past week our team from the Jefferson School of Population Health hosted the ninth annual Population Health and Disease Management Colloquium at a beautiful hotel on the river front in Philadelphia. Despite the worst winter storm of the season, and nearly eight inches of snow, we had a full house for three days of learning. What I took away from our meeting is the emerging confluence amongst wellness, prevention, disease management and care coordination. It seems to me that these concepts are fundamental to the pending reform of the health care system and the leaders who were present made a strong case for making reform happen. The American Recovery and Reinvestment Act (ARRA) , otherwise known as the Stimulus Bill, explicitly recognizes these issues and calls for billions of dollars to be spent upgrading the public health infrastructure of the nation and creating a Center for Comparative Effectiveness Analysis. Our conference, and of course, the Jefferson School of Population Health, are part of the answer for health reform. Also this past week I was featured in a story about care coordination in the Philadelphia Inquirer and a radio interview for National Public Radio WHYY in Philadelphia. We are working tirelessly to get the message out that reform can only happen when we rationalize how care is delivered, increase the evidence basis for health care, and change the pernicious incentives as they are currently structured. I hope that our national leadership is up to this tough task. Thanks for your participation, DAVID NASH

Sunday, March 1, 2009

Saving a Life

Just a few days ago my wife and I were walking to her downtown parking garage following a meeting in center city Philadelphia that we were both attending. Two blocks from the garage, on a bench outside a diner, we noticed a middle aged white male slumped over and another man gesticulating for help. As we approached to see what we could offer, the man on the bench turned blue and I could not feel his pulse. At that moment, a nurse colleague of my wife's was on her way home and she joined us as we put the man on the sidewalk, propped up his head with a pillow, and began CPR. Bystanders began to gather and one of them called 911 for an ambulance. Fortuneately, within minutes, the CPR was successful and the man regained consciousness and was whisked off to my hospital, Jefferson University Hospital blocks away. We have subsequently learned that despite the complete lack of any medical history, a healthy diet, and a normal EKG, he has severe three vessel coronary artery disease and will be undergoing bypass surgery, at Jefferson, tomorrow!!! I am not sharing any more personal information about this lucky guy out of respect for his privacy, but I did want to reflect on my experience. I am so grateful for my training as physician, and in CPR as well, as my instincts just took over as we swung into action to help. I am also grateful for the wonderful care that he received at my own hospital, which makes me proud to be a part of the team. Do you know CPR?? Could you have saved a life too if called upon?? What greater gift could I have given him and in return, my wife and I feel blessed that we were there at the very moment that counted. I hope that we will remain friends with this nice guy for a long time and that he will continue to lead a productive life too. Health reform, the economic crisis, launching our new school are all important, but the one on one connection and saving a life sure helps to put everything else into clear focus. What do you think?? I sure hope everyone gets training in CPR too!! DAVID NASH

Sunday, February 22, 2009

WHARTON ALUMNI ACHIEVEMENT AWARD


I hope you have had an opportunity to view some of my new posts including recent interviews that I have given regarding the health care system and possible reforms, especially in light of the economic crisis. Today, I am very proud to report that I received the Wharton School of Business Alumni Achievement Award from the Health Care Administration Program, arguably the best in the country. The Alumni Association noted that Jefferson is an acknowledged leader in the field, due in no small part to the creation of our Jefferson School of Population Health and our innovative Masters Programs in Public Health, Health Policy, and Quality and Safety. It was a privilege for me to receive the award and to share in the reflected glory with my current team of outstanding faculty at Jefferson. It was also a real treat to see some of my previous professors and mentors, including those who participated in the roasting!!! Wharton taught me many lessons that I use each and every day. Do you think we can teach leadership skills necessary to help us reform our broken health care system?? I know we can and I want to hear what you think too. DAVID NASH

Wednesday, February 11, 2009

Dr. David Nash on Modern Medicine Community Audio Track

Please Click HERE to listen to the audio.

Convenient Care Association, Jefferson School of Population Health Certify Member Convenient Care Clinics

Retail Clinic Members Meet Strict Quality and Safety Standards

MINNEAPOLIS, Feb. 10 /PRNewswire/ -- The Convenient Care Association (CCA), the retail clinic industry's member-based organization, today announced to its Board of Directors that its member clinics are certified and in compliance with the Association's Quality and Safety Standards.

The Association's Board of Directors adopted its Quality and Safety Standards in March of 2007 with input from national medical, nursing and accrediting organizations, as well as its Clinical Advisory Board. A condition for Association membership is an agreement to comply with the Standards. The Association contracted with the Jefferson School of Population Health to administer...


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Sunday, February 1, 2009

A new type of Physician leader

Happy Super Bowl Sunday!! I am just back from a week of teaching for the American College of Physician Executives in Orlando FL. Two other faculty members and I ran our two courses--the Three Faces of Quality and the Advanced Applications in Quality. We had nearly 140 docs total in the classrooms. It was an intense week as I ran back and forth between the two rooms and interacted with colleagues from around the nation. Several themes emerged for me---how hard everyone is working and their desire to make a difference as our nation contemplates major changes in health care. The attendees were enthusiastic and committed. They worked through a huge amount of material and a handful of key cases as well. Another theme that emerged was the widespread recognition that pay for performance will grow exponentially and that every health care organization needs to get ready. Docs can play a key leadership role in this transition too. If you would like to learn more about these courses please visit www.acpe.org. This coming week we will continue to prepare for the opening of our Jefferson School of Population Health and our first Open House, on Saturday, February 7th in downtown Philadelphia, right on our campus. I will have much more to say about the school in subsequent posts. DAVID NASH

Wednesday, January 7, 2009

Interclerkship Day number SIX

Happy New Year and welcome to 2009---it is going to be the year of changes in healthcare!! Speaking of changes, the Jefferson School of Population Health just hosted the Sixth Annual Interclerkship Day for the entire third year class of medical students on our campus. Nearly 265 students jammed into our brand new Hamilton Building auditorium to listen to outstanding national experts like John Nance talk to them about their role in promoting a safer environment for patients, and for themselves. Nearly every student admitted to witnessing an incident or behavior that could be construed as "unsafe", even in their first six months of clinical practice!! Nance explained what lessons we could learn from the aviation industry and how we might improve communication and teamwork---key ingredients to improving patient safety. The students participated in role playing exercises and they also heard from local health care lawyers as to how to more effectively engage with patients following a medical error.Pretty powerful stuff for students and the evaluations of the day were outstanding. WHAT is your medical school doing to teach students about patient safety?? How can we connect this work to the IHI and their new program on the Open School?? We are interested in your views and thanks again, DAVID NASH