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December 23, 2010 Volume VII, No. 24

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

According to a study by Stanford University School of Medicine, an expanded U.S. program of HIV screening and treatment could prevent as many as 212,000 new HIV cases over the next 20 years. Learn more about this cost-effective screening in this week's issue. Also, find out the three factors that determine a Parkinson's patient's level of disability and an unusual marker for autism.

Your colleague in the business of healthcare,
Jessica Papay
Editor, Disease Management Update

This week's DM news:

Table of Contents

  1. Parkinson's & Disparities
  2. Link Between Autism & Freeways
  3. Essentials of an ACO
  4. Best Practices for Medical Home Physicians
  5. Top Telehealth Devices
  6. 2011 Healthcare Trends
  7. HIV Screening
  8. Reducing Hospital Readmissions in 2010

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Study Finds Racial, Socioeconomic Disparities for Parkinson's Disease

African American patients and those with lower socioeconomic status have more advanced disease and greater disability when they seek treatment from Parkinson’s disease specialists, according to a study from the University of Maryland School of Medicine. The researchers found that race, education and income were each significant and independent factors in determining a patient’s level of disability. The disparities in healthcare are associated with greater disease severity and earlier loss of independence.

The analysis revealed that African American patients were less likely to receive medications for their parkinsonian symptoms overall and less likely to receive newer medications, which are generally more expensive. But the researchers acknowledge that the relatively small number of African Americans in the study — 66 — may limit their ability to detect differences and that more study is needed.

The cause of these racial and socioeconomic disparities is unclear, but possible explanations include problems with access to healthcare, reduced physician referral rate or patient reluctance to seek care from a movement disorders specialist. The study focused on a sample of more than 1,000 patients who were seen at the University of Maryland Parkinson’s Disease and Movement Disorders Center for parkinsonism (slow movements, tremor and rigidity, difficulty initiating movement, and problems with gait and balance), mostly due to Parkinson’s disease, but also caused by other conditions, including stroke, head trauma and medication side effects. “Through our evaluation over a five-year period, we found that African Americans and people with lower socioeconomic status had greater disease severity and disability than whites when they first came to our clinic. Very large differences in Parkinson’s disease symptom severity and functional status were seen between blacks and whites, between high and low income groups and between groups with greater and lesser educational attainment,” says Lisa Shulman, MD, lead author and professor of neurology at the University of Maryland School of Medicine.

“Future studies need to evaluate patient attitudes and their beliefs about Parkinson’s symptoms and treatment. It is possible that some patients may believe slowness and tremor are just part of aging or that they have to reach a certain threshold of severity before seeking treatment. On the other hand, it may be that physicians, either consciously or unconsciously, are less likely to refer African Americans and patients of lower socioeconomic status to a Parkinson’s specialist,” notes William Weiner, MD, co-investigator and director of the Maryland Parkinson’s Disease and Movement Disorders Center. With Parkinson’s disease, early medical treatment can have a profound effect on how well a patient functions as the disease progresses.

According to Dr. Weiner, “The results of this study show we need to learn more about the causes of parkinsonism and find ways to overcome these disparities, which clearly are affecting the quality of life of patients who are from different backgrounds and means. The differences in function between patients with different education levels may suggest that patients with more education are perhaps more likely to request a referral to a specialist. Conversely, it is possible that physicians are more likely to refer more highly educated patients to a specialist.”

To learn more about this research, please visit:

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Proximity to Freeway Associated with Autism

Living near a freeway may be associated with increased risk of autism, according to a study published by the Children’s Hospital Los Angeles, the Keck School of Medicine of the University of Southern California (USC) and the UC Davis MIND Institute.

The study found that living within 309 meters of a freeway (or just over 1000 feet) at birth was associated with a two-fold increase in autism risk. This association was not altered by adjustment for child gender or ethnicity, maximum education in the home, maternal age or prenatal smoking. The researchers found no consistent pattern of association of autism with proximity to a major road. Traffic-related air pollutants have been observed to induce inflammation and oxidative stress in toxicological and human studies. The emerging evidence that oxidative stress and inflammation are involved in the pathogenesis of autism supports the findings of this study.

Autism is a developmental disorder that has long been ascribed to genetic factors. While changes in diagnostic criteria and increased awareness have been thought to contribute to the rising incidence of the disorder, these factors alone cannot explain the dramatic increase in the number of children affected. The CDC reported a 57 percent increase between 2002 and 2006. This study supports the theory that environmental factors, in conjunction with a strong genetic risk, may be one possible explanation for the increase. While little is known about the role of environmental pollutants on autism, air pollution exposure during pregnancy has been seen to have physical and developmental effects on the fetus in other studies. Exposure to air pollution during the first months of life has also been linked to cognitive developmental delay. However, the authors said that this study is the first to link exposure to vehicular pollutants with autism risk, though direct measurements of pollutants were not made.

Data from children with autism and typically developing children, who served as controls, were drawn from the Childhood Autism Risks from Genetics and the Environment (CHARGE) study, a population-based case-control study of preschool children. Children were between the ages of 24 and 60 months at the start of the study and lived in communities around Los Angeles, San Francisco and Sacramento. Population-based controls were recruited from state of California birth files, and were frequency matched to the autism cases by age, gender and broad geographic area. Each participating family was evaluated in person. All children were assessed; assessment of autism was done using well-validated instruments. The study examined the locations where the children’s families’ lived during the first, second and third trimesters of their mothers’ pregnancies and at the time of the baby’s birth and looked at the proximity of these homes to a major road or freeway. The participants’ gestational ages were determined using ultrasound measurements and prenatal records.

To learn more about this research, please visit:

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The Essentials of an Accountable Care Organization — Preparing for the ACO Model

The accountable care organization (ACO) is a staple of healthcare reform. CMS will launch its Shared Savings Program — an ACO for Medicare patients — in January 2012. John Harris, principal with the consulting firm of DGA Partners, advises potential participants in an ACO to lay the groundwork now. In this interview, he recommends eight elements of an ACO infrastructure and weighs in on the patient-centered medical home's role in an ACO.

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Best Practices for Medical Home Physicians

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's expert is James Kerby, vice president of medical affairs at Grand Valley Health Plan.

Question: What are some best practices for medical home physicians or practices beyond standard appointment scheduling, asking the doctor a question online etc., to help patients better manage their wellness and chronic disease?

Response: We have implemented several approaches to enhancing our patient’s capabilities. For those that have chronic illnesses, we have implemented shared appointments where a practitioner along with a health coach and often a nurse meet with anywhere between eight and 10 individuals at a shared appointment to do their actual diabetes visit in a group setting to provide education and support for individual DM plans.

Also, we use report cards for our patients with diabetes. After their diabetes visit, we give them a report card of where they stand with goals that have been established for different parameters, such as the HbA1C level or completion of their annual diabetic retinopathy eye examination. Also, for wellness support, we use health risk assessments (HRAs) to interact with our well individuals and try to enhance their activities and maintaining their health.

For more information on patient-centered medical homes and physicians, please visit:

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Top Telehealth Devices

Powered by provisions in the Patient Protection and Affordability Act, healthcare delivery via telehealth and telemedicine is transforming wellness, disease management, medication management services and illness prevention while extending and enhancing access to critical healthcare services. We wanted to see which devices are being utilized in organizations' telehealth initiatives.

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2011 Healthcare Trends

This white paper summarizes results of the Healthcare Intelligence Network’s sixth annual Healthcare Trends for the Year Ahead e-survey conducted in October 2010, which reveals how 73 healthcare organizations perceived the business environment in 2010, are preparing for 2011 and anticipate implementation of the Patient Protection and Affordable Care Act (PPACA).

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Expansion of HIV Screening Cost-Effective in Reducing Spread of AIDS

An expanded U.S. program of HIV screening and treatment could prevent as many as 212,000 new infections over the next 20 years and prove to be very cost-effective, according to a new study by Stanford University School of Medicine researchers. An estimated 21 percent of HIV-infected individuals in the United States are not aware they carry the deadly virus and may continue to spread it to others, according to the CDC. Some 56,000 people are newly infected with the virus every year in the country, according to CDC figures.

In 2006, the federal agency revised its guidelines to recommend that all patients ages 13 to 64 be screened for HIV, and many other professional groups, such as the American College of Physicians, advise routine patient screening as well. Still, universal screening followed by treatment has never been achieved in this country. The researchers set out to see how the course of the epidemic might change with a scaled-up program involving screening, treatment or both. The researchers projected that 1.23 million people would become newly infected in the next 20 years if things remained as they are today. Some 74 percent of new infections would be among high-risk individuals, particularly men who have sex with men and intravenous drug users.

The researchers found that screening high-risk people annually and low-risk people once in their lifetimes was a worthwhile and cost-effective approach to help curtail the epidemic. The screening would have to be coupled with treatment of HIV-infected individuals, as well as programs to help change risky behaviors. “We find that expanded screening and treatment could offer substantial health benefits, preventing 15 to 20 percent of new cases,” said the researchers. “And the strategy of one-time screening of low-risk individuals and annual screening of high-risk individuals is very cost-effective.”

The researchers found that if all adults in the United States were screened annually, regardless of risk, the cost would be staggering — exceeding $750,000 per quality-adjusted life year (QALY) gained. QALY is a measure of how long people live and their quality of life. But screening everyone in the general population just once, together with yearly screening of high-risk individuals, would be significantly more cost-effective: It would have a cost of less than $25,000 per QALY gained. At that price, “screening is a good value for the money,” said researchers, comparable to other widely accepted programs, such as breast cancer mammography and screening for type 2 diabetes.

Screening alone, however, would not be sufficient to stem the epidemic, but would have to go hand in hand with treatment, the researchers found. Treating patients is important because it avoids complications and costly hospitalizations and also makes it less likely they will transmit the virus to others because the amount of virus in their systems is low. If 75 percent of individuals identified as HIV-positive receive access to therapy, the health outcomes are improved and the program provides better value at $22,000 per QALY gained, the researchers calculate. That combination strategy could prevent an estimated 17.3 percent of new infections, or 212,000 new cases, the researchers found.

This expanded screening and treatment program still wouldn’t eliminate the epidemic, as at-risk individuals would still have to change their behaviors. If men who have sex with men reduce their number of sexual partners by half and intravenous drug users cut needle sharing by the same amount, 65 percent of all new infections would be prevented, the researchers found. That would reduce the incidence of HIV to approximately 20,000 new cases per year.

To learn more about this research, please visit:

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Reducing Hospital Readmissions in 2010

Just a few days remain to describe your organization's efforts to reduce hospital readmissions by taking HIN's second annual Reducing Hospital Readmissions Benchmark Survey. Respond by December 31 and receive an e-summary of the results from more than 50 healthcare companies once the survey is completed.

To participate in this survey and receive its results, please visit:

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