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May 6, 2010 Volume VI, No. 49

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

According to the American Association of Clinical Endocrinologists, the process of diagnosing obesity may be a bit different than originally thought — a finding highlighted in one of this week's stories. You will also learn why prostate cancer risk is higher in the north than in the south.

And our prevention story this week answers this question: Did more Americans receive their seasonal flu vaccinations within the past year than in previous years?

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

This week's DM news:

Table of Contents

  1. Underdiagnosis of Obesity
  2. Pollutants & Prostate Cancer
  3. Medical Home Transformation
  4. Measuring Activation
  5. The Medical Home Care Team
  6. Case Management Benchmarks
  7. Flu Vaccination Rates
  8. Managing Care Transitions

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New Research Indicates Massive Underdiagnosis of Obesity when Using BMI

A retrospective analysis of 1,234 Americans indicated a substantial underdiagnosis of obesity when BMI was used compared to the Dual Energy X-ray Absorptiometry (DEXA) scan. To date, no large-scale comparison has been made between BMI and DEXA, a direct measure of percentage body fat. The findings were released at the American Association of Clinical Endocrinologists (AACE) annual meeting.

A team of physicians and scientists from PATH Foundation NY reviewed the medical records of 1,234 patients from 2003 to 2009 to obtain BMI (from height and weight) and percentage body fat (from Hologic DEXA). Subjects were classified as obese or non-obese based on the American Bariatric Societyís classification of obesity, which is a BMI of 30 or higher, or a percent body fat of 25 or higher in males and percent body fat of 30 or higher in females. The CDC traditionally considers an adult with a BMI between 25 and 29.9 as overweight while an adult with a BMI of 30 or higher is considered obese.

DEXA, using percent body fat, identified 56 percent of the total subjects as obese while BMI had only identified 20 percent, thus 36 percent of the obese patients were missed by using BMI alone. Furthermore, 5 percent of patients identified as obese by BMI measurement were actually classified as non-obese when using percentage body fat as the parameter. According to the AACE, using the standard metrics of sensitivity, specificity, false positives and false negatives, BMI is a very inaccurate mathematical formula for detecting obesity in clinical practice. Direct fat measurements are clearly superior with the additional benefit of showing body fat distribution, added the AACE. This is significant in the early determination of a predisposition to certain illnesses, such as hypertension, type 2 diabetes, stroke, high cholesterol, heart disease and early death.

A previous analysis focusing on the limitation of BMI labeled the condition of low BMI and high body fat percentage as normal weight obesity. Although normal weight obesity has been associated with higher risk of dyslipidemia (increased cholesterol), hypertension in men, cardiovascular disease for women, depression and lower physical capacity, it is yet to be shown to be related to memory loss, cognitive processing speed, brain voltage/power, leptin resistance and other medical comorbidities, which was the purpose of this study.

In light of the importance of the global obesity epidemic, Eric Braverman, M.D., a primary author of the study, feels the use of BMI should be greatly curtailed. PATH Foundation NY anticipates future studies that will identify the specific qualifications for patients who may need DEXA analysis in addition to standard BMI measurement, reducing the misclassification of obesity.

To learn more about this research, please visit:

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Pollutants, Not Weather, Cause Increased Prostate Cancer in Northerners

The correlation between cold dry weather and an increased incidence of prostate cancer may be due to the effects of weather on pollutants. Approximately one in six men will develop prostate cancer in their lifetime, but the risk of cancer is higher in the North than in the South. Idaho State University researchers suggest that this pattern may be because organic pollutants, including some pesticides, precipitate out of the atmosphere at colder temperatures and thus may result in higher incidences of prostate cancer. The multidisciplinary team studied the correlation between various weather parameters and the county level incidence of prostate cancer across the United States, controlling for a number of confounding variables.

According to the researchers, "Colder weather and low rainfall were strongly correlated with prostate cancer. Although we canít say exactly why this correlation exists, the trends are consistent with what we would expect given the effects of climate on the deposition, absorption and degradation of persistent organic pollutants, including some pesticides." Environmental chemists have been saying for over 30 years that pollutants such as PCBs and DDT are accumulating in areas of high altitude as well as high latitude. Cold weather slows their degradation while also causing them to precipitate towards the ground, and rain and humidity also play important roles in their absorption and degradation.

"The findings from this ecological type of study are consistent with what we would expect from differential exposure to these kinds of pollutants," said the researchers. "This study provides an additional hypothesis for the north-south distribution of prostate cancer, which builds on the existing supposition that individuals at northern latitudes may be more likely to be deficient in Vitamin D due to low exposure to UV radiation during the winter months." The ISU study suggests that in addition to vitamin D deficiency, a vitamin that is protective against certain cancers, other meteorological conditions may also significantly affect the incidence of prostate cancer, added the researchers.

To learn more about this research, please visit:

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Patient-Centered Medical Home Transformation: 9 Key Hurdles for Physician Practices To Overcome

Michael Earley Dr. Jose Guethon
In the first of several conversations with Metcare of Florida chief executives on its continuing medical home pilot with Humana, CEO Mike Earley and President and COO Dr. Jose Guethon describe Metcare's longstanding commitment to the management of care transitions for its Medicare patients, how its 10 medical home practices keep a handle on patient care in hospital settings, and the clinical and business returns that result from these efforts.

To listen to this complimentary HIN podcast, please visit:

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Measuring Activation at Pre- and Post-Intervention Points

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's experts are Diane Bellard, director of disease management and wellness services for American Health Holding, and Dr. Judith Hibbard, professor of health policy at the University of Oregon and the developer of the Patient Activation Measure™.

Question: Has the Patient Activation Measure (PAM) instrument been used to evaluate activation levels at pre- and post-intervention points to see if activation improves, and with which intervention has this been used?

Response: (Diane Bellard) Yes, we are measuring. That is the reason we do the PAM at the engagement call — that is, a pre-intervention analysis. Then, we repeat it in three months and then every six months at a minimum. Our experience is short here; we donít have much data at this point to highlight improvements, but that is what we are expecting to see.

We are not measuring only individual interventions. Our program is phone-based, so we are doing outreach based on certain call frequencies. We expect to see improvements in the PAM scores. I have been watching it since we started using it and we are seeing some incremental improvements. It is important to measure not only the levels, but also the individual scores. Someone can move up one or two points — it is a 100-point scale — which may not put them in another activation level, but can result in improved health behaviors.

(Dr. Judith Hibbard) The levels are useful for thinking about how to intervene and support the person, but it is not as useful and as strong a measurement as the underlying score. You always want to use the underlying score to track progress. We have seen that a change of three to four points is correlated with behavior change, which is a meaningful change, even though it may not take you out of a full level.

Regarding the different types of interventions that have been looked at pre- and post-measurement, there's a study based on wellness coaching where there is measurement along the way — pre-, during and post-measurement — where they saw improvements. The CDC funded a study of worksite wellness programs, where there were intervention and control groups. The study found that a broad campaign in the worksite did in fact improve activation levels. We have measurement from care management with a high-risk, long-term medical disability population out of Washington state, and they found improvements. They used a PAM-tailored coaching strategy. We have measurement on the Stanford Chronic Disease Self-Management Program and we see improvements in activation as a result of that program. However, we donít see as many low-activation people volunteering for the program. There is a nice range of different types of interventions that have been studied and we can see improvements in activation.

For more information on the use of the PAM, please visit:

We want to hear from you! Submit your question for Disease Management Q&A to info@hin.com.

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There are other free email newsletters available from HIN!

Medical Home Monitor tracks the construction of medical homes around the country and their impact on healthcare access, quality, utilization and cost. As providers and payors reframe care delivery, this twice monthly e-newsletter will cover the pilots, practice transformations, tools and technology that will guide healthcare organizations toward clinical excellence.

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Who's On the Medical Home Care Team?

The medical home care team provides patient-centered, coordinated and high-quality care for its members. We wanted to see which medical professionals besides the physician are players on the medical home care team.

Click here to view the chart.

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Benchmarks in Healthcare Case Management

Healthcare case managers are playing a larger role in the coordination of all phases of patient cares. This HIN white paper examines the expanding focus, responsibilities and impact of case management in healthcare, from populations benefiting from case management to metrics on case loads, ROI and performance measurement through responses provided by 187 healthcare organizations.

To download this complimentary white paper, please visit:

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More Americans Received Seasonal Flu Vaccination in 2009-10 than in Previous Years

More Americans were vaccinated against seasonal flu during the 2009-10 season (40 percent of eligible population) than during the previous flu season (33 percent of eligible population), according to a report by the CDC. The greatest gain in vaccination rates was in children 6 months to 17 years. About 40 percent of children were vaccinated for seasonal flu last season, representing a 16 percentage point jump from the 2008-09 season.

There also was an increase in the percentage of healthy adults (people without a chronic health condition such as asthma or diabetes) aged 18Ė49 years old who were vaccinated against seasonal flu. Coverage in this group increased from approximately 22 percent in 2008-09 to approximately 28 percent for the 2009-10 season. Coverage remained stable among adults 18-49 years of age with chronic health conditions, all adults 50-64 years, and those 65 years and older. This report also highlights state-level seasonal vaccine coverage estimates. Hawaii had the highest percentage of people vaccinated against seasonal flu with nearly 55 percent of people being vaccinated.

According to Dr. Anne Schuchat, director of CDCís National Center for Immunization and Respiratory Diseases, "We are identifying the successful programs and lessons learned from the 2009-10 season and the H1N1 pandemic response, and are working with states to increase vaccination coverage next season. This report shows real success in vaccinating school-aged children, and it underscores additional opportunities to expand the use of school-located clinics in the 2010-11 season. There are also opportunities to vaccinate more adults at higher risk for influenza, such as pregnant women and persons with chronic medical conditions."

To learn more about this research, please visit:

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Managing Care Transitions Across Sites

Tighter management of transitions in care — particularly for older adults with complex acute or chronic conditions — can help to close care gaps, avoid unnecessary hospitalizations, readmissions and ER visits, reduce medication errors and raise the bar on care quality. Please share how your organization is coordinating key care transitions by completing HIN's second annual e-survey on Managing Care Transitions Across Sites by May 31. You'll receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

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

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