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June 3, 2010 Volume VI, No. 53

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

Cigarette smoking accounts for at least 30 percent of all cancer deaths, according to the American Cancer Society. On that note, this week's DM Update includes a CDC study of cancer-causing chemicals in U.S. brand cigarettes versus foreign brands. Also, an NIH study examines the outcome of overweight girls losing weight before adulthood.

Can faith-based organizations help to prevent HIV in Central America? Find out in this week's prevention section.

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

This week's DM news:

Table of Contents

  1. Cancer & U.S. Cigarette Brands
  2. Overweight Girls & Adult Diabetes Risk
  3. Home Visits in Medical Homes
  4. Disease Self-Management Programs
  5. Health Coaching Tech Tools
  6. Patient Registries
  7. Faith & HIV Prevention
  8. Health Risk Assessments

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CDC Finds Higher Levels of Cancer-Causing Chemicals in U.S. Brand Cigarettes

People who smoke certain U.S. cigarette brands are exposed to higher levels of cancer-causing tobacco-specific nitrosamines (TSNAs), the major carcinogens and cancer-causing agents in tobacco products, than people who smoke some foreign cigarette brands. This was one of the findings from the first-ever study to compare TSNA exposures among smokers from different countries. CDC researchers compared mouth-level TSNA exposures and urine biomarkers among smokers from the United States, Canada, the United Kingdom and Australia. Study collaborators enlisted 126 persons from Australia, Canada, the United Kingdom and the United States who smoke cigarettes daily to participate in the study. Cigarettes smoked by study participants represented popular brands in each country.

The types of tobacco in cigarettes vary by manufacturer and location of production. The U.S. cigarette brands studied contained “American blend” tobacco, a specific mixture of tobacco from the U.S. that contains higher TSNA levels. The Australian, Canadian and United Kingdom cigarette brands were made from “bright” tobacco, which is lighter in color and flue-cured. Changes in curing and blending practices could reduce U.S. smokers’ exposure to one type of cancer-causing compound; however, this would not necessarily result in a safer product.

Scientists measured chemicals in cigarette butts collected by each smoker over a 24-hour period to determine how much of a certain TSNA entered the smokers’ mouths during that period. They also collected urine samples from study participants to find out how much breakdown product from this TSNA appeared in the urine. Comparing the results from these two types of sampling showed a correlation between the amount of one TSNA that enters the mouth and the amount of its breakdown product that appears in the urine. This is the first time this relationship has been documented. This study provides additional evidence about the harmful effects of tobacco use. Insight gained during such studies helps identify the different levels of harmful chemicals to which people are exposed as a result of smoking different types of cigarettes.

To learn more about this research, please visit:

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Overweight Girls Who Lose Weight Reduce Adult Diabetes Risk

Overweight girls who lose weight before they reach adulthood greatly reduced their risk for developing type 2 diabetes, according to researchers from the National Institutes of Health (NIH) and Harvard University, who analyzed 16 years of data on nearly 110,000 women. Type 2 diabetes, the most common form of the disease, is marked by high blood sugar levels and difficulties in the body's production or use of insulin. Being overweight, exercising infrequently and having a family history of diabetes are known to contribute to the risk of developing the disease.

The study followed 109,172 female nurses from 1989 to 2005, noting how many developed diabetes during that time. An initial survey collected information about the women’s health, history and lifestyle habits. One question asked them to pick which of a series of diagrams best matched their body shape at ages 5, 10 and 20. The series of nine line drawings depicted female silhouettes of different sizes, ranging from gaunt (size 1) to obese (size 9). The nurses were also asked to provide their height and current weight and to estimate their weight when they were 18. Every two years after the initial survey, the women submitted follow-up information including whether they developed diabetes. The researchers recorded a total of 3,307 cases of type 2 diabetes over the course of the study and found that the nurses who were overweight as girls were more likely to become diabetic as adults. Women who indicated that their size at age 5 matched or exceeded the size 6 figure were more than twice as likely to develop diabetes as those who recalled matching the size 2 figure. The women indicating the size 6 or above at age 10 were 2.57 times as likely to develop diabetes as adults. Those who reported a body mass index (BMI) of more than 30 (considered obese) at age 18 were almost nine times more likely to develop diabetes than their normal-weight counterparts (BMI of 18-19).

In the study, the researchers also examined the combined effect of extra weight at various ages. Compared with women who were not overweight at key ages in childhood, adolescence and adulthood, those who indicated they were overweight at all three ages were 15 times more likely to develop diabetes. Conversely, women who recalled being overweight at age 10 but not overweight as adults were no more likely to become diabetic than their peers who had been normal-weight children.

When the women entered the study, they averaged 34 years old. At that time, they were asked to recall their weight at age 18. The researchers found that women who gained weight after age 18 also increased their diabetes risk. Those who gained more than 25 pounds increased their diabetes risk more than 20 times. On the other hand, women who recalled being overweight or obese at age 18 and subsequently lost 10 pounds or more decreased their risk by more than half, compared with overweight or obese women who maintained that weight as an adult.

To learn more about this research, please visit:

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Home Visits in the Patient-Centered Medical Home

Dr. Larry Greenblatt Jessica Simo
Medicaid patients present their own unique set of needs during home visits, explain Dr. Larry Greenblatt, medical director, Chronic Care Program, Durham Community Health Network, Duke University Medical Center, and Jessica Simo, program manager, Durham Community Health Network for the Duke Division of Community Health. The duo explains the two types of patients that benefit most from home visits, the priorities of the home visit and the most common problems identified during home visits.

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Interventions for Disease Self-Management

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's expert is Danielle N. Butin, M.P.H., O.T.R., founder and executive director of Afya and former director of Northeast Health Services, Secure Horizons, a division of UnitedHealthcare.

Question: Your diabetes intervention is a seven-week self-management program. Is seven weeks an appropriate amount of time for a diabetes self-management program? What percent of people attending those classes complete the seven weeks? What is your average class size?

Response: Five to seven weeks is the maximum time people attend those classes. We revisit this issue each year. Five to six weeks is probably ideal. Seven weeks is pushing it in terms of getting people to make a significant commitment. People do not typically attend every week because other commitments arise. They have a workbook to compensate for missed information. They also develop friendships; they forge relationships with their coach around areas they may have missed. We’re also considering revisiting raffle tickets to encourage attendance. Every week that you attend, you are eligible for a raffle. The prizes are items beneficial to diabetes, COPD or chronic pain care. But you need to be there to drop off your raffle ticket.

In terms of class size, with diabetes we top out at 40. Because we have people using glucometers and testing their blood sugar, we can’t manage more than that. In a chronic pain program, we have had class sizes as high as 55.

For more information on disease self-management in Medicare patients, please visit:

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Top Health Coaching Tech Tools

With so much technology available to wellness and health promotion programs, we wanted to see which IT tools are supporting organizations' health coaching programs.

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Patient Registries — The Track to Better Quality Healthcare

Patient registries are clinical information systems that physicians use to identify and track patients with a defined disease or condition. Besides creating realistic views of clinical practices, patient outcomes, safety and comparative effectiveness, patient registries support evidence development and decision-making and are associated with improved management of chronic illness.

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Faith-Based Organizations Can Play Important Role in Response to HIV in Central America

Faith-based organizations such as churches and religious relief and development groups can play an important role in the response to HIV and AIDS in Central America, according to a new RAND Corporation report. While the role of religious groups often is seen as limited because many do not support certain prevention measures such as condoms, researchers say building on the traditional role of faith-based groups provides an important opportunity to improve a range of services and support.

Researchers say that faith-based organizations, which historically have played a key role in delivering health and social services in developing countries, could play an expanded role in helping raise awareness of HIV and reduce the stigma that surrounds HIV and AIDS. In addition, faith-based organizations could advocate for greater access to healthcare and provide resources such as nutritious food and income-generating assistance to those with HIV, according to the study. Although faith-based organizations' role in prevention remains controversial, RAND researchers concluded that most faith-based organizations could promote HIV testing in ways consistent with their overall mission.

RAND researchers examined the current and potential future role of faith-based organizations in HIV prevention and care in three Central American countries that, at the time the study began, had the region's highest prevalence of HIV — Belize (2.5 percent), Honduras (1.5 percent) and Guatemala (0.9 percent). They visited the countries and interviewed officials from governmental health agencies, faith-based groups, other non-governmental organizations serving people with HIV and bilateral assistance agencies. They also visited clinics, hospices and other HIV-related programs sponsored by faith-based organizations. In the three countries studied, HIV affects mostly young adults, men who have sex with men and sex workers. In all three countries, but especially Guatemala, care for HIV and AIDS is not widely available, and hospitals and healthcare personnel with experience in the illness are located mainly in major cities. Researchers found that governments tend to emphasize treatment more than prevention, although the need to sustain antiretroviral medication long term for those with HIV infection has not been addressed.

While researchers are optimistic about the potential for help from faith-based organizations, they recognize that substantial obstacles exist. Judgmental attitudes and limited engagement with gays, men who have sex with men and commercial sex workers may limit the effectiveness of faith-based organizations' HIV efforts. There is also no single structure that brings together all faith-based groups, which often makes coordination between faith and health sectors difficult, according to researchers. According to Kathryn Pitkin Derose, the study's lead author and a senior policy researcher at RAND, "There is a need for greater recognition among leaders of health and faith-based organizations of the unique and complementary strength that each sector can provide to the response to HIV and AIDS. Public health leaders need to think creatively about ways to make effective use of the strengths and capabilities of faith-based organizations in addressing the challenges posted by the HIV epidemic."

To learn more about this research, please visit:

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Health Risk Assessments

Aggregate data from health risk assessments (HRAs) provides a roadmap for healthcare organizations to deliver health promotion and disease management interventions to targeted individuals — with the goal of improving clinical and financial outcomes. Complete our survey on health risk assessments and get a FREE executive summary of the compiled results.

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