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July 15, 2010 Volume VII, No. 2

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

New behavior-based interventions to reduce heart disease risk are illustrated in this week's issue. And while we're on the topic of heart health, could there be a link between a high fructose diet and blood pressure? Between cardiac risk and anxiety? Read on to find out the latest research in these areas.

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

This week's DM news:

Table of Contents

  1. Anxiety Linked to Cardiac Risk
  2. High Fructose Diet & Blood Pressure
  3. Medical Loss Ratios
  4. Home Visits for Heart Failure
  5. Case Manager Duties
  6. Changing Lives with Lifestyle Management
  7. Reducing Heart Disease Risk
  8. Reducing Avoidable ER Visits

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Anxiety Linked to Increased Cardiac Risk in Heart Disease Patients

Heart disease patients with anxiety disorder were significantly more likely to experience stroke, heart failure, heart attack, transient ischemic attack (mini-stroke) or death than heart disease patients without anxiety, according to a study led by researchers at the San Francisco VA Medical Center (SFVAMC). The authors followed 1,015 men and women with chronic stable heart disease for an average of 5.6 years. Using a standard diagnostic test, they determined which participants had generalized anxiety disorder (GAD), characterized by chronic exaggerated worry and tension without apparent cause.

Over the course of the study, 9.6 percent of the participants with GAD had a cardiovascular event, in contrast with 6.6 percent of the participants without GAD. After controlling for a number of cardiac disease risk factors, the researchers found that anxiety disorder was associated with a 62 percent higher risk of cardiovascular events.

According to principal investigator Mary Whooley, M.D., a physician at SFVAMC, “As we might expect, the participants with anxiety disorder smoked more, exercised less, and were less likely to regularly take their prescribed medication. But the association between anxiety and cardiac events remained even after we controlled for these behaviors and other risk factors.” Dr. Whooley notes that other studies have shown that stress is associated with ischemia, or reduced blood flow to the heart. “The reason may be elevated stress hormone levels or simply increased heart rate and blood pressure.”

To learn more about this research, please visit:

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High Fructose Diet May Contribute to High Blood Pressure

People who eat a diet high in fructose in the form of added sugar are at an increased risk of developing high blood pressure or hypertension. The results of a new study suggest that cutting back on foods and beverages containing a lot of fructose (sugar) might decrease one’s risk of developing hypertension, the most common chronic condition in developed countries and a major risk factor for heart and kidney diseases.

To examine whether increased fructose consumption has contributed to rising rates of hypertension, researchers analyzed data from the National Health and Nutrition Examination survey (2003-2006). The study involved 4,528 U.S. adults 18 years of age or older with no prior history of hypertension. Study participants answered questions related to their consumption of foods and beverages such as fruit juices, soft drinks, bakery products and candy.

The research team found that people who consumed a diet of 74 grams or more per day of fructose (corresponding to 2.5 sugary soft drinks per day) had a 26, 30 and 77 percent higher risk for blood pressure levels of 135/85, 140/90 and 160/100 mmHg, respectively. A normal blood pressure reading is below 120/80 mmHg.

“Our study identifies a potentially modifiable risk factor for high blood pressure. However, well-planned prospective randomized clinical studies need to be completed to see if low fructose diets will prevent the development of hypertension and its complications,” said the researchers. During the past century, a dramatic increase in the consumption of this simple sugar, which is used to sweeten a wide variety of processed foods, mirrors the dramatic rise in the prevalence of hypertension.

To learn more about this research, please visit:

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Minimum Medical Loss Ratios — How Health Plans Should Prepare for the January Compliance Requirements

John Steele Steve Young
What constitutes healthcare quality improvement? CMS's definition of medical costs will likely coalesce around five key areas of quality improvement, say John Steele and Steve Young, managing directors for HealthScape Advisors. These CMS guidelines will impact health plans in January, when new medical loss ratio (MLR) regulations take effect. In this podcast, the advisors also describe the risk that insurers could incur on the rebate side if they don't adequately prepare for the January changes and the impact the regulations could have on consumers' medical care and choices.

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How-to’s of Heart Failure Home Visits

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's expert is Michele Gilbert, M.S.N., education coordinator of the heart failure team and pulmonary hypertension program at Hackensack University Medical Center.

Question: What are the components and goals of the home visits conducted by the heart failure team?

Response: We have spent a lot of time teaching our home care nurses to be astute observers. One thing the nurse will do is interview the patient regarding their health practices and understanding of the disease. We give patients basic educational information. When the nurse conducts the visit, she does a complete physical assessment, as well as an assessment of the patient’s functional abilities. We use the Minnesota Living With Heart Failure Questionnaire, which addresses functional status for the patient. We use that at the first and last visits to ensure that the patient’s functional status and ability to self-manage is improving. We find out what the patient has been eating and what they’re doing, and we get our baseline.

On subsequent visits, the nurse might empty the patient’s pantry and show them how much sodium they’ve been eating. They ensure the patient understands where to find hidden sources of sodium. The nurse continues to assess the patient’s progress. They will provide them with a daily system for weighing themselves and recording their weight. The patient’s ability to self-medicate is also assessed. If they don’t have a system for taking their medications, we provide one, such as a seven-day pillbox with four compartments.

For more information on caring for heart failure patients, please visit:

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Key Case Manager Duties

As the case manager's contribution to healthcare delivery and quality grows, so, too, do the responsibilities of that position. We wanted to see the duties that occupy the time of the healthcare case manager.

Click here to view the chart.

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Changing Lives with Lifestyle Management — Taking the Pulse of Population Health Programs

Numerous healthcare organizations are launching lifestyle management programs for individuals with life-threatening conditions such as diabetes, heart disease and obesity. This white paper summarizes more than 60 such initiatives, including the differing approaches and techniques in identification, treatment and outcome assessment.

To download this complimentary white paper, please visit:

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Combined Behavioral Interventions Reduces Heart Disease Risk

Combining counseling, extended follow-up with a healthcare provider and self-monitoring of diet and exercise is the most effective way to help patients embrace lifestyle changes that can lower their risk for heart and blood vessel (cardiovascular) diseases, according to a scientific statement published in Circulation: Journal of the American Heart Association. Current healthcare policies should be modified to encourage these interventions, according to the study authors. Cardiovascular disease (CVD) is the leading cause of death in the United States. According to American Heart Association (AHA) statistics, about 81.1 million adults, or one out of every three people in America, have at least one type of CVD, such as heart attack, stroke or heart failure. If cardiovascular diseases were completely eradicated, life expectancy could increase by nearly seven years.

The authors analyzed 74 studies conducted among U.S. adults between January 1997 and May 2007. The studies measured the effects of behavioral change on blood pressure and cholesterol levels; physical activity and aerobic fitness; and diet, including reduced calorie, fat, cholesterol and salt intake, and increased fruit, vegetable and fiber consumption. The authors identified several critical parts of effective behavioral change programs, including healthcare providers using a motivational interviewing technique to encourage patients to make healthier lifestyle choices, counseling patients that occasional setbacks are normal and scheduling recurring follow-up sessions with patients. The most effective patient-controlled behaviors include setting specific goals for physical activity and dietary improvements, and keeping track of the progress toward their goals, said the authors.

According to Ralph Sacco, M.D, AHA president, “Lifestyle change is never easy and often under-emphasized in clinical encounters with patients. This statement shows what types of programs work and supports the increased need for counseling and goal setting to improve healthy cardiovascular habits. We need to find more effective ways to make lifestyle change programs available, especially to the groups at highest risk for cardiovascular diseases — older Americans, African-Americans and people of Hispanic origin.” Dr. Sacco added that the first step in making a change is to know your health status, “because a lot of people don’t realize they’re at risk for heart disease and stroke. The AHA’s My Life Check can help identify your risk level and offers simple steps to get started on the path to ideal cardiovascular health.”

Although obesity, physical inactivity and poor diet are well recognized as major risk factors for CVD, it’s often difficult for doctors and nurses to help patients reduce their risk for an extended period. They are faced with numerous obstacles, including time constraints, reimbursement problems and insufficient training in behavioral change techniques, the statement authors write. Despite these difficulties, the authors stated that policy changes will eventually make critical interventions more readily available.

Federal health reform legislation includes provisions that would improve access to preventive services and help Americans make healthier food choices to control risk factors for heart disease and stroke. For example, the new law requires calorie information on restaurant menus and vending machine products and eliminates co-pays for certain preventive services under Medicare and new private health plans. The legislation also includes funding to support public health interventions at the state and local levels aimed at lowering risk factors for chronic disease.

To learn more about this research, please visit:

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Reducing Avoidable Emergency Room Visits

Inappropriate and preventable use of the hospital emergency department is a nationwide problem and a serious drain on healthcare resources. Many healthcare organizations have launched programs to reduce avoidable use of the hospital ER. Complete this month's survey on reducing unnecessary emergency room visits by July 31, 2010 and we will e-mail you a copy of the compiled survey results in August.

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

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