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August 26, 2010 Volume VII, No. 8

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

This week we are focusing on diabetes — the impact of evolution, weight loss surgery and diet on the lives of patients with diabetes and the healthcare costs generated by this condition.

Health coaches also play a role in helping patients to self-manage their diabetes. This is your last chance to take the third annual Health Coaching in 2010 survey and share how your organization is implementing health coaching and the outcomes that result.

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

This week's DM news:

Table of Contents

  1. Weight-Loss Surgery Affects
  2. Type-1 Diabetes & Evolution
  3. Case Management Populations
  4. Patient Psychosocial Factors
  5. Reducing Readmission Rates
  6. Patient Registries
  7. Reducing Diabetes Risk with Veggies
  8. Health Coaching 2010

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Weight-Loss Surgery Frees Most Obese Type 2 Diabetics of Insulin, Other Sugar-Controlling Drugs

A large national study shows that nearly three-quarters of obese patients with type 2 diabetes who undergo weight-loss surgery are able to stop insulin and other antidiabetes drugs within six months. In the Johns Hopkins study of insured, obese, diabetic patients, researchers also found that in the third year following surgery, average annual healthcare costs per patient decreased by more than 70 percent. According to Marty Makary, M.D., M.P.H., an associate professor of surgery at the Johns Hopkins University School of Medicine and the study’s leader, “The cost to care for the average obese diabetic person in America is $10,000 a year, which could be cut to $1,800 with a very safe operation that eliminates more than 80 percent of the medications these individuals have depended on. The results show that bariatric surgery has huge implications for public health and control of healthcare costs.”

Researchers studied 2,235 adults with Blue Cross/Blue Shield insurance from throughout the U.S. who had type 2 diabetes and underwent bariatric surgery during a four-year period from January 1, 2002 to December 31, 2005. The average age of those in the study was 48 years old and 74.5 percent were women. More than 23 percent of participants were insulin dependent while more than 50 percent took metformin hydrochloride to keep their diabetes in check. Researchers found that within one year following surgery, the number of patients dependent on insulin dropped from 524 (23.4 percent) to 101 (5.5 percent). Those on metformin dropped from 1,129 (50.5 percent) to 156 (8.4 percent).

Bariatric surgery, at an average cost of $30,000, reduces stomach capacity, typically by stapling off the stomach and creating a much smaller pouch. Studies show it results in long-term weight loss, improved lifestyle and decreased mortality in some populations. Its use has increased 200 percent during the last five years, the authors note. The risk of mortality from bariatric surgery is .3 percent. Dr. Makary points out that the health risks associated with diabetes and obesity are much greater.

Dr. Makary says more obese diabetic people should be offered a surgical weight-loss option, but notes that insurance coverage of the procedure is not universal, even for appropriate patients. Some private insurers may not cover it and people with Medicaid do not have equal and uniform access to the operation. “Our results suggest that insurance companies would do well to more readily cover bariatric surgery because it improves health and cuts healthcare costs.” Dr. Makary says that while bariatric surgery has been shown to result in long-term weight loss, improved lifestyle and decreased mortality in many patients, its impact on diabetes has not been widely studied. The weight loss that results from the surgery is one explanation for why diabetes symptoms subside, but for some patients, markers of the disease disappear even before significant amounts of weight are lost. One theory is that stomach hormones are somehow altered by the surgery and those changes allow for better natural control of blood glucose levels almost immediately. “Until a successful nonsurgical means for preventing and reversing obesity is developed, bariatric surgery appears to be the only intervention that can result in a sustained reversal of both obesity and type 2 diabetes in most patients receiving it,” Dr. Makary says.

To learn more about this research, please visit:

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Evolution May Have Pushed Humans Toward Greater Risk for Type-1 Diabetes

Gene variants associated with an increased risk for type-1 diabetes and rheumatoid arthritis may confer previously unknown benefits to their human carriers, say researchers at the Stanford University School of Medicine. As a result, the human race may have been evolving in the recent past to be more susceptible, rather than less, to some complex diseases, the researchers conclude. The researchers speculate that at least some of the risky changes may protect carriers against certain viruses and bacteria — a trade-off that may have made evolutionary sense in the not-too-distant past when infectious diseases were devastating and largely untreatable. It’s not clear, however, whether the beneficial effects arise from the disease-associated mutations themselves or from neighboring genes that tag along when DNA is divvied up into sperm and eggs.

Researchers picked seven well-known conditions to study: type-1 and type-2 diabetes, rheumatoid arthritis, hypertension, Crohn’s disease, coronary artery disease and bipolar disorder. Previous genome-wide association studies have identified several hundred single nucleotide polymorphisms (SNPs) associated with each disorder. Researchers found that of the top SNPs associated with type-1 diabetes, 80 have been recently increasing in prevalence, meaning that they underwent positive selection. Of these, a surprising 58 are associated with an increased risk of the disorder, while 22 appear protective. Similarly, SNPs associated with an increased risk for rheumatoid arthritis were found to be positively selected. In contrast to type-1 diabetes and rheumatoid arthritis, researchers found that people are evolving away from a tendency to develop Crohn’s disease (that is, more protective SNPs than risky SNPs have been positively selected). Results for the other three disorders — type-2 diabetes, coronary artery disease and bipolar disorder — showed that protective and risky SNPs were positively selected in about equal proportions. According to the researchers, there are hints as to why this might be the case. For example, a recent study in another lab showed that genetic variations in an antiviral response gene called IFIH1 that improve its ability to protect against enterovirus infection (and the resulting severe, potentially deadly, abdominal distress) also increase a carrier’s risk for type-1 diabetes. And scientists who study global disease patterns have long noted that the prevalence of tuberculosis varies inversely with that of rheumatoid arthritis.

“It’s possible that, in areas of the world where associated triggers for some of these complex conditions are lacking, carriers would experience only the protective effect against some types of infectious disease,” said the researchers, who pointed out that the cumulative effect of many SNPs in a person’s genome may buffer the effect of any one variant, even if it did raise a person’s risk for a particular condition. Regardless of the reason, some evolutionary tenets still apply. Healthier people are, presumably, more likely to reproduce and pass those same genes — be they protective or risky — to their offspring. When conditions changed because of differences in diet, exposures or location as populations move around the globe, carriers of the risky SNPs began to develop the conditions people struggle with today.

To learn more about this research, please visit:

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Identifying, Monitoring and Managing Target Populations with Case Management

As part of CareOregon's initiative to create a more robust care management program, the organization has found new ways of stratifying members and identifying high-risk members, explains Rebecca Ramsay, B.S.N., M.P.H., CareOregon's senior manager of care support and clinical programs. Ms. Ramsay also explains how daily data from CareOregon's emergency departments is informing their member outreach strategy.

To listen to this complimentary HIN podcast, please visit:

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Recognizing Patient Psychosocial Factors

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's expert is Jessica Simo, program manager at Durham Community Health Network for the Duke Division of Community Health.

Question: What are some psychosocial factors that could impact a patient’s ability to self-manage, and how would they be addressed?

Response: At an absolute minimum, most of our patients suffer from depression because they are living with a chronic illness, have low income and struggle to meet their basic needs, let alone the needs their chronic condition necessitated. For many of the other patients, part of the reason their care needs are so complex is because they also struggle with issues of substance abuse, pain management and anxiety disorder. It is a very challenging group to manage and that is why the social worker is critical to be able to identify those possible problems and to make appropriate links with other community agencies that could provide mental health services.

For more information on home visits and patient-centered care, please visit:

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There are other free email newsletters available from HIN!

ReadmissionsRx delivers strategies to reduce hospital readmissions that encompass care plan development, case management, care transitions, pre- and post discharge planning, medication reconciliation and much more — with a special focus on reducing rehospitalizations among the Medicare population.

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Barriers to Reducing Readmission Rate

Responding organizations face many challenges related to the reduction of hospital readmissions. We wanted to see the most significant barriers to reducing readmission rates among their populations.

Click here to view the chart.

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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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Green Leafy Vegetables Reduce Diabetes Risk

Eating more green leafy vegetables can significantly reduce the risk of developing type 2 diabetes, according to new research. According to the authors of the UK-based study, there is a need for further investigation into the potential benefits of green leafy vegetables. In the last two decades there has been a dramatic increase in the number of individuals developing type 2 diabetes worldwide. Diets high in fruit and vegetables are known to help reduce both cancer and heart disease, but the relationship between fruit and vegetable intake and diabetes remains unclear, say the authors.

The researchers also note that previous research found that in 2002, 86 percent of UK adults consumed less than the recommended five portions of fruit and vegetables per day, with 62 percent consuming less than three portions. The study says that “It was estimated that inadequate consumption of fruit and vegetables could have accounted for 2.6 million deaths worldwide in the year 2000.”

The researchers reviewed six studies involving over 220,000 participants that focused on the links between fruit and vegetable consumption and type 2 diabetes. The results reveal that eating one and a half extra servings of green leafy vegetables a day reduces the risk of type 2 diabetes by 14 percent. However, eating more fruit and vegetables combined does not significantly affect this risk. Only a small number of studies were included in the meta-analysis and the benefit of fruit and vegetables as a whole for prevention of type 2 diabetes may have been obscured. The study authors believe that fruit and vegetables can prevent chronic diseases because of their antioxidant content. Green leafy vegetables such as spinach may also act to reduce type 2 diabetes risk due to their high magnesium content. In conclusion, the study authors believe that offering tailored advice to encourage individuals to eat more green leafy vegetables should be investigated further.

In an accompanying editorial, a professor from the University of Otago in New Zealand, and a research assistant from Imperial College London, are cautious about the results and say the message of increasing overall fruit and vegetable intake must not be lost “in a plethora of magic bullets,” even though green leafy vegetables clearly can be included as one of the five portions of fruit and vegetables per day. They argue that given the limited number of studies, “It may be too early to dismiss a small reduction in risk for overall fruit and vegetable intake or other specific types of fruits and vegetables and too early for a conclusion regarding green leafy vegetables.”

To learn more about this research, please visit:

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Health Coaching in 2010

Health coaching's domain has moved beyond traditional disease management to encompass care transitions coaching, medication adherence, and more. Join the more than 125 organizations that have taken HIN's third annual Health Coaching survey to find out how healthcare organizations are implementing health coaching as well as the financial and clinical outcomes that result. Complete the survey by August 31 and 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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