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September 16, 2010 Volume VII, No. 11

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

According to the CDC, the U.S. adult smoking rate has not declined — one in five American adults continues to smoke cigarettes, and four in 10 nonsmokers were exposed to cigarette smoke during 2007-2008. Can e-cigarettes help to reverse smoking rates or cause more youth to start smoking? Read about the debate in this week's issue, along with the link between education and cardiovascular health, and whether body weight can affect colon cancer mortality.

In addition, check out our featured white paper this week on benchmarks in tobacco cessation.

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

This week's DM news:

Table of Contents

  1. Cardiovascular Health & Education
  2. Colon Cancer Mortality & Body Weight
  3. Virtual Medical Home
  4. Heart Failure & the Primary Care Nurse
  5. Top 5 HRA Data Outputs
  6. Tobacco Cessation Benchmarks
  7. Smoking Cessation & E-cigarettes
  8. Telehealth in 2010

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Please send comments, questions and replies to jpapay@hin.com.

Melanie Matthews, mmatthews@hin.com

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Higher Education Predicts Better Cardiovascular Health Outcomes in High-income Countries

In one of the first international studies to compare the link between formal education and heart disease and stroke, the incidence of these diseases and certain risk factors decreased as educational levels increased in high-income countries, but not in low- and middle-income countries, according to a study reported in Circulation: Journal of the American Heart Association. For the two-year study, investigators assessed 61,332 patients from 44 countries with diagnosed heart disease or stroke, or several risk factors, including smoking, high blood pressure, clogged blood vessels and obesity. Thirty-six percent of participants were female, 64 percent were male, and the average age was 69. Investigators used years of formal education and previous classifications of income by world region to divide participants by socioeconomic level.

Researchers found that smoking rates unexpectedly increased with greater education level among women in high-income and low-and middle-income regions. Furthermore, highly educated women in low- and-middle-income countries had a slight increase in the incidence of fatal and nonfatal heart attack and stroke. Among all other groups, heart disease declined as education increased, with highly educated men in high-income countries showing the lowest level of disease. In general, low- and middle-income countries have not achieved a significant degree of industrialization relative to their populations, and often have a medium to low standard of living. There is a strong correlation between low income and high population growth.

Smoking, a major contributor to heart disease and stroke, typically declines as formal education rises. But investigators found that nearly half of the highly educated women from high-income countries smoked, compared with 35 percent for those with the least amount of schooling. Likewise, low- and middle-income countries had higher smoking rates among the most educated women (21 versus 14 percent among the least educated). For men, smoking rates were virtually the same across educational groups in low- and middle-income countries. In affluent countries, however, the most educated men smoked less than did men with the fewest years of formal education (66 versus 75 percent).

As the leading causes of death worldwide, heart disease and stroke killed an estimated 17.5 million people in 2005, according to the latest statistics from the World Health Organization. More than 80 percent of these deaths were in low- and middle-income countries, highlighting the critical need for more research in these areas.

To learn more about this research, please visit:

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Abnormal Body Weight Related to Increased Mortality in Colon Cancer Patients

Postmenopausal women diagnosed with colon cancer may be at increased risk of death if they fail to maintain a healthy body weight before cancer diagnosis, according to a study published in the September issue of Cancer Epidemiology, Biomarkers & Prevention, a journal of the American Association for Cancer Research. Researchers extracted data from the Iowa Womenís Health Study, which included 1,096 women diagnosed with colon cancer who were observed over a maximum 20-year period. During that time, 493 died, of which 289 died from colon cancer. The researchers found that women considered "underweight" or "obese," or who had increased abdominal obesity prior to cancer diagnosis seemed to face a greater risk of mortality.

According to Anna E. Prizment, Ph.D., M.P.H., a postdoctoral fellow in the division of epidemiology and community health at the University of Minnesota, Masonic Cancer Center, "Maintaining a healthy body weight is beneficial for postmenopausal women. This may also be beneficial for those diagnosed with colon cancer later in life. It looks like abdominal obesity may be a useful indicator of higher colon cancer mortality. It is too early to say whether a decrease in weight characteristics after diagnosis will also decrease mortality risk; at that point it may be too late. Therefore, itís best to maintain a normal, healthy body weight throughout life."

Women classified as obese, with a BMI of at least 30 kg/m2, had a 45 percent increased overall mortality rate. The few women classified as underweight, with a BMI less than 18.5 kg/m2, had an 89 percent increased mortality rate compared to those with normal BMI. Furthermore, women with high waist-to-hip ratio had a 30 to 40 percent greater risk of colon cancer-related death. Prizment said that the "exact mechanisms underlying the link between obesity and higher mortality of colon cancer patients are unknown."

"Obese people may be diagnosed at later stage, have different treatment or more comorbidities," said Dr. Prizment. However, the facts that the increased abdominal obesity was associated with colon cancer mortality and those associations persisted after correcting for age, stage at cancer diagnosis and comorbidities suggest that obesity could have a direct biological effect. Obese women, especially those with higher abdominal obesity, have higher hormone levels and may have more aggressive cancer. These women have been already known to have a higher risk of developing colon cancer. Dr. Prizment encouraged further investigation of the potential effect of obesity, in particular, abdominal obesity, on the prognosis after colon cancer diagnosis.

To learn more about this research, please visit:

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Coordinating a Virtual Medical Home in Your Community: Lessons from the Iowa Collaborative Provider Network

Sarah Dixon Gale Michelle Stephan
To create a virtual medical home — also called a virtual healthcare home — primary care providers partner with community organizations to deliver a full continuum of healthcare services in a manner that is transparent to patients and health plan members. Sarah Dixon-Gale, lead contract manager for the Iowa/Nebraska Primary Care Association, explains how Iowa's virtual medical home program has improved access at Siouxland Community Health Center. Also in this podcast, Siouxland CEO Michelle Stephan describes a major challenge faced by the virtual medical home. Learn how this unique community partnership helps to position these organizations for federal Medicaid expansion in 2014.

To listen to this complimentary HIN podcast, please visit:

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Empowering the Primary Care Nurse in a Heart Failure Unit

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's expert is Lenore Blank, M.S.N., N.P-C., administrative manager of the heart failure team and pulmonary hypertension program at Hackensack University Medical Center

Question: In the HUMC care model for the heart failure unit, the nurse must intervene when predetermined practice guidelines are not followed. How do you educate nurses and physicians about these roles?

Response: We saw it was important to empower the primary care nurse — the nurse thatís actually doing the daily hands-on work with that patient. We educate and empower this nurse to be able to communicate to the physician what the patient needs — for example, if certain quality indicators were not met. We tried to empower everyone and bring everyone into the loop and make it a multidisciplinary team and shared by all so that everybody was on the same page. If the primary care nurse is not effective with the physician, he or she can ask the APN to speak with the physician. If there is still some obstruction, we have an avenue to bring it up to our rounding physician on multidisciplinary rounds and upwards.

Weíve been fairly successful with this because our administration embraced this early on. Weíve had huge administrative support in this regard, so itís been a cultural change in our institution. Everybody knows that these things are required and that this does improve patient care and outcomes. Weíve worked very well as a group and as a team.

For more information on heart failure care, please visit:

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Top 5 HRA Data Outputs

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. We wanted to see the top applications for aggregate HRA data.

Click here to view the chart.

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Benchmarks in Tobacco Cessation and Prevention Programs

Smoking is a risk factor with clearly established links to increased healthcare costs. Who are the target populations for smoking cessation programs, and how are incentives driving engagement and participation in these efforts? How do tobacco cessation programs identify candidates and deliver the information to participants? This HIN white paper examines the prevalence of tobacco cessation and prevention among 220 wellness companies, behavioral healthcare providers, PCPs, DM organizations, employers, health plans and hospital/health systems who responded to a recent survey on this topic.

To download this complimentary white paper, please visit:

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Can E-cigarettes Help Individuals to Quit Smoking, Cause Youth to Start?

According to makers of electronic cigarettes (e-cigarettes) — battery-operated devices that look like cigarettes but do not burn tobacco — they allow users to inhale nicotine but not the toxins of tobacco cigarettes. Advocates hail e-cigarettes as a possible quit-smoking aid. But the FDA has criticized e-cigarettes as potentially toxic since they havenít been tested in FDA-recognized scientific trials. Also of concern: there are no age restrictions on sales of these new nicotine-containing products.

E-cigarettes have replaceable cartridges of liquid containing nicotine, which is inhaled as a vapor along with flavors like tobacco and chocolate. E-cigarettes are available in stores, mall kiosks and over the Internet.

According to a report by the University of Michigan C.S. Mott Childrenís Hospital National Poll on Childrenís Health, public concern about e-cigarettes is already quite high. In fact:

  • 91 percent of adults in the U.S. think manufacturers should be required to test e-cigarettes for safety.
  • 85 percent favor prohibiting the sale of e-cigarettes to minors.
  • 82 percent think that the FDA should regulate e-cigarettes like other nicotine-containing products.
  • 68 percent of adults think e-cigarettes should have health warnings like tobacco cigarettes and other nicotine products.
In this latest poll, 42 percent of adults are very concerned that itís easy for youth under 18 to buy e-cigarettes. About half of adults (49 percent) are very concerned that e-cigarettes may increase nicotine and tobacco use among children, and 17 percent of parents are very concerned their children will try e-cigarettes.

Information from the poll adds to the mounting public dialogue about e-cigarettes, which has so far consisted of claims and counter-claims by opponents and proponents but minimal scientific data. Recently, the FDA sent letters to five manufacturers of e-cigarettes, warning them of violations of federal laws regarding new drugs. The FDA stated that the companies claim that e-cigarettes can help tobacco smokers quit but offer no data recognized by scientific experts.

This poll indicates widespread public support for initiatives being considered by some state and local jurisdictions, including warning labels on e-cigarettes, bans on e-cigarette sales to minors, advertising restrictions in youth media and limits on indoor smoking of e-cigarettes.

To learn more about this research, please visit:

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Telehealth in 2010

Join the more than 60 organizations that have taken HIN's second annual e-survey on Telehealth and Telemedicine to find out how organizations are using and benefiting from telehealth and telemedicine. Complete the survey by September 30 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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