June 2009 Archives

As part of the American Recovery and Reinvestment Act (ARRA) of 2009, Congress appropriated $1.1 billion to accelerate the nation's

comparative effectiveness research (CER) efforts and then asked the Institute of Medicine (IOM) to recommend national priorities for research to be supported by ARRA funds.

 

First, the IOM developed the following definition for comparative effectiveness research:

CER is the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care. The purpose of CER is to assist consumers, clinicians, purchasers, and policy makers to make informed decisions that will improve health care at both the individual

and population levels.

 

On June 20, the IOM published a list of the 100 highest-priority CER questions. Heads up: Here is a list of nutrition-focused or nutrition-related topics:

·       Compare the effectiveness of treatment strategies for obesity (e.g., bariatric surgery, behavioral interventions and pharmacologic treatment) on the resolution of obesity-related outcomes such as diabetes, hypertension, and musculoskeletal disorders.

·       Compare the effectiveness of dietary supplements (nutraceuticals) and usual care in the treatment of selected high-prevalence conditions.

·       Compare the effectiveness and cost-effectiveness of conventional medical management of type 2 diabetes in adolescents and adults, versus conventional therapy plus intensive educational programs or programs incorporating support groups and educational resources.

·       Compare the effectiveness of different treatment strategies (e.g., modifying target levels for glucose, lipid, or blood pressure) in reducing cardiovascular complications in newly diagnosed adolescents and adults with type 2 diabetes.

·       Compare the effectiveness of clinical interventions (e.g., prenatal care, nutritional counseling, smoking cessation, substance abuse treatment and combinations of these interventions) to reduce incidences of infant mortality, pre-term births, and low birth rates, especially among African American women.

·       Compare the effectiveness of school-based interventions involving meal programs, vending machines and physical education, at different levels of intensity, in preventing and treating overweight and obesity in children and adolescents.

·       Compare the effectiveness of various strategies (e.g., clinical interventions and selected social interventions such as improving the built environment in communities and making healthy foods more available) to prevent obesity, hypertension, diabetes, and heart disease in at-risk populations such as the urban poor and American Indians.

The June 25 issue of the New England Journal of Medicine features a perspective by Thomas Bodenheimer, MD, et al., titled "A Lifeline for Primary Care." This article provides an interesting look at the challenges facing primary care and outline some possible solutions - one of which intrigues me. The authors maintain that the revitalization of primary care will "entail the formation of teams to assist physicians in providing proactive preventive and chronic care . . . ."

 

To help meet this and related needs (primarily in health information technology), Congress included a provision in the American Recovery and Reinvestment Act of 2009 (aka, the stimulus package) calling for establishment of regional extension centers.

 

Bodenheimer and his colleagues observe: "This model draws from the Department of Agriculture's Cooperative Extension Service, a collaboration among federal and state governments, agricultural experts at land-grant universities, and farmers. Extension field agents in every county provide technical assistance to local farmers, spreading agricultural innovations. Believing that what worked for family farmers may also work for family doctors," especially in the implementation of information technology.

 

What the authors don't mention is Extension Service's longtime link to food, health and nutrition. Registered dietitians know first hand how Extension Service programs strengthen the nation's capacity to address issues related to diet, health, food safety and food security - all critical elements of the "proactive preventive and chronic care" Bodenheimer, et al. call for. Thus, the Extension Service model creates a double whammy opportunity for primary care practices. It's up to registered dietitians to build this connection to its fullest capacity.

Our friends at the Society for Women's Health Research (SWHR) recently participated in a White House meeting on women's health issues and implications for health care reform.

SWHR's key priorities in health care reform include assuring that women are included in clinical research and that resulting discoveries are quickly translated into practice that improves quality of care. Although more women are currently included in clinical trials, participation is still well below 50% in most trials, and analysis by sex, race and ethnicity is not routinely done.

SWHR also raised the importance of screening/diagnostic tools in the prevention of illness in women. Women will be disproportionately affected by these cuts in these areas and lack of access. Additional cuts in reimbursement will prevent access to the latest treatments and detection of disease at an early, more treatable stage, and will negatively impact research and innovation.

 

Promoting women's health research and safeguarding access to screening/diagnostic tools compliments registered dietitians' vested interest in promoting disease prevention. Thanks to our colleagues at SWHR for their advocacy. For more information, click here.

During the nearly 20 years since the Institute of Medicine (IOM) issued guidelines for how much weight a woman should gain during pregnancy, there has been more research on the effects of weight gain in pregnancy on the health of both mother and baby. In addition, American women are now a more diverse group; they are having more twin and triplet pregnancies; they tend to be older when they become pregnant; and a greater percentage of them are entering pregnancy overweight or obese and gaining too much weight during pregnancy.

 

The good new news is that the Committee to Reexamine IOM Pregnancy Weight Guidelines has updated the guidelines to address these new realities. The even better news is that the committee considered not only the welfare of the infant, as was done in 1990, but also the health of the mother.

 

And here is some really great news for registered dietitians: The committee identified specific areas on which the National Institutes of Health and other relevant agencies - for example, the Department of Health and Human Services - should focus to fill major gaps in research, including:

·         How dietary intake, physical activity and other factors affect weight gain during pregnancy in diverse populations

·         The impact of weight gain dur­ing pregnancy on maternal and child health outcomes

·         Eating behaviors for wom­en who gain little or lose weight during pregnancy

·         How to aid care providers and communities in assisting women--especially low-income and minority women--to meet the new guidelines.

·         Cost-effectiveness of interven­tions designed to assist women in meeting the guidelines

 

Whom do you think should be doing this research? Maybe you?

As I reported in Wednesday's post, The American Dietetic Association (ADA) hosted a briefing on Capitol Hill during which ADA leaders shared results from a national online survey of 400 primary care physicians on the role of nutrition in chronic disease management. Also released at the briefing was the abstract of a new study conducted by researchers at the Ohio State University Center for Health Outcomes, Policy and Evaluation Studies (HOPES) with support from Abbott Nutrition. This study examines the cost effectiveness of therapeutic nutritional supplements (TNS) in the treatment of pressure ulcers, wounds, and burns. Preliminary results indicate savings from the use of TNS for these conditions could be nearly $1 billion annually in the United States.

ADA believes that appropriate reimbursement should be available for clinically beneficial TNS and is advocating for this support. I'll repeat what I said in Wednesday's post: If you are a registered dietitian; a dietetic technician, registered; or a healthcare professional who supports the role of nutrition in disease prevention, now is the time to support the American Dietetic Association's public policy efforts. It's that simple; it's that important.

The American Dietetic Association (ADA) hosted a briefing on Capitol Hill today during which ADA leaders shared results from a national online survey of 400 primary care physicians on the role of nutrition in chronic disease management. Hart Research Associates conducted the survey in collaboration with ADA and the University of Tennessee Graduate School of Medicine, Department of Family Medicine, with support from Abbott Nutrition.

Here is the bottom line among primary care physicians surveyed:
· 94% believe that nutrition plays a major role in disease prevention.
· 95% say nutrition plays a major role in chronic disease management and treatment. On average, they estimate that two in three of their adult patients who have chronic disease would benefit from nutrition services.
· 96% believe the nation's healthcare system should place more emphasis on nutrition to treat and manage chronic disease.
· Only 12% believe physicians currently pay significant attention to nutrition in the context of chronic disease.
· More than 80% said lack of reimbursement is either a major reason or the single biggest reason that providing nutrition services is not routine.
· 94% say they would refer more of their patients with chronic ailments for nutrition services if a third-party payer reimbursed costs.

Depending on your perspective, change creates either opportunities or challenges - or, in some cases, both. The changes this country's health care system is likely to undergo over the next decade - perhaps over the next several years - will no doubt be massive. It's important for registered dietitians to recognize the opportunities as well as the challenges this transformation will create.

An article in the June 4 Chicago Tribune brought the yin and yang of healthcare change into sharp focus for me. In this piece, Walgreen's chief executive, Greg Wasson, is quoted as saying that in a transformed healthcare system, he wants his company's more than 25,000 pharmacists to go beyond just filling prescriptions. He sees them as "coaches" in what he calls "medication therapy management" - helping patients stick to taking their medications and make better and more cost-effective choices, thus "helping to save billions in medical care costs." Clearly, Mr. Wasson has zeroed in on an opportunity, and it sounds like a win-win.

Reuters published an online review earlier this week discussing an article by researchers from the Medical University of South Carolina in Charleston that appeared in the June American Journal of Medicine. The authors used NHANES data to compare adult adherence to healthy lifestyle habits related to cardiovascular disease and mortality between 1988 and 2006. They found that over the last 18 years among adults age 40-74:
· The percentage with a body mass index ?30 has increased from 28% to 36%.
· The percentage who participate in physical activity 12 times a month or more decreased from 53% to 43%.
· Smoking rates did not change (26.9% to 26.1%).
· The percentage who eat five or more fruits and vegetables a day decreased from 42% to 26%.
· Moderate alcohol use increased from 40% to 51%.

Adherence to all five healthy habits went from 15% to 8%. Individuals with a history of hypertension/diabetes/cardiovascular disease were no more likely to adhere to a healthy lifestyle than people without these conditions.

After reading these findings, words like "disappointing" and "challenging" - even "shocking" and "frightening" - come to mind. Commenting in the Reuters article, lead researcher Dana King, MD, said that many people may not be following recommended lifestyle changes because they are relying on medication to control their health problems.