Association of Child and Adolescent Psychiatric with Biomedical and Somatic Disorders: Do Population-Based Utilization Study Results Support the Adverse Childhood Experiences Study?
T C R Wilkes, MB, ChB, M Phil, DCH FRCP(Edin), MRCPsych, FRCPC, FAPA; Lindsay Guyn; Bing Li, MA; Mingshan Lu, PhD; David Cawthorpe, PhD
Spring 2012 - Volume 16 Number 2
Context: Few population-based studies have examined the relationship between psychiatric and somatic or biomedical disorders.
Objective: We examined the effect of the presence or absence of any psychiatric disorder on somatic or biomedical diagnosis disorder costs. Guided by the Kaiser Permanente and Centers for Disease Control and Prevention Adverse Childhood Experiences (ACE) Study, we examined our administrative data to test if psychiatric disorder is associated with a higher level of somatic disorder.
Design: A dataset containing registration data for 205,281 patients younger than age 18 years was randomly selected from administrative data based on these patients never having received any specialized, publicly funded ambulatory, emergency or inpatient admission for treatment of a psychiatric disorder. All physician billing records (8,724,714) from the 16 fiscal years April 1993 to March 2009 were collected and grouped on the basis of presence or absence of any International Classification of Diseases (ICD) psychiatric disorder.
Main Outcome Measures: We compared 2 groups (with or without any psychiatric disorder: dependent variable) on the cumulative 16-year mean cost for somatic (biomedical, nonpsychiatric) ICD diagnoses (independent variable).
Results: Billing costs related to somatic and biomedical disorders (nonpsychiatric costs) were 1.8 times greater for those with psychiatric disorders than for those without psychiatric disorders. Somatic costs peaked before the age of 6 years and remained higher than the groupings without psychiatric disorders in each age range.
Conclusion: In support of the ACE study, ICD psychiatric disorders (as an index of developmental adversity) are associated with substantially greater ICD somatic disorders. The findings have implications for health care practice.
The association between general health care costs and mental problems is emerging as an important topic in policy development related to reducing the burden of mental illness on society. Seligman1 proposed in 1989 that an epidemic of depression was on the horizon. A published study in our catchment indicates that psychiatric disorder is indeed epidemic.2 Furthermore, the health care cost reductions associated with health improvement are better for those with somatic or biomedical problems (eg, asthma) than in those with mental problems.3,4
As individuals develop, those with early adversity (eg, abuse and neglect) have a greater likelihood in adulthood of using health services more frequently—an effect modulated by psychiatric status.5 Childhood psychiatric conditions such as depression and substance abuse have a long-term economic cost and are estimated to reduce subsequent lifetime family income by $300,000 US, at a national cost of $1.2 trillion US.6 Felitti et al7 have studied extensively the association between childhood adversity and adult health status, with the finding that adversity-affected adults are at considerably higher risk of having serious health concerns. Here, we present population-based results that support the findings of Felitti et al’s Adverse Childhood Experiences (ACE) study.
Materials and Methods
Health care in Canada is primarily universal. Medically necessary health services in each province include family physician visits and access to specialized ambulatory, emergency, and inpatient health treatment, including mental health, and are covered under public provincial health plans. In addition, family physicians serve as gatekeepers for specialty care. Most people who require mental health care are first served by their family physicians. For each patient visit, physicians bill the provincial health plan directly to receive payment for the services they deliver. Each billing includes at minimum a unique patient identifier, an International Classification of Diseases (ICD) diagnosis, and an associated visit cost.
The April 1993 through March 2009 data used in this study consisted of physician billings (Calgary Research Ethics Board ID 21695) for patients from the Calgary Zone in Alberta who were younger than age 18 years on their index visit. Physician billing data represented the records of all health services rendered to all individuals from the catchment sample who sought health care on a specified date for a specified problem and were assigned an ICD diagnosis.
The group under study consisted of those who had physician health care billings and did not have a personal health number associated with treatment by specialized, publicly funded ambulatory, emergency, or inpatient mental health services. The randomly selected files of physician billing data consisted of 205,281 unique individuals having 8,724,714 billing records submitted by regional physicians. These records included billing data related to somatic or biomedical and psychiatric diagnoses assigned by physicians. All diagnoses were based on ICD-9 or ICD-10 mental health diagnostic codes. The data formed two natural groups of individuals: those with a psychiatric diagnosis and those without any physician-assigned psychiatric diagnoses (no psychiatric diagnosis). Each of these groups had physical biomedical or somatic disorders that formed the basis for comparison.
Diagnosis-related costs were recorded in the dataset as the total amount paid by the provincial health plan to the physician for each visit. Physical (somatic and/or biomedical) diagnosis costs were summed across each group and did not include visit costs related to any psychiatric disorder billings. Psychiatric diagnosis costs were totaled separately.
Groupings based on the presence or absence or any psychiatric disorder represented the dependent or outcome variable. Costs and visits for somatic or biomedical diagnoses represented the main independent variables. Age and sex represented covariates of analysis. Descriptive statistics were calculated as the mean per patient for visits and costs related to somatic or biomedical diagnoses (eg, subtracting billing costs for psychiatric diagnoses) by patient age and sex for each outcome group (those with or without psychiatric diagnoses). In the data shown in the results section, costs related to a somatic diagnosis were calculated independently of psychiatric diagnosis costs.
Age ranged from younger than age 1 year to age 17 years. The sample consisted of 150,380 individuals with no psychiatric diagnosis and 54,901 with any psychiatric diagnosis. Approximately half of the sample was female (49%). There were no differences in the distribution of age or sex between the two groups.
Thirty-seven percent of the sample had a psychiatric disorder over the 16-year study period. The mean number of visits related to somatic or biomedical diagnoses for unique individuals in each grouping was as follows: no psychiatric diagnosis, 28; psychiatric diagnosis, 47. Those with a psychiatric disorder had between 1.7 times more visits for somatic disorders on average than those without a psychiatric disorder. Individual patients had an average of 5 visits during the study period related to treatment of psychiatric disorders, at an average cost of $380 per patient.
Figure 1 represents the mean cost of physician billing for somatic or biomedical diagnoses per unique individual for the 2 study groups. For those with any psychiatric disorder, the somatic or biomedical diagnosis costs were 1.8 times higher than those without psychiatric disorders.
There was, however, an age effect (Figure 2). Even though the relative ratios of cost in each age category were approximately the same, overall costs decreased as age increased and were greatest for preschool children. The decrease occurred because the sample was truncated when any patient reached the age of 18 years, thereby representing only pediatric physician visits.
The ACE Study (www.acestudy.org) has described the relationship between health status in adulthood and reported adverse childhood experiences.8-10 The ACE Study has provided a great deal of information related to the reporting of adversity, present health status, and health economy. We are currently seeking how to implement the ACE survey in our publicly funded health system because of substantial health expenditure savings reported with the use of this survey. For example, at Kaiser Permanente in a sample of 125,000 adult patients in one department using such a questionnaire, routinely gathering this information was associated with a 35% reduction in doctor office visits in the subsequent year (Vincent Felitti, MD, personal communication; 2012 Apr 1).a
Furthermore, a recent study has identified the effect of psychiatric morbidity on mortality, noting that the burden of psychiatric illness goes on largely unattended and unnoticed.10 To our knowledge, no population-based studies to date have provided information about the relationship between psychiatric disorder and health status over time. However, in terms of developmental psychopathology, childhood adversity has long been considered a harbinger of psychiatric disturbance and disorder.
Of the randomly selected study group, 37% had a physician billing for a psychiatric disorder. Prior analysis of a 9-year and 16-year dataset, including adult and geriatric data, indicated that 46% of the randomly selected comparison group had a physician billing for a psychiatric disorder.2 Somatic and biomedical disorder costs among those in the psychiatric disorder group were higher than in the group with no psychiatric disorder.2 Furthermore, the psychiatric disorder rate was higher overall (46%) in the sample that included all ages,2 indicating that the somatic morbidity associated with psychiatric disorder increased with age. In our study, we observed that across childhood and adolescence the rate of contact with regional physicians decreased up to the age of 18 years (Figure 2). The psychiatric disorder group had a consistently higher proportion of biomedical and somatic disorder-related costs at each age. The age-related decrement represents the result of truncating all visit dates when any patient reached age 18 years. Hence, a patient who was age 17 years at the index visit would have accumulated fewer visits before his/her 18th birthday than a patient who was 1 year old at the index visit in the first year of the study (1994). Data inclusion was truncated for all patients when they turned 18 years old because this directly reflects the organization of our health care system, especially in psychiatry.
The results of the present large population-based study demonstrated the physical (somatic or biomedical) liability of having a psychiatric disorder in childhood and adolescence. The cost related to somatic or biomedical disorders, given any psychiatric diagnosis, were 1.8 times as high compared with the group with no psychiatric disorder. Similarly, the burden of a somatic or biomedical disorder given the presence of a psychiatric diagnosis also increased in proportion with age to 3.3 times higher in the previously reported sample that included all ages.2
The burden of somatic or biomedical disorders in the psychiatric disorder group emerged early in life (Figure 2) and much earlier than the investment we make in psychiatric care. Considering that the sample size in this study was approximately two thirds of the total base population of those younger than age 18 years in the catchment, the somatic or biomedical diagnosis-related cost burden having any psychiatric disorder becomes paramount, especially given the early-life onset of physical (somatic or biomedical) disorders. Our current dataset holds the potential to examine patterns of emergence and co-occurrence of somatic and psychiatric disorders over time. For example, preliminary results (unpublished data, 2010) indicate that neurotic and anxiety disorders are much more prevalent in the sample and, therefore, have the highest direct (psychiatric) and indirect (physical) physician billing costs in total, even though their per capita cost is comparatively less than other psychiatric diagnoses, such as organic brain syndromes and mental retardation.
There were several limitations of the study. Any physician billing could include costs associated with up to three diagnoses. If any one of these diagnoses was a psychiatric diagnosis, the total cost of that visit was assigned to the total mental health costs for that unique individual. As a result, the total health costs for each unique individual were marginally underestimated if there were additional somatic or biomedical diagnoses associated with a psychiatric diagnosis for a given visit. Multiple diagnoses, however, were associated with a minority of the physician billings. A second limitation was associated with the reliability and validity of the assignment of psychiatric diagnoses by the billing physicians. Compared with specialists, family physicians have limited psychiatric training (given the large number of unspecified psychiatric diagnoses). However, the same threats to validity and reliability were present in the assignment of all psychiatric diagnoses in each of the study groups. We acknowledge that diagnostic precision may be an issue in some instances. Finally, by excluding in the sampling process patients known to have received publicly funded, specialized ambulatory, inpatient, or emergency psychiatric services, the possible differences between the psychiatric and nonpsychiatric groups in this study have been minimized. We were not able to account for additional privately funded health care in either group, however, where available, privately funded health care is not the norm in Canada.
The association between general somatic and biomedical health costs and the health care costs of psychiatric disorder is emerging as an important topic in policy development related to understanding and reducing the burden of mental illness on society.11 However, there have been few systematic population-based health care utilization studies. We examined the health costs in a pediatric population over a 16-year period. The main finding was that health costs of individuals with a psychiatric diagnosis were about twice as high on average per unique patient given any psychiatric diagnosis compared with those without a psychiatric diagnosis. Psychiatric billing costs independently added on to the costs of somatic or biomedical diagnoses. The physical (somatic and biomedical) disorders were directly comparable between the study groups with and without psychiatric disorders, and the ratio of the average costs per individual between these 2 groups over the 16-year period was the main finding of this study. This ratio (2:1) was lower than the ratio observed in the previous study of the 9-year period for a sample of all ages,2 including child, adult, and geriatric populations, suggesting that the physical burden of psychiatric disorder increases with age.
The type of physical problems and the relationship between patterns of biomedical or somatic disorders and specific types of psychiatric disorder remain to be examined. Whereas a specific pattern of association is beyond the scope of the present report, what has been established is the fundamental relationship between the biologic substratum and psychiatric disorder in a form that may be examined exhaustively in a population. The implications for policy and practice are self evident. Psychiatric assessment and treatment, if required, should always include assessment and treatment of physical conditions. Segregated systems of care may, in fact, be detrimental in terms of long-term outcome and more costly in managed health care.
The present dataset holds the potential to reveal the relationships among specific diagnostic groupings that develop and are observed over time. The order of costs by psychiatric diagnoses provides a logical point of entry to examine the patterns of psychiatric and concurrent or prodromal somatic burden that develop over time. Profiles and patterns may emerge from the combinations and permutations in these data, which permit the identification of standard clinical pathways together with their associated costs. Such analysis represents a classic roadmap problem, and given the large numbers of permutations and combinations, it would take many researchers many years to unravel. Hence, we are developing a standardized algorithm to make the time-dependent results from these data accessible to investigators. This information is beginning to form the empirical basis on which to study and measure future innovation related to optimization of clinical pathways.
The main policy implication of the study’s results points to the universal integration of psychiatric and health care structures and processes. Our findings bring to the fore the call to action embodied in the 1977 observation by Engles,12 the father of biopsychosocial theory:
The dominant model of disease today is biomedical, and it leaves no room within this framework for the social, psychological, and behavioral dimensions of illness. A biopsychosocial model is proposed that provides a blueprint for research, a framework for teaching, and a design for action in the real world of health care.
Although Engle’s theory has been refined and advanced over the years, it is our hope that the present study will facilitate detailed examination of the relationships among the “biopsycho” spheres of a representative population.
a Co-Principal Investigator, The Adverse Childhood Experiences (ACE) Study; San Diego, CA
This study was funded, in part, by the Norlien Foundation.
The author(s) have no other conflicts of interest to disclose.
Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.
1. Seligman MEP. Why is there so much depression today? The waxing of the individual and the waning of the commons. Washington, DC: The G Stanley Hall Lecture Series: Vol 9; 1989. p 77-96.
2. Cawthorpe D, Wilkes TC, Guyn L, Li B, Lu M. Association of mental health with health care use and cost: a population study. Can J Psychiatry 2011;56(8):490-4.
3. Wu P, Katic BJ, Liu X, Fan B, Fuller CJ. Mental health service use among suicidal adolescents: findings from a US national community survey. Psychiatr Serv 2010 Jan;61(1):17-24.
4. Wade TJ, Guo JJ. Linking improvements in health-related quality of life to reductions in Medicaid costs among students who use school-based health centers. Am J Public Health 2010 Sep;100(9):1611-6.
5. Yanos PT, Czaja SJ, Widom CS. A prospective examination of service use by abused and neglected children followed up into adulthood. Psychiatr Serv 2010;61(8):796-802.
6. Smith JP, Smith GC. Long-term economic costs of psychological problems during childhood. Soc Sci Med 2010 Jul;71(1):110-5.
7. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998 May;14(4):245-58.
8. Felitti VJ. Adverse childhood experiences and adult health. Acad Pediatr 2009 May-Jun;9(3):131-2.
9. Brown DW, Anda RF, Edwards VJ, Felitti VJ, Dube SR, Giles WH. Adverse childhood experiences and childhood autobiographical memory disturbance. Child Abuse Negl 2007 Sep;31(9):961-9.
10. Brown DW, Anda RF, Felitti VJ, et al. Adverse childhood experiences are associated with the risk of lung cancer: a prospective cohort study. BMC Public Health 2010 Jan 19;(10):20. Erratum in: BMC Public Health 2010;10:311.
11. Lawrence D, Kisely S, Pais J. The epidemiology of excess mortality in people with mental illness. Can J Psychiatry 2010;55(12):752-60.
12. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196(4286):129-36.
More from this Journal section
Nutritional Update for Physicians: Plant-Based Diets
Wednesday, 27 March 2013
Philip J Tuso, MD; Mohamed H Ismail, MD; Benjamin P Ha, MD; Carole Bartolotto, MA, RD Perm J 2013 Spring; 17(2):61-66 http://dx.doi.org/10.7812/TPP/12-085 Abstract The objective of this article is to present to physicians an update on plant-based diets. Concerns about the rising cost of health care are being voiced nationwide, even as unhealthy lifestyles are contributing to the spread of obesity, diabetes, and cardiovascular disease. For these reasons, physicians looking for cost-effective interventions to improve health outcomes are becoming more involved in helping their patients adopt healthier lifestyles. Healthy eating may be best achieved with a plant-based diet, which we define as a regimen that encourages whole, plant-based foods and discourages meats, dairy products, and eggs as well as all refined and processed foods. We present a case study as an example of the potential health benefits of such a diet. Research shows that plant-based diets are cost-effective, low-risk interventions that may lower body mass index, blood pressure, HbA1C, and cholesterol levels. They may also reduce the number of medications needed to treat chronic diseases and lower ischemic heart disease mortality rates. Physicians should consider recommending a plant-based diet to all their patients, especially those with high blood pressure, diabetes, cardiovascular disease, or obesity. Introduction In the HBO documentary The Weight of the Nation, it was noted that if you “go with the flow” in the US, you will eventually become obese.1 In 2011, Witters reported that in some areas of the country, the rate of obesity is 39% and is increasing at a rate of 5% per year.2 Risks of obesity, diabetes, hypertension, and cardiovascular disease, along with their ensuing complications (eg, behavioral health and quality-of-life problems) often go hand-in-hand and are strongly linked to lifestyle, especially dietary choices.3 Of all the diets recommended over the last few decades to turn the tide of these chronic illnesses, the best but perhaps least common may be those that are plant based. Despite the strong body of evidence favoring plant-based diets, including studies showing a willingness of the general public to embrace them,4 many physicians are not stressing the importance of plant-based diets as a first-line treatment for chronic illnesses. This could be because of a lack of awareness of these diets or a lack of patient education resources. National dietary guidelines for active living and healthful eating are available at www.ChooseMyPlate.gov.5 A typical healthful plate of food is 1/2 plant foods (nonstarchy vegetables and fruits), 1/4 whole grains or unprocessed starchy food, and 1/4 lean protein. The goal of this article is to review the evidence supporting plant-based diets and to provide a guideline for presenting them to patients. We start with a case study and conclude with a review of the literature. Case Study A 63-year-old man with a history of hypertension presented to his primary care physician with complaints of fatigue, nausea, and muscle cramps. The result of a random blood glucose test was 524 mg/dL, and HbA1C was 11.1%. Type 2 diabetes was diagnosed. His total cholesterol was 283 mg/dL, blood pressure was 132/66 mmHg, and body mass index (BMI) was 25 kg/m2. He was taking lisinopril, 40 mg daily; hydrochlorothiazide, 50 mg daily; amlodipine, 5 mg daily; and atorvastatin, 20 mg daily. He was prescribed metformin, 1000 mg twice daily; glipizide, 5 mg daily; and 10 units of neutral protamine Hagedom insulin at bedtime. His physician also prescribed a low-sodium, plant-based diet that excluded all animal products and refined sugars and limited bread, rice, potatoes, and tortillas to a single daily serving. He was advised to consume unlimited nonstarchy vegetables, legumes, and beans, in addition to up to 2 ounces of nuts and seeds daily. He was also asked to begin exercising 15 minutes twice a day. The patient was seen monthly in his primary care clinic. Over a 16-week period, significant improvement in biometric outcome measures was observed. He was completely weaned off of amlodipine, hydrochlorothiazide, glipizide, and neutral protamine Hagedorn insulin. Follow-up blood pressure remained below 125/60 mmHg, HbA1C improved to 6.3%, and total cholesterol improved to 138 mg/dL. Lisinopril was gradually decreased to 5 mg daily and his diabetes is controlled with metformin alone, 1000 mg twice daily. Definitions of Plant-Based Diets The presented case is a dramatic example of the effect a plant-based diet can have on biometric outcomes like blood pressure, diabetes, and lipid profile. The reduction in HbA1C from 11.1% to 6.3% in 3 months is much better than would be expected with monotherapy with metformin6 or daily exercise.7 The improvement in blood pressure observed over a 4-month period with few medications is also rarely encountered in clinical practice and is likely related to a low-sodium diet and the avoidance of red meat. Because the patient was not obese and did not have significant weight loss with the diet, the dramatic improvements appear to be related to the quality of his new diet. A healthy, plant-based diet aims to maximize consumption of nutrient-dense plant foods while minimizing processed foods, oils, and animal foods (including dairy products and eggs). It encourages lots of vegetables (cooked or raw), fruits, beans, peas, lentils, soybeans, seeds, and nuts (in smaller amounts) and is generally low fat.8,9 Leading proponents in the field have varying opinions as to what comprises the optimal plant-based diet. Ornish et al recommends allowing animal products such as egg whites and skim milk in small amounts for reversal of disease.10,11 Esselstyn, who directs the cardiovascular prevention and reversal program at the Cleveland Clinic Wellness Institute, recommends completely avoiding all animal-based products as well as soybeans and nuts, particularly if severe coronary artery disease is present.12 Despite these smaller differences, there is evidence that a broadly defined plant-based diet has significant health benefits. It should be noted that the term plant-based is sometimes used interchangeably with vegetarian or vegan. Vegetarian or vegan diets adopted for ethical or religious reasons may or may not be healthy. It is thus important to know the specific definitions of related diets and to ascertain the details of a patient’s diet rather than making assumptions about how healthy it is. The following is a brief summary of typical diets that restrict animal products. A key distinction is that although most of these diets are defined by what they exclude, the plant-based diet is defined by what it includes. Vegan (or total vegetarian): Excludes all animal products, especially meat, seafood, poultry, eggs, and dairy products. Does not require consumption of whole foods or restrict fat or refined sugar. Raw food, vegan: Same exclusions as veganism as well as the exclusion of all foods cooked at temperatures greater than 118°F. Lacto-vegetarian: Excludes eggs, meat, seafood, and poultry and includes milk products. Ovo-vegetarian: Excludes meat, seafood, poultry, and dairy products and includes eggs. Lacto-ovo vegetarian: Excludes meat, seafood, and poultry and includes eggs and dairy products. Mediterranean: Similar to whole-foods, plant-based diet but allows small amounts of chicken, dairy products, eggs, and red meat once or twice per month. Fish and olive oil are encouraged. Fat is not restricted. Whole-foods, plant-based, low-fat: Encourages plant foods in their whole form, especially vegetables, fruits, legumes, and seeds and nuts (in smaller amounts). For maximal health benefits this diet limits animal products. Total fat is generally restricted. Benefits of Plant-Based Diets The goal of our diet should be to improve our health. In this section, we will review the literature for key articles that demonstrate the benefits of plant-based diets. Our review consists of existing studies that include vegan, vegetarian, and Mediterranean diets. Obesity In 2006, after reviewing data from 87 published studies, authors Berkow and Barnard13 reported in Nutrition Reviews that a vegan or vegetarian diet is highly effective for weight loss. They also found that vegetarian populations have lower rates of heart disease, high blood pressure, diabetes, and obesity. In addition, their review suggests that weight loss in vegetarians is not dependent on exercise and occurs at a rate of approximately 1 pound per week. The authors further stated that a vegan diet caused more calories to be burned after meals, in contrast to nonvegan diets which may cause fewer calories to be burned because food is being stored as fat.13 Farmer et al14 suggest that vegetarian diets may be better for weight management and may be more nutritious than diets that include meat. In their study, they showed that vegetarians were slimmer than their meat-eating counterparts. Vegetarians were also found to consume more magnesium, potassium, iron, thiamin, riboflavin, folate, and vitamins and less total fat. The authors conclude that vegetarian diets are nutrient dense and can be recommended for weight management without compromising diet quality.14 In 2009, Wang and Beysoun15 analyzed the nationally representative data collected in the 1999-2004 National Health and Nutrition Examination Survey. The aim of their study was to analyze the associations between meat consumption and obesity. Using linear and logistic regression analyses, they showed that there was a positive association between meat consumption and obesity.15 The Oxford component of the European Prospective Investigation into Cancer and Nutrition assessed changes in weight and BMI over a five-year period in meat-eating, fish-eating, vegetarian, and vegan men and women in the United Kingdom. During the five years of the study, mean annual weight gain was lowest among individuals who had changed to a diet containing fewer animal foods. The study also reported a significant difference in age-adjusted BMI, with the meat eaters having the highest BMI and vegans the lowest.16 Similar results were reported by the Adventist Health Study.17 According to Sabaté and Wien,18 “Epidemiologic studies indicate that vegetarian diets are associated with a lower BMI and a lower prevalence of obesity in adults and children. A meta-analysis of adult vegetarian diet studies estimated a reduced weight difference of 7.6 kg for men and 3.3 kg for women, which resulted in a 2-point lower BMI. Similarly, compared with nonvegetarians, vegetarian children are leaner, and their BMI difference becomes greater during adolescence. Studies exploring the risk of overweight and food groups and dietary patterns indicate that a plant-based diet seems to be a sensible approach for the prevention of obesity in children. Plant-based diets are low in energy density and high in complex carbohydrate, fiber, and water, which may increase satiety and resting energy expenditure.”18 The authors conclude that plant-based dietary patterns should be encouraged for optimal health. Diabetes Plant-based diets may offer an advantage over those that are not plant based with respect to prevention and management of diabetes. The Adventist Health Studies found that vegetarians have approximately half the risk of developing diabetes as nonvegetarians.19 In 2008, Vang et al20 reported that nonvegetarians were 74% more likely to develop diabetes over a 17-year period than vegetarians. In 2009, a study involving more than 60,000 men and women found that the prevalence of diabetes in individuals on a vegan diet was 2.9%, compared with 7.6% in the nonvegetarians.17 A low-fat, plant-based diet with no or little meat may help prevent and treat diabetes, possibly by improving insulin sensitivity and decreasing insulin resistance. Barnard et al21 reported in 2006 the results of a randomized clinical trial comparing a low-fat vegan diet with a diet based on the American Diabetes Association guidelines. People on the low-fat vegan diet reduced their HbA1C levels by 1.23 points, compared with 0.38 points for the people on the American Diabetes Association diet. In addition, 43% of people on the low-fat vegan diet were able to reduce their medication, compared with 26% of those on the American Diabetes Association diet.18 Heart Disease In the Lifestyle Heart Trial, Ornish10 found that 82% of patients with diagnosed heart disease who followed his program had some level of regression of atherosclerosis. Comprehensive lifestyle changes appear to be the catalyst that brought about this regression of even severe coronary atherosclerosis after only 1 year. In his plant-based regimen, 10% of calories came from fat, 15% to 20% from protein, and 70% to 75% from carbohydrate, and cholesterol was restricted to 5 mg per day. Interestingly, 53% of the control group had progression of atherosclerosis. After 5 years, stenosis in the experimental group decreased from 37.8% to 34.7% (a 7.9% relative improvement). The control group experienced a progression of stenosis from 46.1% to 57.9% (a 27.7% relative worsening). Low-density lipoprotein had decreased 40% at 1 year and was maintained at 20% less than baseline after 5 years. These reductions are similar to results achieved with lipid-lowering medications.10,11 In the Lyon Diet Heart Study, a prospective, randomized, secondary prevention trial, de Lorgeril found that the intervention group (at 27 months) experienced a 73% decrease in coronary events and a 70% decrease in all-cause mortality. The intervention group’s Mediterranean-style diet included more plant foods, vegetables, fruits, and fish than meat. Butter and cream were replaced with canola oil margarine. Canola oil and olive oil were the only fats recommended.22 In 1998, a collaborative analysis using original data from 5 prospective studies was reviewed and reported in the journal Public Health Nutrition. It compared ischemic heart disease-specific death rate ratios of vegetarians and nonvegetarians. The vegetarians had a 24% reduction in ischemic heart disease death rates compared with nonvegetarians.23 The lower risk of ischemic heart disease may be related to lower cholesterol levels in individuals who consume less meat.24 Although vegetarian diets are associated with lower risk of several chronic diseases, different types of vegetarians may not experience the same effects on health. The key is to focus on eating a healthy diet, not simply a vegan or vegetarian diet.25 High Blood Pressure In 2010, the Dietary Guidelines Advisory Committee performed a literature review to identify articles examining the effect of dietary patterns on blood pressure in adults. Vegetarian diets were associated with lower systolic blood pressure and lower diastolic blood pressure.25 One randomized crossover trial found that a Japanese diet (low sodium and plant based) significantly reduced systolic blood pressure.27 Mortality The Dietary Guidelines Advisory Committee also performed a 2010 literature review to determine the effect of plant-based diets on stroke, cardiovascular disease, and total mortality in adults. They found that plant-based diets were associated with a reduced risk of cardiovascular disease and mortality compared with non-plant-based diets.26 The benefit of plant-based diets on mortality may be primarily caused by decreased consumption of red meat.28 Several studies have documented the benefits of avoiding excessive consumption of red meat, which is associated with an increased risk of all-cause mortality and an increased risk of cardiovascular mortality.29 Low meat intake has been associated with longevity.30 In 2012, Huang et al31 performed a meta-analysis to investigate cardiovascular disease mortality among vegetarians and nonvegetarians. They only included studies that reported relative risks and corresponding 95% confidence intervals. Seven studies with a combined total of 124,706 participants were analyzed. Vegetarians had 29% lower ischemic heart disease mortality than nonvegetarians.31 Health Concerns About Plant-Based Diets Protein Generally, patients on a plant-based diet are not at risk for protein deficiency. Proteins are made up of amino acids, some of which, called essential amino acids, cannot be synthesized by the body and must be obtained from food. Essential amino acids are found in meat, dairy products, and eggs, as well as many plant-based foods, such as quinoa.32 Essential amino acids can also be obtained by eating certain combinations of plant-based foods. Examples include brown rice with beans, and hummus with whole wheat pita. Therefore, a well-balanced, plant-based diet will provide adequate amounts of essential amino acids and prevent protein deficiency.33 Soybeans and foods made from soybeans are good sources of protein and may help lower levels of low-density lipoprotein in the blood34 and reduce the risk of hip fractures35 and some cancers. A study in the Journal of the American Medical Association36 reported that women with breast cancer who regularly consumed soy products had a 32% lower risk of breast cancer recurrence and a 29% decreased risk of death, compared with women who consumed little or no soy.36 An analysis of 14 studies, published in the American Journal of Clinical Nutrition, showed that increased intake of soy resulted in a 26% reduction in prostate cancer risk.37 Because of concerns over the estrogenic nature of soy products, women with a history of breast cancer should discuss soy foods with their oncologists. Also, overly processed, soy-based meat substitutes are often high in isolated soy proteins and other ingredients that may not be as healthy as less processed soy products (ie, tofu, tempeh, and soy milk). Iron Plant-based diets contain iron, but the iron in plants has a lower bioavailability than the iron in meat. Plant-based foods that are rich in iron include kidney beans, black beans, soybeans, spinach, raisins, cashews, oatmeal, cabbage, and tomato juice.38 Iron stores may be lower in individuals who follow a plant-based diet and consume little or no animal products. However, the American Dietetic Association states that iron-deficiency anemia is rare even in individuals who follow a plant-based diet.39 Vitamin B12 Vitamin B12 is needed for blood formation and cell division. Vitamin B12 deficiency is a very serious problem and can lead to macrocytic anemia and irreversible nerve damage. Vitamin B12 is produced by bacteria, not plants oranimals. Individuals who follow a plant-based diet that includes no animal products may be vulnerable to B12 deficiency40 and need to supplement their diet with vitamin B12 or foods fortified with vitamin B12.41 Calcium and Vitamin D Calcium intake can be adequate in a well-balanced, carefully planned, plant-based diet. People who do not eat plants that contain high amounts of calcium may be at risk for impaired bone mineralization and fractures. However, studies have shown that fracture risk was similar for vegetarians and nonvegetarians. The key to bone health is adequate calcium intake, which appears to be irrespective of dietary preferences.42 Some significant sources of calcium include tofu, mustard and turnip greens, bok choy, and kale. Spinach and some other plants contain calcium that, although abundant, is bound to oxalate and therefore is poorly absorbed.43 Vitamin D deficiency is common in the general population. Plant-based products such as soy milk and cereal grains may be fortified to provide an adequate source of Vitamin D.44 Supplements are recommended for those who are at risk for low bone mineral density and for those found to be deficient in vitamin D. Fatty Acids Essential fatty acids are fatty acids that humans must ingest for good health because our bodies do not synthesize them. Only two such essential fatty acids are known: linoleic acid (an omega-6 fatty acid) and alpha-linolenic acid (an omega-3 fatty acid). Three other fatty acids are only conditionally essential: palmitoleic acid (a monounsaturated fatty acid), lauric acid (a saturated fatty acid), and gamma-linolenic acid (an omega-6 fatty acid). Deficiency in essential fatty acids may manifest as skin, hair, and nail abnormalities.45 The fatty acids that vegans are most likely to be deficient in are the omega-3 fats (n-3 fats). Consumptions of the plant version of omega-3 fats, alpha-linolenic acid, are also low in vegans. Adequate intake of n-3 fats is associated with a reduced incidence of heart disease and stroke. Foods that are good sources of n-3 fats should be emphasized. They include ground flax seeds, flax oil, walnuts, and canola oil.46 Conclusion A healthy, plant-based diet requires planning, reading labels, and discipline. The recommendations for patients who want to follow a plant-based diet may include eating a variety of fruits and vegetables that may include beans, legumes, seeds, nuts, and whole grains and avoiding or limiting animal products, added fats, oils, and refined, processed carbohydrates. The major benefits for patients who decide to start a plant-based diet are the possibility of reducing the number of medications they take to treat a variety of chronic conditions, lower body weight, decreased risk of cancer, and a reduction in their risk of death from ischemic heart disease. A plant-based diet is not an all-or-nothing program, but a way of life that is tailored to each individual. It may be especially beneficial for those with obesity, Type 2 diabetes, high blood pressure, lipid disorders, or cardiovascular disease. The benefits realized will be relative to the level of adherence and the amount of animal products consumed. Strict forms of plant-based diets with little or no animal products may be needed for individuals with inoperable or severe coronary artery disease. Low-sodium, plant-based diets may be prescribed for individuals with high blood pressure or a family history of coronary artery disease or stroke. A patient with obesity and diabetes will benefit from a plant-based diet that includes a moderate amount of fruits and vegetables and minimal low-fat animal products. Severe obesity may require counseling and initial management with a low-calorie diet or very-low-calorie diet and the supervision of a physician’s team. Patients with kidney disease may need a plant-based diet with special restrictions, for example fruits and vegetables that are high in potassium and phosphorus. Finally, patients with thyroid disease will need to be careful when consuming plants that are mild goitrogens, like soy, raw cruciferous vegetables, sweet potatoes, and corn. These patients should be informed that cooking these vegetables inactivates the goitrogens. Physicians should advocate that it is time to get away from terms like vegan and vegetarian and start talking about eating healthy, whole, plant-based foods (primarily fruits and vegetables) and minimizing consumption of meat, eggs, and dairy products. Physicians should be informed about these concepts so they can teach them to staff and patients. A registered dietitian should be part of the health care team that designs a plant-based diet for patients with chronic disease, especially if multiple medications are involved. Depending on the underlying conditions, patients with chronic disease who take multiple medications need close monitoring of low blood sugar levels, low blood pressure, or rapid weight loss. If these occur, the physician may need to adjust medications. In some cases, such as the one presented here, the need for certain medications can be eliminated altogether. Although the risk of deficiencies may be low, health care teams need to be aware that a motivated patient on a strict plant-based diet may need monitoring for deficiencies of certain nutrients, as outlined above. The purpose of this article is to help physicians understand the potential benefits of a plant-based diet, to the end of working together to create a societal shift toward plant-based nutrition. There is at least moderate-quality evidence from the literature that plant-based diets are associated with significant weight loss and a reduced risk of cardiovascular disease and mortality compared with diets that are not plant based. These data suggest that plant-based diets may be a practical solution to prevent and treat chronic diseases. Further research is needed to find ways to make plant-based diets the new normal for our patients and employees. We cannot cure chronic diseases, but we may be able to prevent and control them by changing how we eat. With education and monitoring for adherence, we can improve health outcomes. Patterns of families and other colleagues who may be reluctant to support the efforts of individuals who are trying to change are a challenge to be overcome. We should invite our colleagues, patients, and their families to a shared decision-making process with the goal of adopting a plant-based diet and a regular exercise program. We should invite health care teams to complete a course on healthy eating and active living. We should encourage staff to be knowledgeable about plant-based nutrition. Finally, we should encourage performance-driven measurable outcomes, which may include: the percentage of physicians who have completed a course on nutrition that includes a discussion of the benefits of a plant-based diet and exercise; the percentage of our hospitals, cafeterias, and physicians’ meeting facilities that serve meals that are consistent with a plant-based diet; the percentage of patients on a physician panel who are obese and who have completed a course on weight management and nutrition that emphasizes a plant-based diet; and the percentage of patients in a physician panel with high blood pressure, diabetes, high cholesterol, or cardiovascular disease who completed a course on nutrition that emphasizes a plant-based diet. Too often, physicians ignore the potential benefits of good nutrition and quickly prescribe medications instead of giving patients a chance to correct their disease through healthy eating and active living. If we are to slow down the obesity epidemic and reduce the complications of chronic disease, we must consider changing our culture’s mind-set from “live to eat” to “eat to live.” The future of health care will involve an evolution toward a paradigm where the prevention and treatment of disease is centered, not on a pill or surgical procedure, but on another serving of fruits and vegetables. Disclosure statement The author(s) have no conflicts of interest to disclose. Acknowledgment Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance. References 1. HBO Documentary Films; Institute of Medicine of the National Academies; Centers for Disease Control and Prevention; National Institutes of Health; Michael and Susan Dell Foundation; Kaiser Permanente. The weight of the nation [documentary]. New York, NY: Home Box Office, Inc; 2012. Available from: http://theweightofthenation.hbo.com/?cmpid=ABC1213. 2. Witters D. More than 15% obese in nearly all US metro areas [monograph on the Internet]. Washington, DC: Gallup Wellbeing; 2012 Mar 7 [cited 2012 Oct 6]. Available from: www.gallup.com/poll/153143/Obese-Nearly-Metro-Areas.aspx. 3. US Department of Health and Human Services. The surgeon general’s call to action to prevent and decrease overweight and obesity [monograph on the Internet]. Rockville, MD: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001 [cited 22 Jan 2013]. Available from: www.surgeongeneral.gov/library/calls/obesity/index.html. 4. Lea EJ, Crawford D, Worsley A. Public views of the benefits and barriers to the consumption of a plant-based diet. Eur J Clin Nutr 2006 Jul;60(7):828-37. DOI: http://dx.doi.org/10.1038/sj.ejcn.1602387 5. ChooseMyPlate.gov [homepage on the Internet]. Alexandria, VA: US Department of Agriculture, Center for Nutrition Policy and Promotion; [cited 2013 Jan 31]. Available from: www.choosemyplate.gov/. 6. Ito H, Ishida H, Takeuchi Y, et al. Long-term effects of metformin on blood glucose control in non-obese patients with type 2 diabetes mellitus. Nutr Metab (Lond) 2010 Nov 12;7:83. DOI: http://dx.doi.org/10.1186/1743-7075-7-83 7. Sigal RJ, Kenny GP, Boulé NG, et al. Effects of aerobic training, resistance training, or both on glycemic control in type 2 diabetes: a randomized trial. Ann Intern Med 2007 Sep 18;147(6):357-69. 8. Blaney D, Diehl H. The optimal diet: the official CHIP cookbook. Hagerstown, MD: Autumn House Publishing; 2009 Jan 1. 9. McDougall, JA, McDougall M. (1997). The new McDougall cookbook: 300 delicious ultra-low-fat recipes. New York, NY: Plume; 1997 Jan 1. 10. Ornish D, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet 1990 Jul 21;336(8708):129-33. DOI: http://dx.doi.org/10.1016/0140-6736(90)91656-U 11. Ornish D, Scherwitz LW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA 1998 Dec 16;280(23):2001-7. DOI: http://dx.doi.org/10.1001/jama.280.23.2001 12. Esselstyn CB Jr. Prevent and reverse heart disease: q & a with Caldwell B Esselstyn, Jr, MD [monograph on the Internet]. Lyndhurst, OH: Prevent and Reverse Heart Disease; [cited 2012 Oct 6]. Available from: www.heartattackproof.com/qanda.htm. 13. Berkow SE, Barnard N. Vegetarian diets and weight status. Nutr Rev 2006 Apr;64(4):175-88. DOI: http://dx.doi.org/10.1111/j.1753-4887.2006.tb00200.x 14. Farmer B, Larson BT, Fulgoni VL 3rd, Rainville AJ, Liepa GU. A vegetarian dietary pattern as a nutrient-dense approach to weight management: an analysis of the national health and nutrition examination survey 1999-2004. J Am Diet Assoc 2011 Jun;111(6):819-27. DOI: http://dx.doi.org/10.1016/j.jada.2011.03.012 15. Wang Y, Beydoun MA. Meat consumption is associated with obesity and central obesity among US adults. Int J Obes (Lond) 2009 Jun;33(6):621-8. DOI: http://dx.doi.org/10.1038/ijo.2009.45 16. Rosell M, Appleby P, Spencer E, Key T. Weight gain over 5 years in 21,966 meat-eating, fish-eating, vegetarian, and vegan men and women in EPIC-Oxford. Int J Obes (Lond) 2006 Sep;30(9):1389-96. DOI: http://dx.doi.org/10.1038/sj.ijo.0803305 17. Tonstad S, Butler T, Yan R, Fraser GE. Type of vegetarian diet, body weight, and prevalence of type 2 diabetes. Diabetes Care 2009 May;32(5):791-6. DOI: http://dx.doi.org/10.2337/dc08-1886 18. Sabaté J, Wien M. Vegetarian diets and childhood obesity prevention. Am J Clin Nutr 2010 May;91(5):1525S-1529S. DOI: http://dx.doi.org/10.3945/ajcn.2010.28701F 19. Snowdon DA, Phillips RL. Does a vegetarian diet reduce the occurrence of diabetes? Am J Public Health 1985 May;75(5):507-12. DOI: http://dx.doi.org/10.2105/AJPH.75.5.507 20. Vang A, Singh PN, Lee JW, Haddad EH, Brinegar CH. Meats, processed meats, obesity, weight gain and occurrence of diabetes among adults: findings from Adventist Health Studies. Ann Nutr Metab 2008;52(2):96-104. DOI: http://dx.doi.org/10.1159/000121365 21. Barnard ND, Cohen J, Jenkins DJ, et al. A low-fat vegan diet improves glycemic control and cardiovascular risk factors in a randomized clinical trial in individuals with type 2 diabetes. Diabetes Care 2006 Aug;29(8):1777-83. DOI: http://dx.doi.org/10.2337/dc06-0606 22. de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation 1999 Feb;99(6):779-85. DOI: http://dx.doi.org/10.1161/01.CIR.99.6.779 23. Key TJ, Fraser GE, Thorogood M, et al. Mortality in vegetarians and non-vegetarians: a collaborative analysis of 8300 deaths among 76,000 men and women in five prospective studies. Public Health Nutr 1998 Mar;1(1):33-41. DOI: http://dx.doi.org/10.1079/PHN19980006 24. Appleby PN, Thorogood M, McPherson K, Mann JI. Associations between plasma lipid concentrations and dietary, lifestyle and physical factors in the Oxford Vegetarian Study. J Hum Nutr Diet 1995 Oct;8(5):305-14. DOI: http://dx.doi.org/10.1111/j.1365-277X.1995.tb00324.x 25. Fraser GE. Vegetarian diets: what do we know of their effects on common chronic diseases? Am J Clin Nutr 2009;89(5):1607S-1612S. DOI: http://dx.doi.org/10.3945/ajcn.2009.26736KErratum in: Am J Clin Nutr 2009 Jul;90(1):248. DOI: http://dx.doi.org/10.3945/ajcn.2009.27933 26. Report of the Dietary Guidelines Advisory Committee on the dietary guidelines for Americans, 2010: to the Secretary of Agriculture and the Secretary of Health and Human Services. Washington, DC: Agriculture Research Service, US Department of Agriculture, US Department of Health and Human Services; 2010 May. 27. Takahashi Y, Sasaki S, Okubo S, Hayashi M, Tsugane S. Blood pressure change in a free-living population-based dietary modification study in Japan. J Hypertens. 2006 Mar;24(3):451-8. DOI: http://dx.doi.org/10.1097/01.hjh.0000209980.36359.16 28. Singh PN, Sabaté J, Fraser GE. Does low meat consumption increase life expectancy in humans? Am J Clin Nutr 2003 Sep;78(3 Suppl):526S-532S. 29. Campbell TC, Campbell TM II. The China study: the most comprehensive study of nutrition ever conducted and the startling implications for diet, weight loss and long-term health. Dallas, TX: BenBella Books; 2006 May 11. 30. Sinha R, Cross AJ, Graubard BI, Leitzmann MF, Schatzkin A. Meat intake and mortality: a prospective study of over half a million people. Arch Intern Med 2009 Mar 23;169(6):562‑71. DOI: http://dx.doi.org/10.1001/archinternmed.2009.6 31. Huang T, Yang B, Zheng J, Li G, Wahlqvist ML, Li D. Cardiovascular disease mortality and cancer incidence in vegetarians: a meta-analysis and systematic review. Ann Nutr Metab 2012;60(4):233-40. DOI: http://dx.doi.org/10.1159/000337301 32. Nutritiondata.self.com [web page on the Internet]. Soybeans, mature seeds, raw. New York, NY: Condé Nast; 2012 [cited 2012 Oct 6]. Available from: http://nutritiondata.self.com/facts/legumes-and-legume-products/4375/2. 33. Young VR, Pellett PL. Plant proteins in relation to human protein and amino acid nutrition. Am J Clin Nutr 1994 May;59(5 Suppl):1203S-1212S. 34. Pipe EA, Gobert CP, Capes SE, Darlington GA, Lampe JW, Duncan AM. Soy protein reduces serum LDL cholesterol and the LDL cholesterol: HDL cholesterol and apolipoprotein B: apolipoprotein A-I ratios in adults with type 2 diabetes. J Nutr 2009 Sep;139(9):1700-6. DOI: http://dx.doi.org/10.3945/jn.109.109595 35. Koh WP, Wu AH, Wang R, et al. Gender-specific associations between soy and risk of hip fracture in the Singapore Chinese Health Study. Am J Epidemiol 2009 Oct 1;170(7):901-9. DOI: http://dx.doi.org/10.1093/aje/kwp220 36. Shu XO, Zheng Y, Cai H, et al. Soy food intake and breast cancer survival. JAMA 2009 Dec 9;302(22):2437-43. DOI: http://dx.doi.org/10.1001/jama.2009.1783 37. Yan L, Spitznagel EL. Soy consumption and prostate cancer risk in men: a revisit of a meta-analysis. Am J Clin Nutr 2009 Apr;89(4):1155-63. DOI: http://dx.doi.org/10.3945/ajcn.2008.27029 38. Waldmann A, Koschizke JW, Leitzmann C, Hahn A. Dietary iron intake and iron status of German female vegans: results of the German vegan study. Ann Nutr Metab 2004;48(2):103-8. DOI: http://dx.doi.org/10.1159/000077045 39. Craig WJ, Mangels AR; American Dietetic Association. Position of the American Dietetic Association: vegetarian diets. J Am Diet Assoc 2009 Jul;109(7):1266-82. DOI: http://dx.doi.org/10.1016/j.jada.2009.05.027 40. Donaldson MS. Metabolic vitamin B12 status 1on a mostly raw vegan diet with follow-up using tablets, nutritional yeast, or probiotic supplements. Ann Nutr Metab 2000;44 (5-6):229-34. DOI: http://dx.doi.org/10.1159/000046689 41. Dietary supplement fact sheet: vitamin B12 [monograph on the Internet]. Bethesda, MD: National Institutes of Health, Office of Dietary Supplements; 2011 Jun 24 [cited 2013 Jan 31. Available from: http://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/. 42. Appleby P, Roddam A, Allen N, Key T. Comparative fracture risk in vegetarians and non-vegetarians in EPIC-Oxford. Eur J Clin Nutr 2007 Dec;61(12):1400-6. DOI: http://dx.doi.org/10.1038/sj.ejcn.1602659 43. Weaver CM, Plawecki KL. Dietary calcium: adequacy of a vegetarian diet. Am J Clin Nutr 1994 May;59(5 Suppl):1238S-1241S. 44. Dietary supplement fact sheet: vitamin D [monograph on the Internet]. Bethesda, MD: National Institutes of Health, Office of Dietary Supplements; 2011 Jun 24 [cited 2013 Jan 31. Available from: http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/. 45. Rosell MS, Lloyd-Wright Z, Appleby PN, Sanders TA, Allen NE, Key TJ. Long-chain n-3 polyunsaturated fatty acids in plasma in British meat-eating, vegetarian, and vegan men. Am J Clin Nutr 2005 Aug;82(2):327-34. 46. Davis BC, Kris-Etherton PM. Achieving optimal essential fatty acid status in vegetarians: current knowledge and practical implications. Am J Clin Nutr 2003 Sep;78(3 Suppl):640S-646S.
Proactive Office Encounter: A Systematic Approach to Preventive and Chronic Care at Every Patient Encounter
Monday, 30 August 2010
2009 James A Vohs Award for Quality Michael Kanter, MD; Osvaldo Martinez, MPH; Gail Lindsay, RN; Kristen Andrews; Cristine Denver, SM Fall 2010 - Volume 14 Number 3 Abstract In 2007, Kaiser Permanente’s (KP) Southern California Region designed and implemented a systematic in-reach program, the Proactive Office Encounter (POE), to address the growing needs of its three million patients for preventive care and management of chronic disease. The program sought staff from both primary and specialty care departments to proactively identify gaps in care and to assist physicians in closing those gaps. The POE engaged the entire health team in a proactive patient-care experience, creating standard work flows and using information technology to identify gaps in patient care. The goals were to improve consistency of preventive care and improve quality of care for chronic conditions and to improve reliability of staff support for physicians. The POE has been implemented in all outpatient settings in KP’s Southern California Region’s 13 medical centers and 148 medical office buildings. The program has contributed to significant improvements in key clinical quality metrics, including cancer screenings, blood pressure control, and tobacco cessation. It is now being extended into the inpatient setting and is being shared with other KP Regions. Introduction “The necessity of living with a limited supply of physicians in the face of increasing demand forces us to focus on the need for a medical care delivery system that utilizes scarce and costly medical manpower properly.”1 Sidney Garfield, MD, the co-founder of Kaiser Permanente (KP), wrote those words in 1970 for an article that appeared in Scientific American (reprinted in the Summer 2006 issue of The Permanente Journal), but they could well have been written today to describe the growing demands on primary care, particularly for preventive care and management of chronic disease. The medical literature reports that for a primary care physician to ensure that all patients on a hypothetical panel of 2000 receive the preventive screenings and treatment of chronic diseases that they need, the primary care physician would need to devote an estimated 18 hours per day.2,3 That being the case, it is hardly surprising that only 54.9% of adult patients receive the preventive care recommended by medical evidence.4 (SCPMG) now serves more than three million KP patients, generating 12 million visits to outpatient offices with 60% of these visits occurring outside of primary care. The concept of the Proactive Office Encounter (POE) began as a question: How can we turn each of these encounters, in either primary or specialty care, into preventive screenings and care for chronic conditions? This is a simple idea to describe, but implementing it meant a cultural shift. The POE, a regionwide in-reach program, gave ancillary staff and specialty departments more responsibility for preventive screenings and management of chronic care. To succeed, the team had to convince administrators, physicians, and staff of its potential value. Other key elements included: Electronic tools to identify gaps in any patient’s care, regardless of which department they visited New work flows and training modules to proactively identify gaps in care to draw them to a physician’s attention Reports to monitor improvement in closing gaps and to identify areas needing more support. Team members are noted in Table 1. Staff now play a more active role in patient care and the culture has changed so that specialty departments are also responsible for identifying and addressing preventive screenings and chronic care needs. Since its inception, POE has contributed to sharp improvement in the Southern California Region’s clinical quality performance, including double-digit improvements in colorectal cancer screening, advice to quit smoking, and blood pressure control. Electronic Tools: Step 1 in the Proactive Office Encounter Early attempts made to systematically identify and address preventive care needs were less comprehensive than the POE; for example, a few years ago, identifying needs required a manual search through a patient’s chart and use of a paper checklist (the Care Management Summary Sheet) to identify preventive screenings and gaps in chronic care. The Pharmacy Analytic Services group converted the paper to an electronic checklist on its Permanente Online Interactive Network Tools (POINT) database, though it was not used consistently in all medical offices until integrated into KP HealthConnect, the electronic medical record (EMR). The electronic POE tools provide physicians and staff with adult primary care, specialty care, and pediatric care checklists (Figure 1), which identify gaps to be addressed and recommended actions. For example, a patient due for a bone-density test or mammogram had a pending order set up and an appointment made for the required examination. Additionally, the POE team created shortcuts known as SmartTools within KP HealthConnect to improve efficiency in the medical office. By scrolling through a list of common preventive care needs, a nurse or medical assistant can set up pending orders for screening examinations or supplies, immunizations, or laboratory tests and can select and print appropriate patient information on topics ranging from body mass index to tobacco cessation. Using “SmartPhrases,” staff can document preventive or chronic care actions taken. Early Technical Challenges Initially, patient information in POINT and KP HealthConnect was not integrated, creating confusion and mistrust early in the implementation of the POE tool, because alerts were sometimes inaccurate or redundant. The project team worked with Pharmacy Analytics Services and the KP HealthConnect team to integrate the POINT database and the EMR. The team added functionality to document or to set up pending orders, streamlining these processes to make the POE tool more efficient and user-friendly. Methods Developing and Implementing New Work Flows: Step 2 in the Proactive Office Encounter Information technology alone is not sufficient to transform the approach to preventive and chronic care. A standardized structure of work flows and processes was built to address individual care gaps in every outpatient setting (Table 2), to increase efficiency and to improve the reliability and consistency of staff support for physicians. The POE includes three main components, detailed in the next section (Figure 2). Before an Encounter (Pre Encounter) Before a patient comes in, a medical assistant or nurse reviews the patient’s record to identify needed laboratory tests and health screenings, and to determine whether the patient is registered with KP.org, which gives the patient online access to most laboratory results, prescription and immunization status, and the opportunity to e-mail the physician’s office. During an Encounter (Office Encounter) In the office, the nurse or medical assistant follows a standard workflow (Figure 3) that includes reviewing and updating documentation of the patient’s chief complaint, vital signs, physical activity levels, medications, allergies, and preferred pharmacy. The nurse or medical assistant then: identifies gaps in care using decision-support tools sets up any necessary pending orders and/or exclusion codes for the clinician flags needed screenings and/or uncontrolled conditions for the clinician to discuss during the visit prepares the patient and examination room for procedures (eg, Papanicolaou test, diabetic foot examination, etc), and assists the clinician through the process. After an Encounter (Post Encounter) Immediately after the visit, the medical assistant or nurse ensures that the patient receives information to obtain preventive screenings or to address health issues, including providing an after-visit summary, after-care instructions, health education materials, information on accessing KP.org, and follow-up appointments or referrals. In addition, the patient may be contacted after the visit at the clinician’s direction. Managing the Change Because the POE represented a cultural shift, it therefore required a comprehensive change in management approach. In 2007, the POE team widely presented the concept to internal audiences, including Medical Directors, Chiefs, nonphysician administrative leaders, and department managers. One challenge was ensuring that tasks remained within the scope of practice for medical assistants and nurses. They identified physicians and administrators who could serve as POE team leads at the local level. The team also developed extensive training materials for both preventive screenings and management of chronic conditions. Participants learned to use the tools and to perform new tasks, for example, communication tips about sensitive patient issues, such as weight. It also provided instructions on how to prepare the patient and the examination room for specific procedures, such as a diabetic foot examination. Persuading people to work in a new way meant engaging them emotionally. To demonstrate the difference that nonphysician staff can make identifying care gaps, the POE team worked with California’s Multimedia Department to produce videos of patients telling how an early screening made a difference in their lives. The videos, which have since been shown in internal meetings and are available on KP’s Intranet, included patients’ physicians and key staff (including receptionists, medical assistants, and nurses). By the end of 2007, all primary care offices trained for the POE. The following year, specialty care staff trained on a streamlined version of the program. In 2009, staff in Urgent Care and Emergency Departments (ED) used work flows for the POE. Those concepts now extend to inpatient settings, with four pilot studies underway. Results Measuring Improvement: Step 3 in the Proactive Office Encounter SCPMG measured the program’s success by tracking Healthcare Effectiveness Data and Information Set results on a bimonthly basis. In addition, SCPMG developed a new set of reports (dubbed “Successful Opportunities”) to measure improvements specific to the POE (Table 3). These reports monitor the frequency of care gaps closure within 30 days of an appointment, including lead, chlamydia, and osteoporosis screening (dual energy x-ray absorptiometry, or DEXA); pneumococcal immunizations; documentation of height and weight to capture body mass index; asthma questionnaire completion; and health education class attendance. These reports are e-mailed to regional leaders, medical center leaders, and local POE leads for identification of strengths and areas for improvement. Specialists in SCPMG have some of their at-risk moneys contingent on their performance on the Successful Opportunities Report. This has been an important step in getting the specialists involved in the POE. The conclusions drawn from the analysis of these data reveal increased success in closing care gaps at every opportunity resulting in a 2% to 18.5% range of improvement in clinical quality for the conditions of diabetes, cancer, immunization, blood pressure, and smoking (Table 4). Future Potential for the Proactive Office Encounter In the outpatient setting, the POE allowed a shift from a reactive care-delivery model to one that is consistently proactive in addressing preventive and chronic care needs. Because SCPMG is part of an integrated system that includes Kaiser Foundation Health Plan and Hospitals, there are more opportunities to expand and embed this approach throughout the organization where patients may seek care, from appointment call centers to hospital discharge. In the near future, SCPMG intends to implement the POE in pharmacy and inpatient settings. Deployment in EDs and urgent-care settings is already in progress. Pre-encounter automated telephone calls were also piloted in 2008 and were deployed throughout SCPMG by year end. Automated pre-encounter calls target patients with HbA1c, lipid, and/or microalbumin laboratory care gaps and ask that they complete the necessary tests before their office visit to maximize their encounter with their clinician. Implementing a proactive approach to care also involves continual improvement to the work flows already developed and requires refining the outpatient encounter with specialty-specific work flows, which are in development, for obstetrics, oncology, and nephrology. With modification of the work flow training materials for SCPMG, other KP Regions could adopt a similar proactive approach, because other Regions have access to the same KP HealthConnect functionality and SmartTools required to support proactive care. Fully implementing this would require processes and structures for staff and physicians to use those electronic tools to close care gaps. That will require a comprehensive change in management approach, including a communication strategy and an extensive training program. More information and educational videos, job aides, and reference sheets are available from: http://proactivecare.kp.org. KP’s Hawaii Region is now adopting a proactive care approach, embracing principles of the POE. In KP’s Mid-Atlantic Region, an ophthalmologist who saw an 82-year-old patient ordered a DEXA scan, which showed osteoporosis (Janice M Beaverson, MD, personal communication, March 2010).a There is much external interest, including in community clinics in Southern California and professional and national health organizations. Conclusion The project’s impact has been widespread and positive, changing the organization’s culture and providing a powerful tool for physician’s, staff, and patients. Proactive care is now an expectation of care delivery. Barriers encountered by the team were overcome through a collaborative approach, which involved labor partners, physicians, and leaders in the implementation from the early stages. Correlation data show a positive impact on the delivery of quality care. a Janice Beaverson, MD, Associate Medical Director, Quality and Health Management for the Mid-Atlantic Permanente Medical Group, Rockville, MA. Disclosure Statement The author(s) have no conflicts of interest to disclose. Acknowledgment Katharine O’Moore-Klopf, ELS, of KOK Edit provided editorial assistance. References 1. Garfield SR. The delivery of medical care. Sci Am 1970 Apr;222(4):15–23. (Reprinted in Perm J 2006 Summer;10:46–55.) 2. Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005 May–Jun;3(3):209–14. 3. Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003 Apr;93(4):635–41. 4. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003 Jun 26;348(26):2635–45
Primary Care DirectConnect: How the Marriage of Call Center Technology and the EMR Brought Dramatic Results—A Service Quality Improvement Study
Thursday, 27 May 2010
Brent Bowman, MBA;
Scott Smith, MD Summer 2010 - Volume 14 Number 2 Abstract Of the key Health Plan patient satisfaction measures used in Kaiser Permanente Colorado, ease of contacting the physician’s office with a medical question was consistently rated as the lowest quarterly patient satisfaction measure. Furthermore, medical office staff had become dissatisfied with their inability to contact patients who had previously left messages. In addition to the shear volume of messages, the return calls were often unanswered, leading to subsequent attempts to reach patients, creating additional work for medical office staff. DirectConnect—the project name for a system and set of processes focused on improving patient satisfaction with the ability to contact Primary Care delivery teams by telephone—focuses on isolating medical advice calls from the other types of calls handled by the centralized Call Center. The system identifies the patient using his/her unique electronic medical record number, then automatically routes medical advice calls directly to the appropriate Primary Care Physician (PCP) or staff. The clinician may then evaluate and respond to the patient’s need quickly, thus managing more of their panel’s requests in real time. How is DirectConnect different from simply having the patient contact their PCP’s office directly? The primary difference is “one-number” convenience that allows all patients to dial one number to access their PCP’s team. In addition, calls are routed to various staff as available to reduce long telephone queues and wait times. The DirectConnect system has resulted in statistically significant improvement in key service quality measures. Patient satisfaction improved from a pre-implementation nine quarter mean of 55.9% to a post-implementation 12 quarter mean of 70.2%. Fourteen percent to 17% of all Primary Care calls are now handled by the patient’s home medical office team, creating a 54% improvement in the centralized Call Center’s speed of answering calls in the first quarter post implementation—making no additions to medical office staffing levels. The efficiencies gained by directly connecting medical advice-seeking patients with their Primary Care team resulted in an estimated savings of 198 and 247 cumulative hours per week in unnecessary telephone work for Call Center and medical office staff regionwide. Introduction Problem Definition For the nine quarters prior to DirectConnect’s implementation, on average only 55% of Kaiser Permanente Colorado (KPCO) patients rated the ability to contact their physician as “extremely easy” or “easy” with a range between 44% and 59% (Figure 1). This served as evidence of KPCO’s “big system” feel when compared to its care delivery competitors. Patients routinely expressed their frustration with the process of leaving a message with someone they didn’t know (Call Center agent) and awaiting a call back at some unpredictable time in the future. The following patient comments on the system of leaving telephone messages were documented in KPCO’s QIII 2005 and QIV 2005 patient satisfaction study:. “It makes it more difficult to wait for them to call back. It might be sometime later in the day, so it’s not convenient because you don’t know when they could call you back.” “It is just hard to give them a call back number if you don’t know where you are going to be and they can’t tell you exactly when [they will] call.” “I would tell [KPCO] that they need to have a different way to actually contact a physician or triage nurse when needed, a lot easier than it is now.” Before DirectConnect, patients with a medical question would call the regional Primary Care Call Center with the hope of speaking with someone from their home medical office. Instead, centralized Call Center agents, located away from all primary care medical office buildings were forced to use an electronic message to route questions to the appropriate medical office building. Patients then awaited a return call from their trusted Primary Care team. Although patients ultimately received the appropriate level of care, the process rarely met preferred service expectations. Beyond the well-documented issues of poor patient satisfaction, the internal system of managing telephone messages was fraught with waste and rework—although the full extent of this waste and rework had not been formally quantified. From the centralized Call Center perspective, inbound call volumes were projected to increase at a rate of 3% to 10% per year and the ability to increase staffing was not available. These challenges resulted in 64% of calls answered within 60 seconds for the year prior to implementation of DirectConnect with an average speed to answer calls of 101 seconds during that period. These statistics are evidence of less than desired telephone service for any need related to Primary Care, be it for appointments or medical questions. Current State Measurement and Analysis Process improvement expert W Edwards Deming, one of the fathers of Lean Manufacturing concepts noted: “Workers are responsible for only 15% of the problems, the system for the other 85%. The system is the responsibility of management.”1p94 In keeping with this philosophy, a small team of management, frontline employee representatives, internal consultants, and analysts were identified to focus on improving the system of telephone message management and to develop the methods by which ongoing measurement of that workflow could be realized (Table 1). Figure 2 depicts the high-level process flow yielded by the analysis of the telephone messaging system. Four to seven process steps were needed to highlight the vast majority of scenarios related to the telephone message system. Weekly volumes were tabulated to capture the average number of electronic messages routed to each medical office building from the Call Center, the average number of documented attempts made by the medical office staff to call the patient back, and any subsequent return calls into the Call Center for transfer to the medical office building because the patient was not available to receive the first call back. For every 100 electronic messages routed from Call Center to medical office, an average of 130 call attempts were made from medical office staff back to the patient and another 21 calls were made from the patient back to the Call Center—ultimately receiving a call transfer to the Primary Care team in the medical office. Scope The scope of the improvement effort focused on medical advice telephone messages that were routed electronically from the centralized Call Center to each of 17 Primary Care medical offices. These messages required a nonclinically trained Call Center agent to answer the call and document the chief complaint and symptoms. The Call Center agent then routed the message to the appropriate medical office where clinical staff and physicians would sort through the messages and return those calls at some future point. These calls represented 20% of the Call Center’s two million annual calls received. The remaining calls handled by the Call Center included appointment requests for Primary Care and other medical specialties, pharmacy requests and general information requests. These calls were considered outside the scope of the improvement effort. Methods Using Lean Manufacturing and Six Sigma concepts coupled with Call Center industry technology, a new program was developed to transform the way telephone-based medical questions from a Primary Care Physician’s (PCP’s) panel would be handled. The Six Sigma DMAIC (Define, Measure, Analyze, Improve, and Control) method was heavily leveraged in the development of the solution. During the analysis phase, Lean Manufacturing methods, in particular value stream mapping, flow,2 and root cause analysis were used. Lean’s concepts of reducing work in process to decrease completion time3 and removing wastes, most notably those related to overproduction and defects, governed many of the decision points of the effort. Measuring and Analyzing the Current State To measure the overproduction and delays associated with the medical advice telephone messaging process, 1) time and motion studies were performed, 2) data was retrieved from Call Center reports, 3) reports were developed to specifically measure the responsiveness of medical offices staff to telephone messages as captured by the electronic medical record, and 4) a third party administered a satisfaction survey sent quarterly to patients. 1. Time and motion studies found that, on average, Call Center agents spent 124 seconds per medical advice telephone message and medical office staff spent, on average, 44 seconds calling back the caller, waiting for the phone to ring, and leaving a message when unable to reach the originator of the request. All of this time was non-value-added4 in the system. From a patient satisfaction perspective, value is primarily added to these types of calls only when speaking to their PCP or a clinical team member of that PCP in their home medical office. 2. Standard Call Center reports were used to assess the impact process and system change would have in the Call Center. Key metrics included the average speed of answer for all inbound calls and the percentage of calls answered within 60 seconds. The number of Call Center agent full-time employee resources needed to provide improved service was also tracked. 3. The electronic medical record (EMR) documentation yielded more evidence of waste in the system. For every 100 telephone messages routed to the medical office by the Call Center on average, EMR documentation revealed that 130 return call attempts were made by that medical office. This highlights the frequency of occurrence that the medical office staff or clinician received no answer or was forced to leave a voice message to have the patient call back. Furthermore, the analysis showed that on average 21% of patients were required to place a second call back to the Call Center before being manually transferred to the medical office after having previously left a message. This loop of wasteful overproduction in the system was referred to as the ratio of telephone tag in the system. 4. Patient satisfaction with the ability to contact physicians or care delivery teams with a medical question was tabulated on a quarterly basis by a third party survey administrator. Before DirectConnect, this measure maintained a nine quarter mean of 54.6% satisfaction with ease of contacting clinician with a range from 44.0% to 59.0%, an upper control limit of 68.9%, and a lower control limit of 40.3%. Intervention DirectConnect seeks to provide a way to more efficiently and effectively handle increases in Primary Care-related call volume that comes with growing patient demand and with increasing use of the telephone as a key channel of communication between patient and physician. By streamlining this channel of communication, DirectConnect aims to increase the level of trust between patients and physicians by increasing the frequency that medical advice is delivered to the patient by a caregiver known and trusted by the patient—typically by their personal PCP or their physician’s team. Increasing the frequency of real-time response to a patient’s medical question by a known, trusted caregiver became the hallmark of the DirectConnect process of telephone request management for PCPs and their care delivery teams. Pilot With the data made available as a result of the analysis phase, a manual system was designed to pilot the removal of the telephone tag associated with the medical advice telephone messaging. Three medical offices—one housing general Internal Medicine physicians, one with Pediatricians, and the third with a mixed Primary Care model of general Internal Medicine, Family Medicine, and Pediatrics—were selected. These medical offices began a pilot in which, when a call was received, the Call Center agent would remain on the line and would transfer the call directly to the patient’s home medical office, instead of creating an electronic message. Although this pilot required that the Call Center absorb the cost of spending more time on the line with patients while waiting for the medical office staff to answer—the return call volume declined dramatically. This decline was as a result of handling a greater percentage of would-be electronic messages in real time—a Lean Manufacturing concept known as single-piece flow, versus the prior method of electronic messaging, which was more akin to the Lean Manufacturing concept of batch-and-queue. Technological Intervention Once the initial pilot was successfully completed, a technological intervention pilot was funded and implemented that allowed the system to automatically identify the PCP, capture the nature of the call—whether a medical question or appointment request—match these attributes, and direct the call to the appropriate staff member. Additional attributes were included in the design that allowed the system to evaluate and to predict the next available staff member and that ensured calls would not be queued for longer than an agreed-upon threshold. Further system revisions were made throughout the implementation to present any waiting callers with the option to remain holding or be immediately transferred to a Call Center agent to leave an electronic message. This put the decision to remain on hold in the hands of the patient. If the caller selected the option to leave a message instead of remaining on hold, the call would be seamlessly routed to the next available Call Center agent where an electronic message would be sent to the medical office in traditional fashion (Figure 3). Models and Options During the first two months of deployment, several call routing models and medical office workflow options were tested. Best practices were shared and adopted. The result has been sustained improvement in all 12 quarters following implementation. Weekly reports indicating medical office performance are posted and accountabilities are in place to ensure results are sustained. Since full deployment in July 2007, DirectConnect calls consistently represent between 15% to 20% of overall Primary Care telephone volume, with one outlier of 22% in November 2008 (Figure 4). This suggests that patients who learn the system are not inclined to abuse the service beyond what is required on the basis of their request. Although medical office staff answers 98% to 100% of all DirectConnect calls to the medical office, some physicians have chosen to log into the system as part of their daily routine when returning calls to patients. This capability allows physicians who wish to deliver a significantly higher level of service to their patients the opportunity to do so. Results With the system and associated processes implemented, dramatic gains have been achieved without adding any resources in the medical offices and while reducing the resource requirements of the Call Center. Today, 14% to 17% of total annual inbound call volume is answered by the home medical office. For each of these calls, the Call Center need not answer them, create telephone messages for them, or route them to the medical office where the patient must await a return call later in the day. Furthermore, the Call Center’s speed of answering calls improved by 54% in the first quarter after implementation compared to the same quarter from the year before. Now, for every 100 documented inbound telephone advice encounters that fall within the scope of DirectConnect on average, 79 requests are handled on the first call by the patient’s home medical office physician or team. Although the remaining 21 requests require additional research or a higher skill set to be satisfied, the return calls required to reach the patient are lower when the telephone encounter originates in the home medical office—presumably because the medical office team can provide a more targeted call back time than the centralized Call Center. This increases the odds of reaching the patient when the return call is made. Thus, the system has experienced a documented 26.9% reduction in required return calls because of DirectConnect. This reduces the number of non-value-added steps associated with the medical advice request process from 193 (Figure 2) to 45 (Figure 5). The removal of these non-value-added process steps yields a weekly time savings of between 198 and 247 hours per week in unnecessary telephone work for Call Center and medical office staff. Patient satisfaction with the ability to contact their PCP or Primary Care delivery team with a medical question, the key driver of improvement, has improved a statistically significant 14% and maintained a nine quarter mean of 70.2% satisfied with a range from 65% to 79% and an upper control limit of 77.9% and a lower control limit of 62.6% since implementation. Discussion Key Successes DirectConnect enabled significant improvements for the patients of KPCO while eliminating system barriers that hampered PCPs and staff from providing the high level of service they desired (Table 2). By systematically driving 14% to 17% of KPCO’s inbound telephone volume directly to the home medical office of the patient, Call Center service levels have improved beyond the internal target of 80% answered within 60 seconds (Figure 6) while maintaining an average speed of answering inbound calls below the 60 second mark in each month following the DirectConnect deployment. These Call Center improvements occurred without adding Call Center staff. In fact, the DirectConnect system’s financial breakeven point occurred ten months after full deployment as a result of savings generated by Call Center agent attrition—while maintaining these improved levels of service. Removing call volume from the centralized Call Center and routing those calls directly to the home medical office of the patient will, on the surface, appear to necessitate a need to shift resources to those medical office buildings to handle the volume; however, because of the single-piece flow nature of the new system, this process is far more efficient for the medical office staff than the previous batch-and-queue process associated with electronic messages. Medical office staff and PCPs make 26.9% fewer return calls; this equates to a time savings 198 to 247 hours per week across the system. Most importantly, these measurable improvements in both Call Center and medical office areas have led to statistically significant improvements in patient satisfaction—the ultimate objective of the DirectConnect implementation. From the pre-DirectConnect mean of 55.9% satisfaction with the patient’s ability to contact their physician, this measure increased to a mean of 70.2%—14.3% higher than the mean of the previous process, and 3.3% higher than the eight quarter upper control limit of the previous process (Figure 7). DirectConnect has brought KPCO patients closer to their physicians and the Primary Care delivery teams that know them. The barriers that once existed as a result of the desire to gain economies of scale through a large, centralized Call Center have been mitigated. This system has pleased physicians, medical office staff, and those seeking care (Table 3). As health care seeks to better meet the needs of the population, systems like DirectConnect lend credence to the concept that large health plans and provider groups can foster better communication with members and patients without sacrificing affordability of care. Future The future implications of this marriage between Call Center technology and the electronic medical record are exciting. Once a technical interface is created between the caller’s EMR and the Personal Physician—as in the DirectConnect system—new opportunities to creatively connect patient and physician exist. For example, on the basis of diagnosis, stratification of patients may occur to automatically route them to the nurse who is most equipped to handle questions related to their condition. Additionally, physicians may be able to establish one-time clinical rules that permit the patient to be directly routed to the physician’s mobile phone upon their next call if important information exchange is needed. Within the context of the telephone system, a mobile phone could be considered part of the greater call routing system, thereby falling under the umbrella of load balancing and call handling redundancy to ensure that calls are not left unanswered. This system creates a foundation on which the relationship between the patient and their personal physician can be further enhanced. Disclosure Statement The author(s) have no conflicts of interest to disclose. References 1. Walton M. The Deming management method. New York: Penguin Putnam; 1986. 2. Womack JP, Jones DT. Lean thinking: banish waste and create wealth in your corporation. New York: Simon & Schuster; 2003. 3. Gerst R. The little known law. Six Sigma Forum Magazine 2004 Feb;3(2):18-23. 4. George ML. Lean six sigma for service: How to use lean speed and six sigma quality to improve services and transactions. New York: McGraw-Hill; 2003.
Obesity: Problem, Solution, or Both?
Wednesday, 30 June 2010
Vincent J Felitti, MD, FACP; Kathy Jakstis; Victoria Pepper, MS; Albert Ray, MD Spring 2010 - Volume 14 Number 1 Since 1982, the Southern California Permanente Medical Group’s Positive Choice Weight Loss Program in San Diego has treated more than 30,000 adults, predominantly middle-aged, for obesity—some successfully, some not. This has been an extraordinary experience and provided us with numerous counterintuitive observations. We now are convinced that obesity is widely misunderstood, and we realize that the unusual program we have operated safely and effectively for more than a quarter century is often misunderstood as well. There is growing interest in our program and in using our approach as a model for other Kaiser Permanente (KP) Regions. We therefore share an overview here of our experience with this specific program. Consequently, most referenced works in this report are publications emanating from our program, sometimes contrasting those findings with conventional views on the subject. The Positive Choice Weight Loss Program has two integrated components: • Prolonged absolute fasting, with the use of a supplement to support health and to prevent death from such fasting. • A lengthy and complex group program to explore the basis of each participant’s unconscious compulsive use of food, as well as to explore the hidden benefits of obesity for that individual. Given that the average weight loss of someone completing our 20-week program is 62 lb (28 kg) and that approximately 5000 patients each have lost more than 100 lb (45 kg), we realize we have challenged the belief systems of some who assume either that such weight loss cannot commonly be achieved or that the process of supplemented absolute fasting must be dangerous. In fact, the process has been notably safe, and major improvements in biomedical outcomes have been the norm. This article addresses four basic issues: 1. The safety of properly supplemented prolonged absolute fasting in obesity 2. The observed origins of obesity, and their implications 3. The components of a relevant treatment program 4. Outcomes of the Program. Overview of Unsupplemented Starvation The Irish hunger strikers of the early 1980s illustrated the outcome of unsupplemented, prolonged, absolute fasting. They only drank water, and it was clear after six weeks that all involved had sustained significant weight loss and were mortally ill. By seven weeks, all were dead. They died because of profound potassium and magnesium deficiency, with consequent lethal cardiac arrhythmia. Had they received electrolyte supplementation and had the hunger strikers been obese, they could have lived for several months longer before dying because of major protein deficiency. Supplementing two essential fatty acids and the essential amino acids needed for anabolic protein turnover would have prevented such a death. Had this been done, the hunger strikers would have died toward the end of a year because of beriberi, pellagra, and scurvy. Preventing these diseases by vitamin supplementation would be straightforward. To simplify the example, we have left out the problem of calorie deficiency in these nonobese individuals. In obese individuals, body fat stores of course resolve this problem; the metabolism of these fat stores is obviously the basis for weight loss. Details of unsupplemented starvation can be found in the famous work of Ancel Keys, described in his two-volume Biology of Human Starvation.1 Safety of Supplemented Fasting The nutritional supplement Optifast 70 was created by Sandoz Pharmaceuticals to supply electrolytes, amino acids, two essential fatty acids, and vitamins. At 420 cal/d in five feedings, this superbly designed product allows a sufficiently morbidly obese individual to cease eating all food and caloric beverages for at least a full year. In our entire experience, no death or biomedical harm has occurred in any of these individuals. During a year of supplemented absolute fasting, a weight loss of approximately 300 lb (136 kg) will occur (Figure 1). To the degree that this does not occur, it means that the patient is consuming food, regardless of denial. Surprisingly, hunger is not a problem. However, the desire to eat is variable, ranging from minor to uncontrollable. Interestingly, this desire to eat is an issue separate from hunger. Indeed, it attests to the profound psychoactive benefits of food, as illustrated by a commonplace observation that is even built into our language: “Sit down and have something to eat; you’ll feel better.” There is truth for many in the phrase “comfort food.” Origins of Obesity In the early years of the Weight Program, we naively were taking morbidly obese individuals down 300 lb (136 kg) at a time, a rate of loss distinctly exceeding that of bariatric surgery. The striking results perhaps understandably led us to believe that we understood what we were doing. Counterintuitively, some of our most successful patients forced us to realize we were merely in possession of a powerful technology and had no idea what we were doing in other regards. They did this by demonstrating that massive weight loss could precipitate divorce, severe anxiety, and sometimes suicidality. Some patients, sensing these outcomes early, fled their own success in the Program. Surprisingly, our high dropout rate was mainly limited to patients who were successfully losing weight. By contrast, we had other patients who were eating during the Program, routinely denying it, and losing no weight while paying a fairly significant fee, seemingly to accomplish nothing. With these patients, it took some time for us to realize that we were supplying an important support system with our group approach. It turned out that many of our obese patients had no functional support systems at home. The striking and frankly annoying conflict between our ability quickly and safely to reduce a person’s weight and what patients appeared capable of tolerating emotionally led us to detailed exploration of the life histories of 286 of our patients. Here, we unexpectedly discovered that histories of childhood sexual abuse were common, as were histories of growing up in markedly dysfunctional households. It became evident that traumatic life experiences during childhood and adolescence were far more common in an obese population than was comfortably recognized.2 We slowly discovered that major weight loss is often sexually or physically threatening and that obesity, whatever its health risks, is protective emotionally. Ultimately, we saw that certain of our more intractable public health problems such as obesity are often also unconsciously attempted solutions to problems dating back to the earliest years but hidden by time, by shame, by secrecy, and by social taboos against exploring certain areas of life experience. The antecedent life experiences of the obese are quite different from those of the always-slender.3 Eventually, these Program findings led to the 17,000-member Adverse Childhood Experiences (ACE) Study, in which we established that the developmental damage initially discovered in our obese patients was broadly applicable to many aspects of everyday medical practice.4,5 Ultimately, we learned from our patients that in obesity, we are dealing with two core problems: • The unconscious, compulsive use of food for its psychoactive benefits • The unrecognized and unspoken benefits of obesity. These two core problems are markedly at variance with conventional thinking about obesity, starting with the government’s food pyramid. Worse yet, these two basic problems are uncomfortable to deal with. In reviewing the medical literature, one quickly notes that most articles purporting to discuss the causes of obesity quickly switch to describing the unhealthy consequences of obesity and never pursue their stated goal. One also notes the tendency to confuse intermediary mechanism with basic cause. For instance, several years ago, leptin deficiency was proposed as the cause of human obesity. Although that idea has now been discarded, someday the “real leptin” will be discovered, but it will no more be causal than increased levels of epinephrine are the cause of anxiety. Each is a necessary intermediary mechanism, not a basic cause. Understanding the difference is as essential to progress in treatment as it is to primary prevention. Any physician choosing to validate in his patients the points being made here will be in the position of asking about topics that we have all learned are not discussed by polite people. Incest, rape, family suicides, and parental brutality are not readily brought up. That being the case, we physicians typically have no basis for opinions on the frequency or rarity of such life experiences. We documented these experiences as surprisingly common among our patients, but we did not know that before we began routinely inquiring about them. Counterintuitively, we learned that discussion of these experiences is usually not uncomfortable to those who have had them, if they are supported by someone comfortable with their discussion. Patients often find a great sense of relief in discussing their life experiences. As one patient wrote, “The shame, guilt, and pain for the abuse and molestations of childhood, and being raped, was so great that I had to come forward or die. If your questionnaire had been put in front of me, it would have shown me that people existed in the medical profession who knew about the sad things that happen to some people.” This poignant statement imposes a huge responsibility on us that we can of course avoid by falling back on lack of time or lack of training as being the factor that precludes our inquiry. The now internationally recognized ACE Study was initiated to determine the prevalence and outcomes of ten categories of such life experiences in more than 17,000 consecutive adults from KP’s San Diego population.6 These experiences are common, and their consequences are devastating in terms of emotional damage, biomedical disease, and the costs of health care. Like a child’s footprints in wet cement, the consequences are lifelong. Putting it plainly in regard to obesity, we have seen that obesity is not the core problem. Obesity is the marker for the problem and sometimes is a solution. This is a profoundly important realization because none of us expects to cure a problem by treating its symptom. Treatment Given the nature of our observations about the causes of obesity, repeatedly documented in thousands of responses to our preprogram questionnaire (See http://www.thepermanentejournal.org/files/Obesity/PreprogramQuestionnaire.pdf to view the questionnaire) and in more than 50 videotaped interviews, it was inevitable by the early 1990s that we revise our program to fuse two separate goals: weight loss by supplemented fasting, and helping patients identify and resolve the life experiences underlying obesity. By far the easier of the two goals is the medical management of supplemented absolute fasting. Weekly checks of potassium levels, blood pressure measurements in patients taking antihypertensive medications, and blood sugar levels in patients with diabetes are our most common tracking measures other than weight itself. Other details of biomedical management are equally straightforward but are not the point of this article. Chronic disease is not a reason for exclusion from the Program; most such patients should actually be sought for Program inclusion if obese. Our only absolute exclusions are pregnancy and recent myocardial infarction or stroke. Optifast 70, drunk five times daily for a total daily intake of 420 cal, is a remarkable material that makes biologically safe the otherwise unthinkable. The remainder of the day’s caloric needs come from body fat stores as long as those fat stores exist. It is important to understand that Optifast 70 has one function only: the prevention of death from prolonged absolute fasting. It does not take weight off people; not eating does that. And it has nothing to do with whether lost weight is regained or kept off; that outcome is solely a function of what is accomplished or not accomplished by the group work of the Program. By contrast with the simplicity of fasting, the weekly two-hour group meetings of the Program are a complex endeavor that is difficult for some patients to engage in and is difficult to train staff to pursue vigorously. By the mid-1980s, we had learned that our initial goal of teaching people to “eat right” was totally irrelevant to obesity, although it seemed a reasonable thing to do when we did not know what to do. In retrospect, we should have known better because most of us knew that overweight, middle-aged women commonly know enough about calorie content to give a dietitian a run for his or her money any day of the week. Nutrition is an interesting and important subject that has no more relationship to obesity than it does to anorexia. The role of the Program is to help people recognize and find an acceptable alternate solution or resolution to the underlying problems being treated with food. We are at an early stage of success; the work is difficult because it is resisted by some patients and can awaken personal ghosts in staff, but we have clearly established a beachhead on the right beach and slowly are moving inland. In the course of detailed interviewing of about 2000 obese patients over the past 20 years, in-depth and often repetitively over time, we have noted several recurrent findings: • It is rare for anyone to be born obese. In 2000 adult obese patients, only one individual was born overweight, at 14 lb (6 kg), to a 550-lb (250-kg) mother, and she was slender throughout childhood and adolescence until age 20, when she married an alcoholic and suddenly began massive weight gains, ultimately matching her mother’s weight. “Born fat” is a defensive concept. • A significant minority of our Program participants are born at subnormal weight because of prematurity. • Obesity indeed runs in families, as does speaking the same language. It is the distribution pattern of body fat deposition that is genetically determined, not its presence. • Major weight gain is typically abrupt, episodic, and life-event related. • The forces underlying extreme morbid obesity are relatively easy to discern for those seeking them. They are qualitatively similar to those underlying mild overweight, though they are much harder to discern in the latter. • The age at which weight gain first began is critically important because it allows one to inquire why it began then. Some patients will know and others will not want to know, but this is an essential point not to be dropped because of patient avoidance. • Obesity commonly is beneficially protective: sexually, physically, and socially. This is an uncomfortably difficult point for many nonobese individuals to accept. • Major weight loss may present a significant threat, usually to the person involved, but sometimes to others. • Emotional support from others for major weight loss is uncertain. With adequate medical monitoring, there is no biologic risk to supplemented absolute fasting. Supplemented fasting has two treatment advantages: • When large amounts of weight are to be lost, it reduces weight quickly enough to provide positive and supportive feedback. • By removing eating as a major coping device, we expose the underlying issues that are being treated by the psychoactive properties of food. The main work of the Program enters personal territory that is comfortably off-limits to polite people. It is therefore difficult and demanding, though conceptually simple. Doing the work in groups is essential because of the implicit support of the group and because participants quickly learn from each other’s self-observations. To the degree that counselors pose meaningful questions to their groups, and insist on answers to the questions asked and not to some enfeebled version of their questions, they are successful. To the degree that they teach by lecturing, they fail. In actual fact, our task is to help the participants discover what they already know at some level, and then to use that discovery for their own benefit. To illustrate the process, some seemingly simple questions may be offered for our readers to try, understanding that this works best in small groups and initially will be stressful for the group leader: 1. Why (not how) do you think people get fat? 2. How old were you when you first began putting on weight? Why do you think it was then and not a few years earlier or later? 3. Sometimes people who lose a lot of weight regain it all, if not more. When that happens, why do you think it happens? 4. What are the advantages of being overweight? Patients’ answers to these questions are staggeringly counterintuitive to conventional thinking about obesity. Moreover, their answers have been consistent over the many years we have posed these questions in group sessions. For instance, answers to question 1 routinely are: “stress, depression, people leave you alone, men won’t bother you.” There are of course occasional escapist responses like “I just like food.” In that case, the following response to the answer given for question 2 is helpful: “Really? Can you tell us why you suddenly liked food more at 22 when you first began putting on weight?” Responses to question 3 always are versions of “If you don’t deal with the underlying issues, the weight will come back.” About 60% of the time, someone in a group will also propose that regain occurs because major weight loss is threatening. Answers to question 4 repeatedly fall into three categories: obesity is sexually protective; it is physically protective (eg, “throwing your weight around”); and it is socially protective—people expect less from you. Ultimately, we were forced to recognize that patients in a supportive setting speak of things that we ourselves may find it easier not to know. This embarrassing recognition exposes the tempting opportunity that a physician or group leader has to become part of the problem by authenticating as biomedical disease that which is actually the somatic inscription of life experience onto the human body and brain. The frequent reference to “the disease of obesity” is grossly in error, diagnostically destitute, and apparently made by those with little understanding of the antecedent lives of their patients. Obesity, like tachycardia or jaundice, is a physical sign, not a disease. What we have learned about obesity has been more widely applicable in everyday medical practice than we would ever have contemplated. The general principles underlying the unconscious, compulsive use of food as a psychoactive agent are common to any of the addictions. We unwittingly recognized this at some level in the early years of the Program by giving as gifts, coffee mugs bearing the inscription, “It’s hard to get enough of something that almost works.” The psychoactive benefits of food are profound though not curative: “Sit down and have something to eat; you’ll feel better.” Hunger is not at issue in that saying. Whether we are talking about the next mouthful, the next drink, the next cigarette, the next sexual partner, or the next dose of whatever psychoactive chemical we might buy on the street, the concept is equally applicable: It’s hard to get enough of something that almost works. Slowly, we have come to recognize that overeating is not the basic problem. It is an attempted solution, and people are not eager to give up their solutions, particularly at the behest of those who have no idea of what is going on. Nor is obesity the problem. Obesity is the consequence, the marker for the problem, much in the way that smoke is the marker for a house fire. Often enough, obesity is even the solution—to problems that are buried in time and further protected by shame, by secrecy, and by social taboos against exploring certain areas of human experience. A memorable response comes to mind from 1985 when a patient, going with us through a timeline of her life in which weight, age, and events were matched, told us that at age 23 she was raped and that in the subsequent year she gained 105 lb (48 kg). Looking down at the carpet, she then muttered to herself, “Overweight is overlooked, and that’s the way I need to be.” Not knowing how to respond at the time, we said nothing. A few weeks later when she had lost 35 lb (16 kg), enough to be noticeable, she abruptly disappeared for 2.5 years, quickly regaining the weight. When she attempted to rejoin the Program after that hiatus, we discovered that she had no recollection of this conversation. Prompted by this to look into the issue of amnesia, we found in a sample of 300 consecutive obesity program patients that 12% acknowledged a history of focal amnesia, typically for the few years antecedent to the onset of weight gain. Amnesia is a high-grade marker for dissociation, which is a high-grade marker for abuse.7 Just as no one becomes amnesic because of good experiences, no one becomes fat out of joy. Depression is common in the Program and is a major stumbling block to weight loss. Not surprisingly, until the recent advent of pharmacologic blockers of fat absorption, every single “diet pill” save one has had potent antidepressant activity. The exception was fenfluramine, whose potent antianxiety activity was linked with the antidepressant phentermine as the first component of fen-phen. These medications can play a useful supportive role, but it should be understood that what is being treated is depression or anxiety, the consequences of antecedent life experiences, and not obesity per se. Overall, we have found and documented that the antecedent life experiences of the obese are quite different from those of the always-slender.3 Subsequent to the 20-week weight-loss phase of the Program, we have a 12-month Maintenance Phase. Initially thinking that this was necessary to teach people how to eat right, we slowly came to see that Maintenance indeed is essential, but for other reasons: to provide group support when major weight loss is threatening, usually to the person involved but sometimes to those who are close. Some of our patients regain all their weight, and others do not. The question we posed was: What are the differences between those who regain and those who do not? We have identified two major predictors of regain: a history of childhood sexual abuse and currently being married to an alcoholic.8 The latter can probably be generalized into having a significantly dysfunctional marriage, but that concept was too nebulous to study as an outcome. Today the prevalence of obesity is rapidly increasing in children. Although our experience with obese children is quite limited, we are impressed by the number of adults who date the onset of their initial weight gain to coincide with parental loss in childhood, usually by divorce. Our most obese female patient, weighing 840 lb (381 kg) at age 29, was born weighing slightly less than 2 lb (0.9 kg) and was thin until her parents divorced when she was 11 years old and she never again saw her father. By age 17, she weighed 500 lb (227 kg). This correlation with parental divorce has escaped general attention, although a search in Google Scholar using the phrase childhood obesity divorce quickly indicates its presence in the literature. Given the high prevalence of divorce in the US, we suspect that “McDonald’s” may be a more comfortable explanation for childhood obesity, although it obviously misrepresents mechanism as cause. Bariatric surgery has been increasing in popularity since its initiation in 1967 by Edward Mason, the remarkable Iowa surgeon who introduced gastric bypass surgery to the US.9 Our own experience in the Program with bariatric surgery is biased because we see a disproportionate number of cases where “the surgery failed” and patients consequently enter the Weight Loss Program. We have found alternate explanations that are not usually considered. An unexpectedly clear insight was provided by a recent patient comment: “The antidote [sic] to bariatric surgery is Karo Syrup.” The psychological implication is blatant; the physiologic insight is ingenious. One may not be able to chew one’s way through a lot after bariatric surgery, but the ability to ingest highly caloric liquids is unlimited. The question, of course, is: Why would a patient do that? A different take on bariatric surgery is depicted in a brief video clip of an interview with a patient available at: http://www.thepermanentejournal.org/files/Obesity/EllaHNoBariatricSurgery.avi. These comments from patients are, once again, counterintuitive to conventional views about obesity. We have slowly learned that our average patient on the one hand wants very much to lose weight but on the other hand often has significant unconscious fear of the changes that major weight loss will bring about. In keeping with this unexpressed conflict, it is worth remembering that opposing forces are routinely present in biologic systems. Outcomes We have measured our Program outcomes in three categories: • Weight loss • Maintenance of weight lost • Benefits of weight loss. The average weight loss in one 20-week cycle of our program has been 62 lb (28 kg). The most anyone has ever lost in our former 26-week cycle was 157 lb (71 kg). This was a highly motivated man with a large underlying muscle mass. Eighteen months after completion of the Program, half of our patients are keeping off 60% or more of the weight lost. These are old data and have probably improved with the revised Program, but we have not restudied the point. Instead, we have studied the differences between those who regain and those who do not.8 Our ability to predict regain offers the possibility for preventive treatment in advance. The biomedical benefits of such major weight loss have been dramatic. Of 400 consecutive patients taking medication for hypertension who completed the Program, 62% were able to discontinue all medication and no longer had hypertension. Of 400 consecutive patients with hypercholesterolemia, the average starting cholesterol level was 285 mg/dL; the average cholesterol level for those completing the Program was 204 mg/dL. Most impressively, of 320 patients with Type 2 diabetes who completed the Program, 71% were able to discontinue medication and had normal fasting blood sugars. In terms of health care economics, there is a 25% reduction in physician office visits while patients are in the Program and a 40% reduction in such visits in the subsequent year. Certainly, some of this is due to a reduced disease burden, but we suspect that a significant portion is due to reduced emotional distress in patients who have been helped in supportive settings to speak of the worst secrets of their lives and have been enabled to emerge feeling still accepted as human beings. Summary We have had an unusual opportunity to become deeply involved in the treatment of major obesity since 1985. What we have counterintuitively learned from that experience is that obesity, though an obvious physical sign and easily measured, is not the core problem to be treated, any more than smoke is the core problem to be treated in house fires. Supplemented absolute fasting is a highly effective treatment for obesity, but only if it is combined with a meaningful program that is designed to help patients explore the psychodynamic issues that underlie overeating as a coping device, as well as exploring the possible protective benefits of obesity itself. The work is difficult because it threatens social conventions and beliefs and often awakens personal ghosts in staff. This can lead to nonalignment of purpose and reminds us of Michael Balint’s famous comment, “Patients see doctors because of anxiety, while doctors see patients because of disease. Therein lies the problem between the two.”10 Although our work with obesity is difficult to carry out, we have nevertheless found that the work we have described can be done and that the benefits are major. v Disclosure Statement The author(s) have no conflicts of interest to disclose. Acknowledgment Katharine O’Moore-Klopf, ELS, of KOK Edit provided editorial assistance. References 1. Keys A. Biology of human starvation. Minneapolis: University of Minnesota Press; 1950. 2. Felitti VJ. Long-term medical consequences of incest, rape, and molestation. South Med J 1991 Mar;84(3):328–31. 3. Felitti VJ. Childhood sexual abuse, depression, and family dysfunction in adult obese patients: a case control study. South Med J 1993 Jul;86(7):732–6. 4. Felitti VJ, Anda R, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998 May;14(4):245–58. 5. Felitti VJ. The relation between adverse childhood experiences and adult health: turning gold into lead. Perm J 2002 Winter;6(1):44–7. 6. Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult health, well-being, social function, and healthcare. In: Lanius R, Vermetten E, Pain C, editors. The impact of early life trauma on health and disease: the hidden epidemic. Cambridge, UK: Cambridge University Press; in press 2010. Chapter 8. 7. Edwards V, Fivush R, Anda RF, Felitti VJ, Nordenberg DF. Autobiographical memory disturbances in childhood abuse survivors. In: Freyd JJ, DePrince AP, editors. Trauma and cognitive science: a meeting of minds, science, and human experience. New York: Haworth Maltreatment and Trauma Press; 2001. p 247–64. 8. Felitti VJ, Williams SA. Long-term follow-up and analysis of more than 100 patients who each lost more than 100 pounds. Perm J 1998;2(3):17–21. 9. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am 1967 Dec;47(6):1345–51. 10. Balint M. The doctor, his patient, and the illness. Rev ed. New York: International Universities Press; 1972.
Nurse Empowerment from a Middle-Management Perspective: Nurse Managers’ and Assistant Nurse Managers’ Workplace Empowerment Views
Wednesday, 08 December 2010
Loretta C Regan, RN, MS; Lori Rodriguez, RN, PhD Winter 2011 - Volume 15 Number 1 Abstract Background: Researchers have explored empowerment as an important condition for nursing staff but little current research focuses on empowerment from a middle-management perspective. Aims and Objectives: The purpose of this study was to assess the empowerment of a middle-management group made up of only nurse managers (NMs) and assistant nurse managers (ANMs) in an acute-care hospital setting. Methods: A questionnaire was distributed online to a convenience sample of NMs (n = 11) and ANMs (n = 31) working in an ethnically diverse acute-care hospital. Results: Overall, this middle-management group did not feel empowered. Conclusions: Empowerment as perceived by middle management is crucial for carrying out leadership duties and, in turn, empowering frontline staff. Even though the work is challenging, resources and support, among other constructs of empowerment, must be improved to increase the empowerment of middle management. Nursing administration must understand the importance of an empowered middle management so that middle management can lead effectively and facilitate the delivery of safe, high-quality patient care. Introduction Nurse managers (NMs) and assistant nurse managers (ANMs) play an essential role in creating an empowering work environment for their staff. Empowerment is defined as the ability to get things done and includes a capacity to mobilize resources and to provide support, opportunity, and information.1,2 Additionally, for NMs and ANMs to be able to empower others, management must provide access to resources. The organizational power structure itself must be identified, because it can affect perceptions of empowerment at all levels.3 In practice, a leader must have a sense of empowerment in order to empower others. The literature contains extensive information on empowering the nurse at the bedside and frequently points to the first-line manager as the person to provide empowerment for the staff nurse. However, little is known about how NMs and ANMs themselves are empowered and experience empowerment in their roles. NMs and ANMs are the frontline leaders for nursing staff in acute-care hospitals. NMs and ANMs make up the middle layer of leadership between nursing administration and staff nurses. Their role involves communication with staff, patients, and members of the interdisciplinary health care team.4 The middle manager handles an immense amount of responsibility, such as the hiring and firing of staff, judging competency of staff, assuming budgetary responsibility, and taking overall responsibility for the delivery of safe, high-quality patient care.2,5 Further, NMs and ANMs are responsible to the service-line Director and Chief Nursing Officer in most acute-care hospitals. Creating an environment that ensures the delivery of safe and high-quality patient care, high patient satisfaction rates, and positive patient outcomes is also the responsibility of NMs and ANMs. In addition, they are required to implement policy changes that are often driven by regulatory agencies, such as state health departments and the Joint Commission. Block emphasized that “as managers, our task is to empower ourselves and to create conditions under which others can do the same.”6 A health care culture that values growth and input from frontline staff requires an empowered leader who facilitates the delivery of safe, high-quality patient care.2 However, if a middle manager does not feel empowered, how can s/he be expected to create conditions that will empower others? We explored how NMs and ANMs, also referred to as middle managers, perceive their own empowerment. Given their multiple responsibilities and the fact that empowerment contributes to getting a job done, it is important to assess NMs’ and ANMs’ perceptions of empowerment. Literature Review We used Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed to conduct a literature review, searching on the following phrases: staff nurse empowerment, NM and ANM empowerment, and nurse engagement and job satisfaction. We found a scarcity of information specific to understanding how NMs and ANMs experience empowerment in the hospital setting. Nevertheless, a literature review conducted by Lee and Cummings7 found that organizational support within the institution was a significant contributing factor in empowerment. This is consistent with the organizational theory described by Kanter,8 an expert in the field of organizational behavior. The literature revealed extensive research on empowerment and its importance as experienced by employees. Stichler9 examined ways in which staff nurse engagement could affect operations within a facility and concluded that empowerment of employees enhanced the sustainability of change. Change is, of course, a constant in health care, and sustainability is a major area of importance. Therefore, researchers have worked to better understand the ways in which different groups of workers perceive empowerment from a multidisciplinary perspective. Currently, the full range of the consequences of empowerment in the nursing profession is not fully understood. However, findings from the Institute of Medicine reveal that a likely value of the empowerment of nurses is the promotion of safe patient care and improved patient outcomes.10 A study of the nurse’s role in quality improvement found that an effective nursing staff delivered improved patient care as measured by improved patient outcomes.11 Empowerment is important at most levels of health care delivery. Just as staff nurses do, nurse educators who feel engaged, effective, and valued experience empowerment that allows them to be effective in staff development and to make decisions quickly on the job. Johnson also found that empowered nurse educators demonstrated greater flexibility in adapting to ongoing change.12 Similar characteristics were found among staff nurses who expressed a feeling of empowerment in their work.13 Laschinger et al14–18 have conducted extensive research on the empowerment of nursing staff and on leadership’s ability to instill empowerment. Of particular interest here is work by Laschinger et al19,20 that used Kanter’s organizational theory as a foundation for clarifying the ways in which empowerment is understood and maintained by nursing staff, as well as how it is used effectively by nursing leaders. Another study by Laschinger et al,21 conducted in an acute-care setting, demonstrated that effective leadership is a source of empowerment for staff. McDermott et al22 found that organizational commitment is important particularly when human and economic resources are limited and when a high quality of nursing care must be maintained. Excellence in nursing may be successfully cultivated by finding new ways for NMs to empower their staff. Safety in the hospital environment is of primary concern for leaders, health care providers, patients, and their families. Working conditions within the hospital setting are often influenced by environmental and human concerns. Empowerment of nurses with regard to their work environment is recognized as an important factor in acquiring the desirable status of magnet hospital from the American Nurses Credentialing Center.23 Moreover; nursing leadership strives to identify ways to improve patient outcomes. In the acute-care clinical setting, empowerment of nurses can be key to such improvement.15 Faulkner and Laschinger24 found that empowerment within the context of structural and psychological parameters was a significant factor in the delivery of high-quality health care. Their data showed a positive correlation between improved care and nurses’ feelings of being respected, as well as between improved care and nurses’ levels of self-respect. A study of nurses found that job satisfaction and reduced job stress can be two of the positive consequences of promoting nurse empowerment and can serve to reduce nurse burnout.18 Enhancing hospital nurses’ experience of empowerment may stem the growing shortage of experienced nurses.25 A workforce is more likely sustainable when staff nurses trust and respect their direct managers. Unhealthy work environments, where nurses are emotionally drained and feel overwhelmed, are more likely to be settings that risk patient safety.26 Nurses who feel empowered in their role express confidence, and successful NMs who can empower their staff serve an important role in creating a healthy and safe work environment.27 The literature shows a gap in the understanding of the empowerment of direct NMs and ANMs in the clinical setting. Therefore, we explored how NMs and ANMs experience empowerment. Conceptual Framework The conceptual framework that guided our research was based on organizational empowerment, as described by Kanter,1,8 and psychological empowerment, as described by Conger and Kanungo.3 Kanter’s theory on organizational empowerment is composed of four components that are imperative to promoting structural empowerment. Access to resources and information28 and the skill to fulfill role expectations make it possible to achieve more and to pass on more to subordinates. Employees who believe that their manager can get things done are more likely than those who do not believe in their manager’s abilities to come together as a high-functioning team.8 Kanter’s theory provides both a framework for exploring empowerment and moves toward developing interventions to improve work environments so that they will ultimately offer more meaningful work. Kanter1 described organizational empowerment as necessary for providing opportunity and power in companies for optimal staff effectiveness and achievement. Theoretically, staff respond effectively to work environments in which they feel empowered. The organizational benefit is manifested in better staff attitudes and increased efficiency. Empowerment is possible when employees have access to information, support, resources, and the chance to discover and develop. Kanter’s components of empowerment are as follows1,8: Ability to advance in a current role or the opportunity to be involved in activities beyond the current scope of practice Access to information that allows staff to fulfill role expectations and understanding of the proper source from which to obtain correct information Knowledge of job expectations and support in fulfilling them Ability to obtain resources required to accomplish tasks. Psychological empowerment, as described by Conger and Kanungo,3 is a motivational state that is based partially on Bandura’s theory of self-efficacy. That theory proposes that those who believe that they will succeed have a greater chance of doing so than do those who do not hold that belief.29 Conger and Kanungo explained empowerment as a process that begins with the elimination of barriers that prevent staff from feeling the power needed to accomplish their work.30 Empowered staff are more likely than nonempowered employees to start behaving in ways that maintain professionalism even in challenging environments, and this increases work effectiveness.3 Psychological empowerment is the emotional investment that staff need for empowerment to be successful.30 Organizational empowerment and psychological empowerment are the key components of employee empowerment.24 Staff nurses report to NMs and ANMs, who must be empowered to fulfill their role as leaders so that staff nurses can in turn fulfill their role in acute-care hospitals. Given the dynamic role of NMs and ANMs in an extremely complex health care system, we used this conceptual framework as a guide to study empowerment from the perspectives of NMs and ANMs. Research Question We aimed to explore how NMs and ANMs experience workplace empowerment in their role as middle managers in the acute-care hospital setting. Given the very complexity of health care, NMs and ANMs must be empowered to perform leadership roles.4 NMs and ANMs must be able to persuade staff that they are empowered to facilitate positive patient outcomes.13 Empowerment is the ability to get a job done well with the necessary information and equipment to accomplish the work.28 We focused on the perception of empowerment: How do NMs and ANMs perceive their sense of empowerment in an organizational setting—in particular, in an acute-care hospital? Their perceptions, if positive, can facilitate empowerment of staff nurses, allowing delivery of safe, high-quality patient care. Methods Study Design Ours was a nonexperimental quantitative, cross-sectional, descriptive survey designed to measure organizational empowerment among NMs and ANMs in a 327-bed private teaching hospital accredited by the Joint Commission. The hospital was opened in August 2007. It is located in an ethnically diverse metropolitan area. The Nurse Work Empowerment Scale, also referred to as the Conditions of Work Effectiveness Questionnaire II (CWEQ-II), was distributed to a convenience sample of 49 NMs and ANMs from all of the clinical units in the hospital; all participants were employed by the hospital during the research and were at least 18 years old. All members of middle management in the hospital were eligible to participate. Approval for the study was obtained from both the Kaiser Permanente (KP) Northern California Institutional Review Board and the institutional review board of the university in our service area. The data were collected through Survey Monkey (www.surveymonkey.com). We obtained permission to use the CWEQ-II from Heather Laschinger-Spence, MD.31 We sent an e-mail to all participants that outlined the purpose of the study, explained that respondents would remain anonymous, and invited participants to complete an online survey. The Research Instrument We used the CWEQ-II, which has been applied primarily in research aimed at frontline nurses, to survey NMs and ANMs. The CWEQ-II also includes the Job Activity Scale II (JAS-II) and the Organizational Relationship Scale II (ORS-II). The CWEQ-II consists of 19 items that measure opportunity, information, support, resources, formal power, and informal power; these are the components of organizational empowerment as described by Kanter.8 A two-item global empowerment scale is included for construct-validation purposes. Scores for items on each of the six subscales are summed and averaged to provide a score for each subscale, on a Likert scale ranging from 1 to 5. A score of 5 on the Likert scale represents the highest level of agreement; 1 indicates none—the strongest level of disagreement. The scores of the six subscales are then summed to create the total empowerment score (score range, 6–30). Higher scores represent higher perceptions of empowerment. The two global empowerment items are summed and averaged to create a score ranging from 1 to 5. This score is not included in the structural empowerment score. The correlation between this score and the total structural empowerment score provides evidence of construct validity for the structural empowerment measure. Results The CWEQ-II questionnaire was completed by 11 NMs and 31 ANMs; this represents an 86% response rate. The NMs’ ages ranged from 46 to 50 years; 73% were female. The ANMs were slightly younger, with an age range of 36 to 40 years; 81% were female. In the two groups, 36% of the NMs reported having one to three years of management experience and 36% as having four to six years in management. Nearly 84% of ANMs reported having less than three years’ experience in a management role. The CWEQ-II demonstrated a Cronbach alpha of 0.91 for organizational empowerment. Table 1 shows subscale scores by role. We performed an independent two-tailed t-test for each of the subscales and for the total CWEQ-II as well as the JAS-II and ORS-II used for construct validity. The Cronbach alpha was 0.05 for all statistical testing. There were no statistically significant differences in the perceived organizational empowerment for the NMs versus ANMs for any of the subscales, for global empowerment, or for total empowerment. When asked about the amount of opportunity that middle managers believed they had in their job, half (50%) reported that their work was challenging, about half (45%) reported that their work gave them a chance to gain new skills and knowledge, and fewer than half (41%) reported that their work used all of their skills (Table 2). Less than 49% of participants reported that they had sufficient access to information from top management regarding the state of the hospital, values, and leadership’s goals. Some access to support was evident: 38% reported receiving information about things done well, 52% reported receiving specific comments about things that they could improve, and 57% reported receiving helpful hints or problem-solving advice. The largest percentage of respondents (38%–57%) reported that they lacked access to the support they needed to do their job as managers. Many respondents (36%–38%) reported that they lacked resources to meet their managerial job requirements. Only 36% reported that temporary help was readily available when needed. Fifty-one percent of respondents reported, on the JAS-II, that they believed that there were rewards for innovation on the job. Less than 46% reported that their job allowed flexibility, but half (50%) reported that they had visibility for work-related activities. Fifty percent of respondents reported, on the ORS-II, that they collaborated with physicians on patient care. Less than half (48%) reported being sought out by peers for help with problems, and 48% reported being sought out by managers for help with their problems. Only 41% reported that they were sought out for advice by other professionals, such as dietitians or physical therapists, on a multidisciplinary team. On the two-item global empowerment subscale used for construct validity, which was not used for the total empowerment score, less than half (45%) of respondents reported that their current work environment empowered them to accomplish work in an effective manner and only 37% considered the workplace to be an empowering environment (Figure 1). The mean score for total empowerment was 21 (SD = 2.91) for NMs and 20 (SD = 3.36) for ANMs, revealing a lack of empowerment felt by this group of middle managers (Table 1). CWEQ-II = Conditions of Work Effectiveness Questionnaire II. CWEQ-II = Conditions of Work Effectiveness Questionnaire II. Figure 1. Two-item global empowerment subscale of the Conditions of Work Effectiveness Questionnaire II. This subscale was used only for construct validation, and its scores were not included in the total empowerment score. Discussion Our findings indicate that NMs and ANMs who are relatively inexperienced in management lack the information, support, and resources necessary to accomplish required work. Lee and Cummings7 found that the amount of perceived organizational support significantly contributes to a perception of empowerment. We found that middle managers perceived a lack of organizational support. Both empowerment theory and the literature on organizational support point to a possible negative impact of such a perception on staff development and even patient safety. Our findings also reveal that empowerment of NMs and ANMs, which is a required characteristic for those who are leaders in a complex health care environment,4 is lacking. As McDermott et al22 noted, middle managers must feel empowered if they are expected to empower their staff and thus achieve excellence in nursing. To empower middle managers, leadership must pay attention to those empowerment constructs that are often perceived as minor, such as providing adequate time and support to do a job. We found that although some middle managers feel some empowerment in their work, managers with less experience particularly need additional support and resources. Suggestions on how to empower middle managers can be gleaned from the research tool itself. To increase empowerment, nursing administrators must take the lead in breaking down barriers to success by providing necessary resources, improving communication, and displaying support. A significant limitation of our study is that its findings were from a single medical center. Because empowerment is strongly linked to organizational culture,22 exploring the sense of empowerment at one facility informs about that facility. Because of the high response rate for our survey, our findings are informative about the setting; however, they may not be generalizable to other settings. Another limitation of our study was its small sample size. Conclusion Our study serves as a pilot study for better understanding the ways in which NMs and ANMs in a hospital setting perceive empowerment and how empowerment influences their role perception, satisfaction, and ability to carry out their varied responsibilities as middle managers. NMs and ANMs with less experience in a leadership role may have more difficulty feeling empowered, especially when key elements are not provided. The next step for research at this facility would be to determine what behaviors and actions from upper management increase empowerment in middle managers. The work that has been done at magnet hospitals, although focused largely on empowerment of staff, may provide further insight into empowering behaviors for managers. If empowerment of middle managers is the desired outcome, then middle managers must work collaboratively with upper management to make their needs known and design reasonable and affordable ways to reach this desired outcome. Failing to empower middle management will lead to retention difficulties at both the management and staff level and will ultimately impair the delivery of safe patient care. Disclosure Statement The author(s) have no conflicts of interest to disclose. Acknowledgment Katharine O’Moore-Klopf, ELS, of KOK Edit provided editorial assistance. References 1. Kanter RM. Men and women of the corporation. 2nd ed. New York: Basic Books; 1993. 2. Greco P, Laschinger HK, Wong C. Leader empowering behaviours, staff nurse empowerment and work/engagement burnout. Nurs Leadersh (Tor Ont) 2006 Dec;19(4):41–56. 3. Conger JA, Kanungo RA. The empowerment process: integrating theory and practice. Academy of Management Review 1988;13(3):471–82. 4. Mathena KA. Nursing manager leadership skills. J Nurs Adm 2002 Mar;32(3):136–42. 5. Platt JF, Foster D. Revitalizing the charge nurse role through a bespoke development programme. J Nurs Manag 2008 Oct;16(7):853–7. 6. Block P. The empowered manager: positive political skills at work. San Francisco: Jossey-Bass; 1987. 7. Lee H, Cummings GG. Factors influencing job satisfaction of front line nurse managers: a systematic review. J Nurs Manag 2008;16(7):768–83. 8. Kanter RM. Men and women of the corporation. New York: Basic Books; 1977. 9. Stichler JF. Staff nurse engagement in health facility design. J Nurs Adm 2008 Jul–Aug;38(7–8):315–8. 10. McCarthy V, Freeman LH. A multidisciplinary concept analysis of empowerment: implications for nursing. Journal of Theory Construction & Testing 2008 Fall;12(2):68–74. 11. Draper DA, Felland LE, Liebhaber A, Melichar L. The role of nurses in quality improvement: research brief number 3 [monograph on the Internet]. Washington, DC: Center for Studying Health System Change; 2008 [cited 2009 Nov 11]. Available from: www.hschange.org/CONTENT/972/. 12. Johnson BH. Empowerment of nurse educators through organizational culture. Nurs Educ Perspect 2009 Jan–Feb;30(1):8–13. 13. Manojlovich M. Power and empowerment of nursing: looking backward to inform the future. Online J Issues Nurs 2007 Jan 31;12(1):2. 14. Laschinger HK. A theoretical approach to studying work empowerment in nursing: a review of studies testing Kanter’s theory of structural power in organizations. Nurs Adm Q 1996;20(2):25–41. 15. Laschinger HK, Havens DS. Staff nurse work empowerment and perceived control over nursing practice, Conditions for work effectiveness. J Nurs Adm 1996 Sep;26(9):27–35. 16. Laschinger H, Finegan J, Shamian J. Promoting nurses’ health: effect of empowerment on job strain and work satisfaction. Nurs Econ 2001 Mar;19(2):42–52. 17. Laschinger HKS, Finegan J, Shamian J, Wilk P. Impact of structural and psychological empowerment on job strain in nursing work settings: expanding Kanter’s model. J Nurs Adm 2001 May;31(5):260–72. 18. Laschinger HKS, Finegan J, Shamian J, Wilk P. Workplace empowerment as a predictor of nurse burnout in restructured healthcare settings. Hosp Q 2003;6(4):2–11. 19. Laschinger HK, Purdy N, Almost J. The impact of leader-member exchange quality, empowerment, and core self-evaluation on nurse manager’s job satisfaction. J Nurs Adm 2007 May;37(5):221–9. 20. Laschinger HK, Sabiston JA, Kutszcher L. Empowerment and staff nurse decision involvement in nursing work environments: testing Kanter’s theory of structural power in organizations. Res Nurs Health 1997 Aug;20(4):341–52. 21. Laschinger HK, Wong C, McMahon L, Kaufmann C. Leader behavior impact on staff nurse empowerment, job tension, and work effectiveness. J Nurs Adm 1999 May;29(5):28–39. 22. McDermott K, Laschinger HK, Shamian J. Work empowerment and organizational commitment. Nurs Manage 1996 May;27(5):44–8. 23. Laschinger HK, Almost J, Tuer-Hodes D. Workplace empowerment and magnet hospital characteristics: making the link. J Nurs Adm 2003 Jul–Aug;33(7–8):410–22. 24. Faulkner J, Laschinger H. The effects of structural and psychological empowerment on perceived respect in acute care nurses. J Nurs Manag 2008;16(2):214–21. 25. Laschinger HK, Finegan J. Using empowerment to build trust and respect in the workplace: a strategy for addressing the nursing shortage. Nurs Econ 2005 Jan–Feb;23(1):6–13. 26. Parsons ML, Cornett PA, Golightly-Jenkins C. Creating healthy workplaces: laying the groundwork by listening to nurse managers. Nurse Leader 2006 Jun;4(3):34–9. 27. Feltner A, Mitchell B, Norris E, Wolfle C. Nurses’ views on the characteristics of an effective leader. AORN J 2008 Feb;87(2):363–72. 28. Kanter RM. Power failure in management circuits. Harv Bus Rev 1979 Jul–Aug;57(4):65–75. 29. Pajares F. Overview of social cognitive theory and of self-efficacy [monograph on the Internet]. Atlanta, GA: Emory University: 2002 cited 2010 Oct 4]. Available from: www.emory.edu/EDUCATION/mfp/eff.html. 30. Spreitzer GM. Psychological empowerment in the workplace: dimensions, measurement, and validation. Academy of Management Journal 1995 Oct;38(5):1442–65. 31. Laschinger HKS, Finegan J. Cronbach alpha reliability results—CWEQ, CWEQ-II, MAS [PowerPoint presentation on the Internet]. London, Ontario, Canada: The University of Western Ontario School of Nursing; 2005 [cited 2009 Nov 10.] Available from: http://publish.uwo.ca/~hkl/Workengagement2005.ppt.
An Alternate Model for Medical Education: Longitudinal Medical Education Within an Integrated Health Care Organization— A Vision of a Model for the Future?
Monday, 30 August 2010
Innovation Quentin Eichbaum, MD, PhD, MPH, MFA, FCAP; Tim Grennan, MD, FACP; Howard Young, MD; Myra Hurt, PhD Fall 2010 - Volume 14 Number 3 Editor’s note: This article was developed as a hypothetical model from the June 2009 session of the Harvard Macy Institute—Program for Leading Innovations in Healthcare and Education on innovations in medical curriculum. As the health care debate in the US rages on, we need also to examine whether our medical education system is keeping pace with the changing landscape of medicine and how well it will cope with the proposed changes in health care delivery. Are we graduating sufficient numbers of physicians in the correct specialties and in a timely manner? Are medical trainees being adequately trained for the molecular and digital revolutions in science and technology? Are there other models of medical education outside of the universities that we might explore for training outstanding physicians in America in the 21st century? We propose situating a medical school program within one of the larger progressive, nonprofit, integrated, managed care organizations in the US. At first, this may appear an audacious suggestion. The recent health care reform legislation and current policy discussions suggest that these integrated delivery systems may become the model for future care delivery. It seems legitimate to try to use their strengths in seeking solutions to the country’s health care dilemmas. From this perspective, we suggest that situating modular and longitudinal medical education within a progressive integrated health care system such as a large, multispecialty group model, nonprofit health maintenance organization might provide a valid alternate stream of education and training for physicians (and other health care workers). It could draw its trainees from a broader but ultimately not less deserving pool of applicants and potentially also help alleviate certain health care worker shortages. We conceive of this alternate medical education course operating alongside the traditional university-based medical schools rather than replacing them. We suggest the hypothetical name Kaiser Permanente School of Medicine (KPSOM) to exemplify the alternative model we describe. Kaiser Permanente (KP) is a large, integrated, prepaid Health Plan with 8.6 million members and more than 14,000 physicians in eight Regions.1 The organization has established for itself a solid reputation as a progressive health care delivery organization with a focus on preventive, patient-centered care and patient satisfaction. The KPSOM for the training of health care workers would be one that 1) uses the existing structures of a progressive health care management organization (with existing graduate physician-training programs) and does not require the construction of new medical schools; 2) co-trains physicians, physician’s assistants, nurses, nurse practitioners, and potentially even health care administrators; 3) has a streamlined and less costly admissions process and functions alongside traditional university-based medical schools; 4) acknowledges the student-centric learning style and computer proficiency of the incoming Millennial Generation (or Generation Y) students; 5) maximizes human potential by taking into account differences in learning styles and accommodating self-paced modular learning; 6) increases the number of physicians (as well as other health care workers) by drawing on a pool of applicants, some of whom may conventionally be considered underqualified for admission but will prove to be equally qualified after training; and 7) enhances opportunities for medical careers to students from economically disadvantaged backgrounds. Applicants to the Kaiser Permanente School of Medicine A central component of the school would be the admission and training of what we call the pluripotential health care worker. The baseline 1 to 3 years of learning in this school (depending on how the students pace their learning) would involve the training of a generic or pluripotential student apprentice who would be well versed in both basic science and basic medical skills at a level of competence necessary for medical students, physician’s assistants, and nurses or nurse practitioners. Because baseline training before specialist training would be pluripotential, applicants could also be selected from a broader background of applicants. In particular, applicants from underprivileged and underserved areas might be accepted into the program because learning in the program is self-paced and modular in nature, with backup mentoring and academic support (as described in the following section). The school would be attractive to a diverse range of students, including those from resource-poor settings; students interested in a career in health care but undecided about the specific direction; students who prefer the option of self-paced learning; and students attracted by the option of remaining within a large organization for residency, fellowship, and subsequent employment opportunities. An advantage of this hypothetical model would be that it could function without some of the current constraints that render the current admissions process to university medical schools cumbersome, expensive, and drawn out. Students applying to the KPSOM would not need to apply to and interview at numerous medical schools. The current highly competitive system is draining and costly and entails students crossing the country for multiple interviews and schools investing substantial time and money into screening applications and interviewing students—overall, an exhausting, time-consuming, and costly process. This new hypothetical institution might not require the MCAT (Medical College Admission Test) for admission, because it would conduct its own in-house assessment of candidates. It would not directly compete with university medical schools because it would accept trainees from a wider pool of applicants and nurture them within the organization to the required level of competence. The school would conduct its own in-house evaluations, monitored by the Liaison Committee on Medical Education (LCME), of students it admits. These could take the form of an initial basic competency test, followed by formative and summative testing as students progressed through the modular self-paced learning system (see the next section). This progressive admissions policy would allow applicants from a broader range of educational backgrounds, not only from elite schools but also from underserved areas. This would make for a healthy diversity among trainees. It has been recently noted that about 75% of US medical students come from the upper wage-earning quintile of the population. According to a report on the Web site of the Association of American Medical Colleges (AAMC), the Matriculating Student Questionnaire, All Schools Summary Report for the years 2006, 2007, and 2008, 69% to 71% of students reported that their parents’ gross income was $75,000 or more, and the average was between $149,779 (2006) and $164,483 (2008). In these same years, 15% or less reported that their parents’ gross income was less than $40,000.2 In keeping with the community mission of KP, this new training model could help redress this imbalance by accepting minority and less-privileged students. Recruitment from a wider pool of applicants would likely also increase numbers of medical, nursing, and physician’s assistant graduates and might have the added consequence of increasing the supply of qualified health care workers to underserved areas. Modular Self-Paced Learning Education and training at this new school would be modular and self-paced but would be buttressed with sophisticated academic support and mentoring. An organization the size of KP has ample resources to provide such academic support. Students would not study in lockstep with the entire class being at the same point in the curriculum at any one point, as in most current medical school curricula, but would instead pace their own learning. Coursework would be completed in modules, and trainees could be tested for competency at critical steps in their learning before being permitted to move on to the next learning module. Modular learning in the basic sciences would be largely Web based. Because it would not be a classic university, this new alternative medical school would not employ basic science faculty for lecture-style teaching. The school might partner with universities for parts of the basic science teaching. Students would be assigned (as apprentices) to KP clinical faculty members, many of whom are already clinical faculty members at local universities and are engaged in the teaching of graduate physicians. The students would shadow the faculty in clinics and hospitals while they also engaged in completing modules in clinical skills. Students would not be permitted to proceed to the next level of learning in the basic sciences or clinical skills until they had demonstrated adequate competency at each prior level of learning. Although the program would be self-paced, there would nonetheless be a limited time frame for completion of specific tracks (possibly five to seven years). We envisage students learning the basic sciences concurrently with clinical skills so that concepts from these two spheres of knowledge would reinforce each other. The specifics of the school’s curriculum model would remain to be deliberated but would be based on recommendations of the AAMC for small interdisciplinary group teaching that would incorporate aspects of problem-based and team-based learning as well the more recent recommendations of the Carnegie Foundation’s 2010 report for supportive learning environments that encourage curiosity, encourage feedback improvement, and promote learners’ ability to work collaboratively in health care teams.3 As recommended in the Carnegie Foundation report, the KPSOM would also, through its apprenticeship model, incorporate more clinical experiences earlier in the curriculum. Examples of current curricula that may provide guidance are Harvard Medical School’s New Pathway MD Program (http://hms.harvard.edu/admissions/default.asp?page=pathway); the symptom-based curriculum of Calgary Medical School in Canada (www.medicine.ucalgary.ca/) and the new Paul L Foster Medical School in El Paso, Texas (www.ttuhsc.edu/elpaso/); and the “longitudinal integrated” clerkship curriculum of the Cambridge Health Alliance and Harvard Medical School (www.cha.harvard.edu/academics/integrated_clerkship.shtml) in Boston. It is anticipated that the students would learn better and more quickly because the program would be embedded in an integrated health care system. While proceeding with their modules in the basic sciences, students would work at KP as clinician apprentices. Initially, they would do very basic clinical work while shadowing experienced physicians in clinics and hospitals, and only after demonstrated basic clinical competencies would they proceed to more self-reliant clinical work. Millennial Generation or Generation Y: Self-Based Style of Learning A curriculum of self-paced modular learning has a number of advantages. First, it would accommodate differences in students’ learning styles and would be advantageous to students from challenged backgrounds by allowing them to proceed through the program at their own learning pace (within certain time limits). Second, it would accommodate the self-based learning style of the “Millennial” or “Generation Y” students who are generally adept at computers and are swift at information retrieval from the Internet, who ostensibly have shorter attention spans than students in past generations, and who prefer to take charge and be at the center of their own learning.4 Third, it would take account of the exponential increase in medical knowledge by presenting it in modular form and allowing students to pace their learning. The Pluripotential Baseline Trainee The first benchmark phase of the KPSOM would be the training of a pluripotential health care worker who would subsequently proceed with more specific training along designated tracks toward becoming a physician, physician’s assistant, nurse, nurse practitioner, or health care administrator. Each track would have graduated levels of competency in training, and trainees would have to demonstrate adequate competency at each level before being admitted to the next. Many students might know from the start which graduation track they wish to pursue, but all would initially go through the gatekeeping pluripotential track, during which they would also be tested for their natural learning styles, aptitude, and acquired competencies before being admitted to the graduation track of their choice. Such monitoring would maximize human potential because there would presumably be a closer fit between candidates’ aspirations and their true capabilities. A trainee who did not qualify for the physician track might still be offered the choice of the less demanding physician’s assistant track. After completion of the basic gatekeeping pluripotential track, the different tracks would, however, not be melded but would be separate and have strict competency attainment requirements. This hypothetical new school could afford having different tracks of health care professional training because unlike a university medical school, it would ultimately offer employment to most graduates in the different tracks. Regarding administrative regulation of the school, the LCME—which currently appears to be interested in innovative projects in medical education—would maintain its standard accrediting and regulatory role at all stages of the school’s development, as it does for all other US medical schools. Students would be required to pass the standardized National Board of Medical Examiners subject examinations as well as the US Medical Licensing Examination steps 1, 2, and 3 for licensure. In any case, in 2010, the centennial year of its groundbreaking Flexner Report, the Carnegie Foundation released another call for reform, Educating Physicians: A Call for Reform of Medical School and Residency,3 in which it drew attention to the need for reform with regard to admissions, accrediting, certifying, and licensing in medical education in a manner that resolves conflicts but ensures diversity of medical schools. The first two of the report’s seven recommendations read as follows3: AAMC and medical schools work together to revise premedical course requirements and admission processes, ensuring the diversity of those in medical schools. Accrediting, certifying, and licensing bodies together develop a coherent framework for the continuum of medical education and establish effective mechanisms to coordinate standards and resolve jurisdictional conflicts. Students as Reduced-Tuition Employees of the Organization Tuition would be reduced because students would be admitted as part-time employees and would perform, in their roles as clinical apprentices, basic clinical service functions for the organization’s clinics and hospitals. Conceivably, as employees they might also receive a reasonable stipend to cover living expenses. Analogous education models exist within engineering schools in which students may spend half the year within the university and the other half employed by an engineering firm (Richard K Miller, personal communication, May 2009).a,5 The organization would ensure that appropriate supervision is provided at all times to quarantee that patient safety and quality of care is maintained.Students of the new school would graduate with less financial debt than students of university medical schools and would therefore not be unduly influenced by considerations of the size of tuition loans in their choice of medical specialty training, as is happening with current medical school graduates applying for residency. Moreover, a less costly system may be enticing to students from disadvantaged educational backgrounds as well as to more accomplished students from better endowed institutions. This would enhance the diversity of the school’s student population and may ultimately also increase the numbers of physicians choosing to return to work in resource-poor settings. The financing of the school itself, which may require some additional infrastructure but little physical construction, may come from KP itself, particularly if it viewed the venture as a good investment. Because the school would attract students from resource-poor settings, additional financing might be obtained via the federal government, such as through new health care legislation,6 or through state support, or from large philanthropic organizations with an interest in education such as the Carnegie or Rockefeller Foundations. The Lifelong Medical School: Residency, Fellowship, Cross-Training, and Continuing Medical Education The KPSOM would continue and expand its own in-house residency and fellowship programs that encompass a number of medical specialties and subspecialties. Medical student trainees would apply from within the organization for specialty training at any one of its many hospitals. Because the medical school and residency programs would be housed within the same organization, applications for residency would also be greatly facilitated. The drawn-out and costly process of the current residency application and cross-country interview process, which consumes the better part of the fourth year of medical school, would be obviated. This time saving could eliminate a year of medical training for the motivated, quicker-paced student or else provide the additional time required for the slower-working, self-paced student. During their ‘medical school’ training, students would be carefully monitored, evaluated, and assessed for their aptitudes and learning styles in deciding about residency. The processing of applications from within the organization would not only streamline the process but also might improve quality control and standardization of applications. Residency programs would also be largely modular in structure and self-paced for the learning of clinical competencies. Although there might be some loss of diversity among residents who all derive from the same organization, compared with residents entering from a variety of different medical schools, the gain to the residency program would be in having a more carefully monitored, standardized, and appropriately matched (by aptitude, learning style, and intellectual capability) program of residents. Students would not be required, however, to complete all their clerkships and rotations within the school but would be encouraged to do rotations outside of KP, which already has formal affiliations with medical schools such as those with the University of California, San Francisco; Stanford University; the University of California, Los Angeles; the University of California, Davis; the University of Southern California; and the University of California, Berkeley (public health). Depending on their examination grades, performance, and recommendations, students from KPSOM applying for rotations, residencies, and fellowships outside of the organization should be readily competitive with students from other medical schools. Applications to outside programs should not present a compatibility problem, as KP already interfaces with several such residency programs. The program might also admit a limited number of residents from other US medical schools as well as graduates of foreign medical schools, who would also be carefully assessed and then slotted into the appropriate phase of the training program. Currently, international medical applicants to US residency programs are required to repeat their entire residency training regardless of their prior training and competency. In this proposed alternative medical school, foreign residency applicants would nonetheless still have to pass US medical board examinations and satisfy all LCME accrediting requirements. Applications to fellowship programs, which would also be in-house, would be similarly handled. The proposed KPSOM would also readily accommodate cross-training of its employed physicians into different associated subspecialties, a trend that is occurring increasingly as medical knowledge expands. For instance, the increasing role of invasive radiologic techniques and laparoscopic surgical techniques has changed management in a variety of surgical disciplines. Finally, continuing medical education programs would be easier to implement and monitor from within the organization, whereas the current system of accumulating continuing education credits is often seemingly haphazard and fragmented. Continuity of Care, Preventive Care, and Patient Satisfaction in the Lifelong/Longitudinal Medical School Because most trainees would continue their training within the organization initially as medical students, then as residents, fellows, and finally as fully employed physicians, they could provide better continuity of care for patients over this extended period of participation in the organization. This would lead to both enhanced patient care and, as a consequence, overall higher levels of patient satisfaction. Instead of experiencing continual disruptions in their care with frequent changes in physicians and hospitals, patients would continue to see the same physicians they initially encountered when these physicians were medical students or residents and who would therefore have a more substantial grasp of their ongoing health care needs over time. In addition, with enhanced continuity of care, the organization could implement highly effective longitudinal preventive-care programs, which would lead to improved health outcomes and patient satisfaction. The integrated modular nature of this course would allow for flexibility in learning styles to be matched with the flexibility that would be needed of the future workforce. It would promote the concept of teamwork at an early stage, improve communication between trainees and teachers, and redefine the apprentice model in the 21st century. Summ ary In brief, the hypothetical KPSOM could be envisaged as a model of a lifetime medical school that would initially draw candidates from a diverse socioeconomic pool of applicants and guide them through a series of carefully monitored, modular, self-paced basic science and clinical skills learning programs, up to a phase where they would branch out into specialty programs leading to graduation as physician, physician’s assistant, nurse, nurse practitioner, or health care administrator. Tuition would be less costly because students would also be employees of the organization and would likely remain in the organization throughout their extensive training careers, from medical school and into subspecialty certification—and possibly as full-fledged physician employees. This system would be satisfying to patients as well as students because it would provide more effective longitudinal and preventive care. The model is offered as an alternate stream of medical education that would not supplant university medical schools but would operate alongside them. This alternate model might serve to increase the number of qualified physicians without the need to build more costly medical schools, and it would train a broader range of health care professionals from diverse backgrounds within the same organization. a President, Franklin W Olin College of Engineering Disclosure Statement The author(s) have no conflicts of interest to disclose. Acknowledgments We gratefully acknowledge Elizabeth Armstrong, PhD, Director of the June 2009 session of the Harvard Macy Institute—Program for Leading Innovations in Health Care and Education and our seminar group for the ideas generated in the group on innovations in the medical curriculum. Katharine O’Moore-Klopf, ELS, of KOK Edit provided editorial assistance. References 1. Fast facts about Kaiser Permanente [monograph on the Internet]. Kaiser Permanente News Center. Oakland, CA: Kaiser Permanente; © 2010 [cited 2010 Jul 5]. Available from: http://xnet.kp.org./newscenter/aboutkp/fastfacts.html.2. Matriculating Student Questionnaire, All Schools Summary Report [Web page on the Internet]. Washington, DC: Association of American Medical Colleges. © 1995–2010 [cited 2010 Jul 5]. Available from: www.aamc.org/data/msq/start.htm.3. Cooke M, Irby DM, O’Brien BC. Educating physicians: a call for reform of medical school and residency. San Francisco: Jossey-Bass; 2010.4. Baron RA. Why it’s important to export our field—and how we can do it effectively. In: Saville BK, Zinn TE, Meyers SA, Stowell JR, editors. Essays from e-xcellence in teaching, 2006. Washington, DC: Society for the Teaching of Psychology; 2006 [cited 2010 Jul 7]. Available from: http://teachpsych.org/resources/e-books/eit2006/eit06-05.pdf.5. Miller RK. President’s message [monograph on the Internet]. Needham, MA: Franklin W Olin College of Engineering; 2010 [cited 2010 Jul 7]. Available from: www.olin.edu/about_olin/presidents_message.asp.6. Patient Protection and Affordable Care Act of 2010, Pub L. No. 111-148, 124 Stat 119. Title V. Health Care Workforce; Subtitle B: Innovations in Health Care Workforce; Section 5101: National health care workforce commission; Section 5102: State health care workforce development grants. Available from: http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf.
False Estimates of Elevated Creatinine
Wednesday, 23 May 2012
Corridor Consult Manpreet Samra, MD; Antoine C Abcar, MD Spring 2012 - Volume 16 Number 2 Abstract One of the most common reasons for a nephrology consult is an elevated creatinine. An elevation in the serum creatinine concentration usually reflects a reduction in the glomerular filtration rate (GFR). Given the association of elevated creatinine and risk of cardiovascular mortality, it is important to keep in mind that at times the elevation of the creatinine is not representative of a true reduction in GFR. There are various causes of factitious elevation of creatinine. They can be broadly grouped into increased production of creatinine, interference with the assay and decreased tubular secretion of creatinine. Introduction A colleague asks about a patient: a woman, age 48 years, diagnosed with hypertension for 2 years and with hyperlipidemia for 10 months who has had a steadily increasing creatinine level, from 0.7 to 1.8 over the last 8 months. Her medications include hydrochlorothiazide per os 12.5 mg/day and fenofibrate per os 200 mg/day. One of the most common reasons for nephrology consult is elevated creatinine, which usually reflects a reduction in glomerular filtration rate (GFR). Given the association of elevated creatinine with cardiovascular mortality, it is important to keep in mind that elevated creatinine is not always representative of a reduction in GFR. Here, we will discuss the various causes of false estimates of elevated creatinine. Patients have few signs and symptoms during early renal disease. Early detection of abnormal kidney function is important, because early treatment usually slows disease progression. Because it is not possible to directly measure kidney function or the GFR, a surrogate is needed. The endogenous marker most commonly used to measure kidney function is creatinine.1 Creatinine is generated in muscle and is proportionate to muscle mass and remains relatively constant. Eighty-five percent to 90% of creatinine is excreted by the kidney; the rest undergoes tubular secretion. It is most commonly measured by a colorimetric assay called the Jaffe reaction. In the Jaffe reaction, creatinine combines with picric acid to form a colored complex that is measured to quantify the creatinine. With this in mind, we can discern multiple factors that may artificially increase the estimated creatinine level. These can be grouped into three categories: increased production of creatinine, interference with the assay, and decreased tubular secretion of creatinine. Increased Creatinine Production Creatinine is produced in muscle by the nonenzymatic conversion of creatine and phosphocreatinine. The creatinine generated is proportional to muscle mass and is relatively constant. The liver has an important role in the formation of creatinine through methylation of guanidine aminoacetic acid. The serum creatinine can vary by 0.5 to 1.0 mg/dL according to diurnal and menstrual variations, race, and diet (and method of meat preparation). An increase in serum creatinine can result from increased ingestion of cooked meat (which contains creatinine converted from creatine by the heat from cooking) or increased intake of protein and creatine supplements, in excess of the recommended dosage. Creatine is present in the organs, muscles, and body fluids of animals. Creatine supplements promote protein synthesis and are a quickly available source of energy for muscle contraction, hence they are used to enhance athletic performance. Furthermore, intense exercise can increase creatinine by increasing muscle breakdown.2,3 Interference With the Assay As stated earlier, the Jaffe reaction is a colorimetric assay. It can be influenced by other endogenous chromogens such as acetone and acetoacetate (such as in diabetic ketoacidosis), fasting, lipemia, and hemolysis, resulting in an overestimate of the serum creatinine. Drugs that can interfere with the assay include antibiotics such as cephalosporins, specifically cefoxitin and cefazolin; barbiturates; N-acetylcyteine; and chemotherapeutic agents such as flucytosine (although by a different assay: the Kodak Ektachem method).4,5 Another material known to interfere with the Jaffe reaction is nitromethane, a common component of radio-controlled-vehicle fuels. The Kodak Ektachem method uses an ammonia reaction to quantify creatinine. Creatinine is converted to N-methylhydantoin and ammonia. Flucytosine is the only agent known to cause a false elevated creatinine result when this method is used.6 This artificial result is attributed to the 4-amino group of flucytosine, which is converted to free ammonia by creatine iminohydrolase. More specific creatinine assays not subject to such interference are being investigated. One such assay, the VITROS CREA, employs an oxidation reaction to measure endogenous creatinine levels and will soon be available at laboratories within Kaiser Permanente. The VITROS CREA assay will quantify creatinine with greater precision. Decreased Secretion Approximately 15% of creatinine is secreted in the tubules. It is secreted by the organic cation secretory pump that can be inhibited by other organic cations. Trimethoprim, cimetidine, and other H2-blockers medications can inhibit this process and cause an increase in the measured serum creatinine7,8 (Table 1). Case in Question In the above-mentioned patient we stopped the fenofibrate, and we saw her creatinine trend toward normal in a few months. It is postulated that fibrates (particularly fenofibrate) impair the generation of vasodilatory prostaglandins and could alter intrarenal hemodynamics, possibly altering GFR, but the definitive mechanism by which this occurs is still to be elucidated.9 Case studies of renal transplant patients have shown evidence of tubular toxicity caused by fenofibrates and increased creatinine production.10 The magnitude of changes in creatininemia ranged from 8% to 18% for fenofibrate. The change in creatinine, though, has been shown to be reversible after fibrate withdrawal. In conclusion, when elevated serum creatinine is detected, it is important to evaluate the patient as a whole to rule out possible causes. Disclosure Statement The author(s) have no conflicts of interest to disclose. Acknowledgment Leslie E Parker, ELS, provided editorial assistance. References 1. Shemesh O, Golbetz H, Kriss JP, Myers BD. Limitations of creatinine as a filtration marker in glomerulopathic patients. Kidney Int 1985 Nov;28(5):830-8. 2. Hamilton RW, Gardner LB, Penn AS, Goldberg M. Acute tubular necrosis caused by exercise-induced myoglobinuria. Ann Intern Med 1972 Jul;77(1):77-82. 3. Oh MS. Does serum creatinine rise faster in rhabdomyolysis? Nephron 1993;63(3):255-7. 4. Molitch ME, Rodman E, Hirsch CA, Dubinsky E. Spurious serum creatinine elevations in ketoacidosis. Ann Intern Med 1980 Aug;93(2):280-1. 5. Saah AJ, Koch TR, Drusano GL. Cefoxitin falsely elevates creatinine levels. JAMA 1982 Jan 8;247(2):205-6. 6. Mitchell EK. Flucytosine and false elevation of serum creatinine level. Ann Intern Med 1984 Aug;101(2):278. 7. Berg KJ, Gjellestad A, Nordby G, et al. Renal effects of trimethoprim in ciclosporin- and azathioprine-treated kidney allografted patients. Nephron 1989;53(3):218-22. 8. Kemperman FA, Silberbusch J, Slaats EH, Prins AM, Krediet RT, Arisz L. Follow-up of GFR estimated from plasma creatinine after cimetidine administration in patients with diabetes mellitus type 2. Clin Nephrol 2000 Oct;54(4):255-60. 9. Broeders N, Knoop C, Antoine M, Tielemans C, Abramowicz D. Fibrate-induced increase in blood urea and creatinine: is gemfibrozil the only innocuous agent? Nephrol Dial Transplant 2000 Dec;15(12):1993-9. 10. Angeles C, Lane BP, Miller F, Nord EP. Fenofibrate-associated reversible acute allograft dysfunction in 3 renal transplant recipients: biopsy evidence of tubular toxicity. Am J Kidney Dis 2004 Sep;44(3):543-50.