Friday, May 7, 2010

Boston Trip (2): IHI

The Institute for Healthcare Improvement (IHI) was my major stop the next day in Boston. This organization is a very interesting one that may play an important role in the healthcare reform. On April 19, President Obama nominated the CEO of IHI, Dr. Donald M. Berwick, to run the Medicare and Medicaid Service (CMS) which serve nearly one-third of all Americans. Founded in 1991 and based in Cambridge, Massachusetts, IHI works to improve health care quality while reducing its cost. This nomination personifies Mr. Obama’s determination to forge some new ideas in the new health care law.

As Madge Kaplan, the director of communications in IHI, told me while she took me on a tour of IHI’s headquarters in Boston, this organization is very positive and optimistic. People are working in an open and transparent office environment, and the sunshine coming through the big window makes the large space bright. Walking down aisle close to the window, I read IHI’s ambitious goals—the “no needless list” adapted from the IOM’s six improvements: no needless deaths, no needless pain or suffering, no helplessness in those served or serving, no unwanted waiting, no waste and no one left out—which are printed on the pillars. On the other side of the aisle, a poster board shows energy and water saving fact sheets that explain for what the staff did.

It is very interesting for me to know that IHI began its work with some little and simple things, rather than with some complex, high-tech, and extremely costly programs. Rather than spend huge amount of money to develop the advanced technique, what IHI does is more like cultivating ideas for improvement. One simple example is helping nurses save time when looking for things and making the flow of hospital work more effective. As a result, they don’t have spend too much time running from floor to floors, answering phones, or doing paper works; instead, this precious time can be devoted to patients who really need it.

Another renowned idea is Dr. Atul Gawande’s “checklist.” Gawande has been named one of the 2010 Time 100 people for the success of his the best-selling book—“The Checklist Manifesto.”This is all about a reminder sheet to be used by a surgery team to make double-check everything right before an operation. Since this national campaign is well known, you can check for more details online. I would still like to cite Ms. Kaplan’s words as the central message for this program—“our goal here is the patient, not your ego.”

The new innovative program in IHI is the hospital Improvement Map. It is an interactive tool to guide hospitals to take actions to improve their management according to their interests and situation. For me, it is more like an idea library which collects and distills all the best knowledge available on the key process improvements. And a hospital could choose the best idea that matches its need. Or, you can call it a map, if you prefer, which will lead you to choose the best way to the final goal—better health care. To better understand it, check it out.

IHI is growing, not only nationwide, but also worldwide. IHI has an international forum every year which draws almost 6,000 people, and also has cooperation campaigns in many other countries, such as the UK and Japan. Although currently there is no connection with China, I believe there will be in the not so distant future.

Saturday, April 24, 2010

Boston Trip (to be continued)

The sunny day that greeted me was a pleasant surprise when the flight landed at Logan International Airport in Boston, because I expected that it would be a cold and wintry day since it was late March in the North. I was reading a book called "China Ink," which introduces current Chinese journalists, during my whole flight and wasn't aware of our arrival until the last minute. I had prepared a long time for his journey which was going to give me a great chance to meet some great journalists from the Knight Journalism Fellowships program at MIT--and most important, they are experienced journalists working in China. That would be a great trip, I told myself. Actually, it was indeed.

The first thing in my tiny scheduler was to attend the program's regular Tuesday seminar. It was very much like what we have in every Wednesday's class--a guest speaker tells us his/her stories about his/her fields and answers our questions. The speaker--Mr. Brendan Foley--introduced how to use deep water robots to survey the sea floor and explore the human past. The most interesting thing was that the archaeologists began to use molecular biological techniques to analyze the substances in the ancient jar which was found in the deep sea. According to the result of DNA analysis, some substances have been proved to be olive and grape fragments. Out of curiosity, I asked the speaker whether his team had ever tried to analyze the substances by using a microbiological technique? As I know, in some forms, the bacteria and virus can survive for hundreds of years or under extreme conditions. If the scientists had already successfully determined the 1918 flu virus's genetics sequence by using historic tissue samples recovered from a female flu victim buried in Alaska, why can't we imagine that we might find something more in those jars? Maybe some ancient virus, I guess.
(To be continued... upcoming--visiting of IHI)

Thursday, April 22, 2010

Meals on Wheels in Athens, GA

Finally, I have uploaded this slide show of my feature story-- "Meals on Wheels in Athens"-- in my blogger. Many thanks to all the people who helped me in uploading this file, especially to Michael and the guy from digital lab in Tate!

Now, please enjoy this short piece story.

Brief introduction of this story:

In United States, there are about 2.5 million seniors who are at risk for going hungry. Georgia ranks 6th among the 50 states in terms of senior hunger, according to a nation-wide study conducted by researchers at the University of Kentucky. Meals on Wheels in Athens Community Council on Aging is a program that provides hot noon-day meals, five days a week, to homebound adults in Clarke County. For those who are especially likely to go hungry without outside help, MOW also delivers frozen and shelf-stable products in addition to hot lunches. All the food is delivered by 135 vounteers who drive 16 delivery routes in Clarke County.

In case for any further questions in uploading slide show, I write down some notes to remind myself for next time:
(1) If you use the soundslide plus software online to finish your work, you can just use the Filezilla to upload your whole folder to a web server, then you can generate a URL address which helps you to embed your slide show in your blogger.
(2) If you use the free soundslide plus software to finish your work at home, you may need a webstorage to save the folder "publish-to-web" which is generated when you export your final files. In this case, according to Michael's suggestions, we can choose the Netstorage of UGA.
(3) Upload all the files from your "publish-to-web" into a new fold (whatever you name it, I guess, I will try different names next time) in the webstorage. Try to play the slideshow in a new tab (I think it's the process how to gain your URL address). Tip is using the images from full screen rather than from other folders.
(4) Edit HTML to add a frame into which you can embed your slideshow. Tips are you should look out for the width, height and broader (I guess because my blogger template is a narrow one, I better choose the small.html).
(5) Test it and adjust it.

Tuesday, March 23, 2010

ACC: ICD shocks management

An implantable cardiac defibrillator (ICD), is a relative new cardiac rhythmic management device. Other similar cardiac rhythmic management devices include the well-known pace-maker. Different from the pace-maker, the ICD has a special wire, called a lead, which is implanted inside the heart, and can deliver an electrical shock to the heart muscle to adjust the heart beat. In the past decade, ICD market sharply increased 10 times, from 25,000 to 250,000.

Repetitive shocks are a medical emergency, which are associated with significant morbidity. An ICD is associated with a 2- or 5- fold increase in mortality, with the most common cause being progressive Heart Failure.

“Among patients with heart failure in whom an ICD is implanted for primary prevention, those who receive shocks for any arrhythmia have a substantially higher risk of death than similar patients who do not receive such shocks”--according to content showed by the speaker in ACC. About 65% of deaths were from progressive heart failure versus 35% arrhythmic deaths.

Only 20-35% of ICD shocks are appropriate. 33% are inappropriate shocks, while the last is “Phantom” shocks which only can be sensed by patients, but no record in ICD memory data.

Cardiologists are looking for effective ways to reduce inappropriate ICD shocks to insure the patient security.

Antiarrhythmic drugs are a controversial topic among experts about how to reduce the ICD shocks. Some scholars argue that these drugs can both decrease appropriate and inappropriate ICD shocks, but a few of them hold a counterview.

Catheter ablation may favorably affect mortality. Because it is effective in the short-term treatment of ventricular tachyarrhythmia storm by preventing it recurrence, it may play protective role over the long-term together with pharmacological therapy.
Other approaches to manage ICD inappropriate shocks are staying away from electromagnetic interference resource, and fixing a malfunctioning device if it is not working properly.

ACC--Biomarkers, future clinical endpoint in heart failure trials

A biomarker is in general a substance used as an indicator of a biological state. In clinical trials, the candidate markers include dyspnea, weight change, blood pressure, natriuretic peptides, markers for left ventricular (LV) and gene expression and so on. For example, COMPANION biomarker is a well established endpoint for morbidity in clinical trials, while SCD-HeFT is used for mortality.

In recent heart failure clinical trials, the biomarkers are also being widely used as primary and secondary indications. The primary biomarkers are dyspnea, weight loss, LV size and composite. The secondary biomarkers are LV size and function-ACE-I, BB trials, BNP-Val-HeFT, NYHA class-ACTION-HF.

However, these common biomarkers are not relevant endpoints in heart failure trials as a result of lacking better fidelity, cleaner signal to noise ratio, convincing evidence of meaningful clinical benefit and ideal surrogacy. Cardiologists keep looking for the ideal biomarkers which can better address these questions and become the clinical endpoints in heart failure trials in future.

They have even already written down the scenarios for the future of biomarkers not so far away.
Scenario I: clinical trial XXX tests the ability of treatment YYY to reduce the likelihood of developing heart failure; a biomarker assay is used as the endpoint that biomarker ZZZ is used as a surrogate for heart failure.

Scenario II: clinical trial XX hypothesizes that intervention YYY will improve outcomes in patients with established heart failure; rather than follow longitudinal events, a biomarker assay is used as a surrogate for prognosis.

Scenario III: because an elevated biomarker corresponds with a poor prognosis company AAA develops a “biomarker blocker”; clinical XXX is then done with drug YYY, endpoint combined morbidity/mortality.

Scenario IV: a new antihypertensive purportedly works in part via unregulation of natriuretic peptide production.

Beverage vending environment

Last Tuesday (March 16th2010), the world’s second-biggest soft-drink maker, PepsiCo Inc., announced its plan for removing full-calories sweetened drinks from schools in more than 200 countries by 2012. This happened at the same day first lady Michelle Obama urged major companies to put less fat, salt and sugar in foods and reduce marketing of unhealthy products to children.

Rather than only persuading people to resist outside temptation, building a healthy environment is a way to improve people’s health as well. Especially, when we are living in a world which has vending machines everywhere, even in the healthcare facilities.

In a study about vending machines in California (published at in Pediatrics, Jun 2009), hospitals hospitals averaged 9.3 vending machines per facility compared with 3 vending machines per health department and 1.4 per small clinic. Across all health care facilities, 75% of beverages sold in vending machines did not adhere to the California school nutrition standards. Sodas comprised the greatest percentage of all beverages offered in vending machines, more than 30%.

Not just sweetened beverages like soda, foods are an even bigger problem. 81% of foods sold in vending machines did not adhere to the nutrition standards.

If you logged into the homepage of Georgia Vending Service, whose FREE snack & soda machine service covers a large area including Athens-Clarke County, you will find out that having a free vending service is just one “click” away. You can get all kinds of vending machines, from snack & soda machines to medical machine, even cigarette machines.

I don’t know how many vending machines there are in Athens-Clarke County, but I found out that at UGA, with vending services provided by Coca-Cola Enterprises Inc., there are more than 500 vending machines located in over 150 buildings on campus. Fortunately, not all of them are for snacks and soda, some of them provide newspapers and magazines. But compared to the fact that we only have one Health Center on campus, the average number of vending machines that sell unhealthy food and beverages is still large. The same day when I am writing this post, I checked the Tate Center where hold many activities for students, staff, faculty and visitors. There are 10 vending machines, but there are also some ones in the Bulldog CafĂ©.

Monday, March 22, 2010

The guilty conscience and health promotion

When we want to persuade somebody to do something, we always would like to tell him or her how much he or she will benefit from the new thing. For example, in most commercials the audience hears, “If you eat this new one but not that old one, you will lose weight,” or “if you buy this equipment, you will save heat/gas/time/money.” That is the same way healthcare promoters work in most cases. They give people new medicine, show them how to exercise and teach them to try new things.

But the first time I heard someone using a guilty conscience in health promotion was when I was talking with Katie Porter, a Ph.D student in UGA. She is working on the senior obesity issue in Northeast Georgia. Her job is teaching them how to cook healthy food and do exercise, like yoga. She mentioned guilty conscience because she just realized that she met a great challenge that when people take their poor health condition as a normal and common situation that also happens in others around them, they won’t change their lifestyle simply to gain some “benefit.”
The increasing body weight and waist circumference always are considered as the natural result of aging. Most senior people are satisfied with their bodies, because their parents, friends and neighbors all seem to be living the same way.

Exercise and healthy diets, all the ways for losing some weights, seem more attractive to young adults. Part of the reason may be that they want to become attractive in the society and gain more benefit by their health condition. But as a person ages, this motivation is also missing.
When this happens, the guilty conscience seems to become more effective in persuading older adults to lose weight.

So Katie Porter always tried to drive home the question about how much impact they are going to have on other people if her target population doesn’t change its behavior. For a senior, the main thing for him or her is to live independently as long as he or she can. If seniors’ health conditions become worse, they can’t take care of themselves, and may need somebody else to take care of them, even end up in a nursing home. And more money will go from the healthcare system to taking care of them. By getting that point across to those seniors, Katie Porter hopes she might be able to change their behavior. But so far, this is just a goal for her program and a hypothesis for her thesis. She and her colleagues may need more time before providing more convincing evidence in the future.