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Tuesday, February 26, 2013


Heard a cool NPR segment on the way into the office yesterday. Interview with the author of this book, Jeff Speck.


In any meaningful discussion about American health (and health care), obesity has to be front and center. In the mid-1970s, only about one in ten Americans was obese, which put us where much of Europe is right now. What has happened in the intervening thirty years is astonishing: by 2007, that rate had risen to one in three,  with a second third of the population “clearly overweight.” The childhood obesity rate has almost tripled since 1980 and the rate for adolescents has more than quadrupled. 10 According to the rules of the U.S. military, 25 percent of young men and 40 percent of young women are too fat to enlist.

As recently as 1991, no states had adult obesity rates over 20 percent. By 2007, only one state, Colorado, was under 20 percent. 11 Projecting current trends forward, it would seem that 100 percent of the population will be obese by 2080, a year that my children will probably live to see— but perhaps not if they are obese. 

In terms of actual weight, men are now seventeen pounds heavier than they were in the late 1970s, and women nineteen pounds heavier. This means that, independent of population growth, as a nation we have gained 5.5 billion pounds. The real problem, of course, is not obesity itself, but all the other maladies that obesity causes or makes worse. These include coronary disease, hypertension, a variety of cancers— including colorectal and endometrial— gallstones, and osteoarthritis. Excessive weight now kills more Americans than smoking.

Over the past decade, there has been a series of studies that attribute obesity and its related illnesses directly to the automotive lifestyle and, better yet, to the automotive landscape. One effort found that for every additional five minutes Atlanta-area residents drove each day, they were 3 percent more likely to be obese. Another showed that drivers who switch to public transit drop an average of five pounds. A third, in San Diego, reported that 60 percent of residents in a “low-walkable” neighborhood were overweight, compared to only 35 percent in a “high-walkable” neighborhood. Another Atlanta study found that “the proportion of obese white males declined from 23 percent to 13 percent as neighborhood residential density increased from less than two to more than eight dwellings per acre.” These are careful academic studies that control for age, income, and the other factors that correlate with body mass. 

Finally, a six-year analysis of 100,000 Massachusetts residents found that the lowest body mass index averages were located in Boston and its inner-ring suburbs, while the highest could be found in the “car-dependent” outer ring surrounding Interstate 495. The Boston Globe noted that “health officials suggest these higher rates are due, in part, to a lack of opportunities for everyday recreation and the time-squeezed lifestyle of many residents who have long commutes."

I am wary of confusing causality with correlation, and it would be fair to say that heavier people are probably more likely to prefer driving over walking, and are therefore also more likely to prefer sprawl over urban neighborhoods. It is theoretically possible that, rather than suburbs making people fat, fat people make suburbs. But only a soulless pundit funded by the automotive industry— and there are several— would claim that people are not more likely to be healthy in environments that invite walking. 

You can tell that an idea has reached its tipping point when it makes enemies, and the sprawl-obesity connection finally has. The American Dream Coalition (“ Protecting Freedom, Mobility, and Affordable Homeownership”), a consortium of automotive and sprawl-building interests, has come up with the fairly hilarious concept of the Compactorizer. As celebrated on their website in the (stereotypically effeminate) voice of the fictional Biff Fantastic:
Urban planners and metrosexuals agree that suburbs make you fat! With the Compactorizer, you’ll move out of boring and subtly racist suburban homes and into smallish apartments in high-density transit-oriented developments. Only the Compactorizer uses a patented planning doctrine to create noisy nights, random crimes, and panhandler harassment, triggering the high-stress and abnormal dietary patterns so important for rapid weight loss.
As both an urban planner and a purported metrosexual, I can feel my credibility tanking here. But I have to admit that this piece is funnier than it is offensive and it appropriately pokes fun at an antisuburban snobbery that I probably share. But, ultimately, I have to ask myself: whom do I trust more: the doctors— who have nothing to gain either way— or the sprawl-builders? I’m going with the doctors.

Below: props to my friends at Stratasan.


LOL, not even close.


“We’re looking forward to another turn at HIMSS, because we love technology, but only if it’s moving quickly past staid, broken processes in health care. Our mission at athenahealth is to be caregivers’ most trusted service, helping them do well by doing the right thing, and we don’t get paid unless our clients do—period,” said Jonathan Bush, Chairman and CEO of athenahealth. “Because we have skin in the game, we aim to deliver services that are future-proof. In other words, our services scale based on need, can be managed without heavy IT support and cost, and most importantly, are flexible to adjust to new challenges ensuring they improve with time and will not become obsolete.”
I hope to interview him.


Medical errors, patient safety, etc...

Study: Missed Diagnoses in the Doctor's Office are Leading to Thousands of Deaths
Feb 25, Forbes, David DiSalvo

A new study published in JAMA indicates that primary care doctors are increasingly missing diagnoses at the office, resulting in thousands of deaths and disabilities per year.

Researchers used electronic health records to track 190 diagnostic errors made during primary care visits at one of two healthcare facilities. In each of those cases, the misdiagnosed patient was hospitalized or turned up back at the office or emergency room within two weeks.

Pneumonia, heart failure, kidney failure and cancer each accounted for between five and seven percent of conditions doctors initially diagnosed as something else, according to a report in Reuters Health.

Dr. David Newman-Toker from Johns Hopkins University School of Medicine in Baltimore, who co-wrote a commentary on the new study, told Reuters: “We have every reason to believe that diagnostic errors are a major, major public health problem. You’re really talking about at least 150,000 people per year, deaths or disabilities that are resulting from this problem.”...
From the JAMA piece:
Diagnostic errors are increasingly recognized as an important source of preventable harm in many health care settings. Missed, wrong, and delayed diagnoses have been underappreciated by internal peer review, autopsy reports, and examination of malpractice claims. All of these methodological approaches have limitations. Internal peer review is often challenging because of local hospital politics, physician-vested interest, and sampling error. Autopsy studies may overestimate diagnostic performance when necropsy rates are low, and they often miss nonlethal diagnostic errors. Malpractice claims may capture nonlethal errors; however, they are most often associated with permanent disability or death. Only about 1% of adverse events due to medical negligence result in a claim. Thus, malpractice-based rates of diagnostic errors substantially underrepresent the true impact of these events and are biased toward cases with a clear paper trail (eg, missed cancers evident on radiographic images), in which the burden of legal proof can be met more easily. None of these approaches is well suited to real-time surveillance for errors that might be rectified before harm occurs.

Singh and colleagues are to be congratulated for their substantial body of work developing electronic health record–based “trigger tools” to help overcome shortfalls in traditional approaches to diagnostic error detection. These tools seek to use readily available electronic data to identify patient encounters with a high risk for diagnostic errors to have occurred. The triggers were based on unanticipated readmissions or revisits within 14 days of an initial primary care visit. Triggered visits then were assessed manually for errors. Electronic triggers are relatively easy to measure across visits and likely could be tracked over time as quality metrics. Some triggers might eventually enable us to detect and rectify errors in real time, before harm occurs.

However, even systematically applied trigger tools do not give us a full picture of the burden from diagnostic errors. Singh et al found that roughly 0.1% of all primary care visits were associated with missed opportunities to make an earlier diagnosis and prevent “considerable harm.” This estimate, however, does not include cases in which misdiagnoses did not result in a readmission or a revisit within 14 days (even if the errors eventually caused harm) or cases in which a misdiagnosis occurred but reviewers could not determine whether the diagnosis might reasonably have been made initially. Nevertheless, with more than half a billion primary care visits annually in the United States, if these data from Singh et al are generalizable, at least 50 000 missed diagnostic opportunities occur each year at US primary care visits, most resulting in considerable harm. Combining this figure with autopsy-based estimates of US hospital deaths from diagnostic errors (40 000/y to 80 000/y) and unaccounted nonlethal morbidity from hospital misdiagnoses and acknowledging another half billion visits annually to non–primary care physicians, more than 150 000 patients per year in the United States might have undergone misdiagnosis-related harm.

Why are there so many diagnostic errors? In some sense, the answer is simple: medical diagnosis is extremely difficult. It may not be as difficult as accurately predicting a specific weather forecast 6 months in advance, but it is one of the toughest tasks human minds routinely face. Diagnosing can be messy, and scientific understanding is imperfect. Decisions must be made with limited time and information under conditions of uncertainty, often with inadequate experience or expertise in diagnosing a given symptom or disease. Consistent patient follow-up with feedback on diagnostic performance is usually lacking or biased away from detecting diagnostic errors, creating a serious barrier to ongoing skills improvement...
One of their proposed remedies will surely be red meat for the anti-HIT crowd.
  • mandatory, structured recording and coding of presenting symptoms, rather than simply diagnoses, in our electronic health record systems. This step alone, if consistently performed, would radically transform our ability to track and reduce diagnostic errors.
Interesting. From AHIMA:
How to Code Symptoms and Definitive Diagnoses
by Sue Prophet, RHIA, CCS 
Determining when a symptom, definitive diagnosis, or both should be coded can be challenging for coding professionals. This challenge is complicated by the varying rules regarding the coding of symptoms versus definitive diagnoses, according to the type of encounter and the particular service rendered. In an era of increased focus on fraud/abuse and regulatory compliance, it is especially important for coding professionals to understand and properly apply official coding rules and guidelines. This article will explore the various guidelines affecting symptom and definitive diagnosis coding and what guidelines to apply...
A good read, but nothing much beyond dx coding which takes into account symptoms.

Below, an old school SOAP note example:


Coding Symptoms, Signs and Ill-Defined Conditions Under ICD-10-CM
Written by Michael Calahan, PA, MBA, Monday, July 25, 2011

In preparation for conversion from ICD-9-CM to ICD-10-CM diagnosis coding, and in anticipation of the new coding system’s implementation (effective Oct. 1, 2013), providers will need to take stock of their coding patterns as well as review their internal charge capture tools (i.e. the practice superbill) to see which frequently reported ICD-9 codes they immediately will want to research within ICD-10.  Becoming familiar with the updated codes will be a pivotal step in this transition. One of the coding patterns that should be scrutinized is the frequency with which unspecified and “not otherwise specified” (NOS) codes currently are assigned appropriately. Often, as explained below, unspecified and/or NOS codes are the only options for diagnosis coding at certain levels of patient study and care.

Many of these codes, though certainly not all, are found in the ICD-9-CM chapter dedicated specifically to unconfirmed diagnoses and similar conditions; this chapter aptly is named “Symptoms, Signs and Ill-Defined Conditions.” A quick glance at the practice encounter form may be telling in this regard. Often superbills are packed with nonspecific codes to help facilitate quick, at-a-glance coding by providers on the run instead of having certified coders assign diagnosis codes from detailed, well-written medical record documentation. The latter obviously is preferred – and even mandatory, in many instances – to establish medical necessity and obtain appropriate reimbursement for services rendered.

That said, unspecified and nonspecific coding scenarios are actually commonplace in general practice, family practice and internal medicine, among other primary care specialties in which the level of evaluation and assessment may be more limited until a patient has been sent to specialists for further work-up, evaluation and treatment. Which unspecified and nonspecific codes are available for use promises to change slightly under ICD-10, however. In fact, the ICD-9-CM chapter now housing most of these codes, Chapter 16 covering “Symptoms, Signs and Ill-Defined Conditions” (code series 780 – 799), has many organizational changes under the new ICD-10-CM format, now falling under Chapter 18 and renamed “Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified” (code series R00-R99).

Some of the codes that previously were found in body system chapters are now in this particular ICD-10-CM chapter, and the reverse is true for some ICD-9 codes that once were located in the symptoms/signs chapter and now will be located in specific ICD-10 body system chapters. For example, in ICD-9-CM “hematuria, unspecified” currently is coded to 599.70 in Chapter 10, “Diseases of the Genitourinary System” (code series 580 – 629), but in ICD-10-CM this has been moved to Chapter 18 and is included under symptoms/signs of the GU system (being coded to R31.9). Likewise, conditions such as “systemic inflammatory response syndrome” (SIRS), “severe sepsis” and “septic shock” currently found in ICD-9-CM Chapter 17, “Injury and Poisoning” (code series 800 – 999) are located in Chapter 18 under general symptoms/signs in code series R65 in ICD-10-CM – specifically, R65.10, “SIRS of non-infectious origin without acute organ dysfunction.”

Conversely (and curiously), ICD-9-CM code 785.4, representing “Gangrene NOS,” which currently is located in Chapter 16 for symptoms/signs is to be found under code I96 (eye-96) in the specific body system Chapter 9, “Diseases of the Circulatory System” (code series I00 – I99) in ICD-10-CM.

The preamble for Chapter 18, “Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified” in the new ICD-10 coding system remains much the same as it was in ICD-9, specifying that the codes found within this range include “(a) cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated; (b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined; (c) provisional diagnosis in a patient who failed to return for further investigation or care; (d) cases referred elsewhere for investigation or treatment before the diagnosis was made; (e) cases in which a more precise diagnosis was not available for any other reason; (f) certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right.”...

More to come...

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