Goodbyes are hard to do, but Dr. Bloch and I would like to thank you for joining us for the Weekly Wellness blog. Reviewing and interpreting GE’s Centricity Database has been an eye-opening and thought-provoking experience for us, and we hope that you took something away from it as well.

“GOOGLING” WELLNESS
Right now, the ability to aggregate raw data that was formerly limited to paper charts represents a major step forward in Big Health Data. The old adage, “you can’t manage what you can’t measure” has never been more true. Having access to these highly accurate and insightful clinical tools has the potential to revolutionize the healthcare system, from patients to hospitals to doctors and even insurance companies, much like Google trail-blazed the internet. What is crystal clear is that the healthcare system is falling in love with data – and the critical point of professional data collection is the Electronic Medical Record. With the federal government’s mandate and financial incentives to get physicians on the data grid, we are witnessing a sea-change in medical data collection.

However, before we delve into the way EMRs are redefining the way medical professionals examine data, we should take a step back and define one of the most basic, yet baffling, medical concepts out there. In fact, it’s the one that inspired this blog to begin with. In one word: wellness.

DEFINING WELLNESS
Is wellness the absence of illness, a sense of well-being, or an active process of engaging in healthy activities? Or, is it something entirely different? As physicians, we are traditionally trained to deal with illness; however, increasingly we are being charged with promoting wellness, which in many cases can seem nebulous and confusing. Meanwhile, entire industries have taken root promoting wellness ranging from supplements to diet books and meditation clinics. Whether or not these industries complement or compete with medical care is debatable. However, what is not debatable is many patients have turned to these health alternatives because they are better equipped to focus on discussing wellness rather than illness.

TAKE GOOD CARE
Wellness is a state of mind, one where physical and mental health converge. It goes beyond just eating good foods and going to the gym; it requires a holistic understanding of the profound complexities of the human condition. Simply put, it is a desire to participate with our body by listening to our body.

While EMRs enable medical professionals to gain insight from a vast resource of valuable information, it’s important that individuals use wellness as a proxy for caring about the self. It represents engaging in activities that prolong the sense of well-being while simultaneously valuing the concept of disease screening and surveillance. After all, we are complex physiologic organisms that require regular check-ups, tests and procedures.

KEEP IN TOUCH – IGNORANCE IS NOT BLISS
It is known that, in many cases, we can prevent type II diabetes if we eat well and exercise regularly. Likewise, colon cancer is also preventable, if it’s detected early enough through tests. Preventative measures like a colonoscopy can find a young tumor and remove it before it turns into a nasty colon cancer.

Wellness is taking surveillance and detection seriously and not playing roulette with your health while making time to read, laugh, and socialize with levity. And certainly it does not require cutting costs today only to spend more money to combat disease once it becomes evident.

HEALTHPRINT IN YOUR HANDS
We all have a unique and dynamic health signature, or “healthprint,” that is the summation of our health illness status and wellness quotient. It is partly defined by genetic fingerprint, but many studies have found that our healthprint is also impacted by other forces, such income and social status, education and literacy, and employment/working conditions, as well as factors, like gender, culture, child development, physical environment, and coping skills.

PUTTING A TRACE ON YOUR HEALTHPRINT
Right now, in tandem with the shift toward EMRs, there is another movement gaining ground among individuals and groups interested in health. Started originally by the founders of Wired, the ‘quantified self-movement’ arms curious individuals with technologies such as sensors and calorie counters to monitor their our personal healthprint. Complementing the way doctors are studying the data of EMRs to take society’s status report, this type of individual monitoring puts wellness back into the hands of the accountable self. Diseases are not something that “just happens” to us, instead, they often have trackable pathologies, which medical professionals can follow in EMRs and individuals can trace as well. This interplay creates a balance between community and individual responsibility, which ultimately promotes the overall wellness of society as a whole.

HEALTH IS AT OUR FINGERTIPS
If we are to achieve a national wellness that pulls us out of the chronic disease ditch we’re falling headlong into, we will certainly be relying on data to point us in the right direction. EMR data combined with medical claims data and quantified self data will surely enable the accuracy of a healthprint.

Our trip into GE’s database has shown we may have an uphill journey ahead of us as a society. However, our bodies represent one of the most fascinating, complex, and resilient organic structures on Earth. As we hurdle into the 21st century, our ability to define, refine, and redefine our healthprint will become more dependent on how we measure ourselves. Before we bid you farewell, we leave you with some good advice for tough times from another ancient philosopher:

“The part can never be well unless the whole is well.”—Plato

For some, high cholesterol is hereditary, but for most it’s all about lifestyle. Changing the way we eat is so vexing for some that a multibillion dollar drug industry has emerged as a result. Isn’t it odd that we’ll change our ways to pop a pill every day, but won’t change the way we eat?

At the heart of cholesterol lowering agents are “HMG Co-Reductase inhibitors,” more commonly known as statins. Statins are one of the most popular types of medicines used in the U.S. Every day tens of millions of Americans take one—mostly those in their Golden Years. Using de-identified patient records from GE’s Medical Quality Improvement Consortium (MQIC) database, we found somewhere between 15 to 20 percent of patients in their 50s, 60s, and 70s, regularly took a statin in 2010.

BIG BUSINESS, BIG BENEFIT, BUT ARE THEY SAFE?
Few practitioners would argue that statins are not effective in reducing LDL (better known as bad cholesterol) and decreasing the risk of heart disease and stroke, especially in higher risk patients. However, while statins have been widely studied and commercially available for decades, questions still linger about their safety.

Many older types of statins have been available as generics for some time, often for as little as $4 a month. And now, the big headline in the pharma world is the blockbuster drug Lipitor becoming available as a generic. As these medications become more affordable, their use will only increase and so too could the questions about their risks versus benefits.

BACK IT UP: WHY LOWER CHOLESTROL?
ONE BAD CHOLESTROL SPOILS THE BUNCH
Elevated blood levels of cholesterol, and specifically the “bad” cholesterol, lead to plaque in the arteries, which is the main cause of heart attack and stroke. In people with other vascular risk factors like hypertension or smoking, this plaque may begin to form as early as in our 20s.

The first step in the formation of plaque is when the lining of the arteries becomes damaged and more permeable to “bad” cholesterol, which begins to accumulate in the wall of the artery.

Blood vessels don’t like to have foreign substances growing in their walls and therefore cellular scavengers come in to gobble up the “bad” cholesterol. This process eventually leads to the blockage and erosion of the blood vessel lining.

Ultimately, heart attacks or strokes occur when the plaque cracks open. This is why heart attacks and strokes occur suddenly, often in patients with no previous symptoms. A plaque may have been forming slowly for years, but then suddenly blows its top like Mount St. Helens.

HOW STATINS WORK
STATINS AT WORK
Here is the hypothesis: Through complex actions in the liver, statins reduce the blood levels of “bad” cholesterol. When blood levels of “bad” cholesterol fall, the cholesterol in the wall of the artery diffuses back out into the blood stream.

Now here’s the critical point: These medications should not be prescribed with the primary goal of lowering cholesterol, but rather with the ultimate goal of stabilizing plaque to decrease the risk of heart attack and stroke.

HAS THE HYPOTHESIS BEEN TESTED?
As physicians, we aim to practice evidence-based medicine whenever possible. Therefore what we look for are blinded, randomized controlled trials. For statins specifically, this type of study calls for subjects to be randomly allocated to either a statin or an inactive placebo tablet. Neither the subject nor the treating practitioner should know which the patient has been prescribed until the study is completed. It’s kind of like not spoiling the end of a movie, which is foolproof when no one’s seen the film before.

SPOILER ALERT
There have been numerous studies performed with statins, and, in general, they demonstrate a substantial—30 to 50—percent reduction in cardiovascular events with statin therapy.

THERE’S A BENEFIT, BUT WHAT ABOUT SAFETY?
Many claim that these medications are perfectly safe, however, virtually all meds have potential for side effects. There are several reasons people worry about this class of drugs. One of the biggest reasons is good old healthy skepticism.

Admittedly, the number of patients reporting problems in these studies has been small, but it’s still not zero. The primary potential side effects are liver and the muscle issues. Fortunately, the liver issues are rare, and can easily be ID’d before they develop into major problems.

The muscle issues, one the other hand, are more complex: Only about 1 in 1,000 patients will develop actual muscle damage, but a few percent of patients will find the muscle pain annoying enough that they have to stop or at least change medications.

WHAT’S THE CONTROVERSY?
Another concern is how the studies are actually performed. In general, they are relatively short-term and, usually only last three to five years. This means they have the potential to miss rare side effects or ones that develop after decades of use.

While the Internet is filled with tales of people who believe statins caused them to develop memory issues, cancer, multiple sclerosis, connective tissue diseases, and other problems, the bigger question is did the statins cause the condition or was it an innocent bystander?

In general, there is little high-quality evidence that these conditions are more common in people who take statins than in people who don’t. For example, when we examined de-identified patient records from GE’s Medical Quality Improvement Consortium (MQIC) database of over 90,000 adult Americans, we found that the incidence of reported cancer was almost exactly the same in those who took statins as those who did not. But, as we always remind our medical students, “lack of proof of harm” is not the same as “proof of lack of harm.” (Try and say that one five times fast.) As a result, it couldn’t hurt to more rigorously assess not just the effectiveness of statins but their safety as well.

STATUS UPDATE: STATINS
WHAT’S NEXT
Based on the available data, we do believe statins are effective in reducing cardiovascular events, like heart attack and stroke, but contrary to what others may say, we do not believe that these medications should be put in the water or given to every adult in the country.

Their use should really be limited to those who need them. Even though there isn’t much convincing evidence of significant issues or rare side effects, we don’t think that such reports should be dismissed. Instead, we think that more time and effort should be put into studying their long-term safety and risks.

Dr. Bloch wishes to disclose that he has received payment for research, speaking, and consulting services from a number of companies that make HMG Co-A Reductase Inhibitors (statins), but that those companies have had no influence on the content of this blog.

Recent data suggests that more than 50 percent of adults in the U.S. take at least one dietary supplement daily. The results? Well, for one, a robust $25 billion a year nutritional and vitamin supplement industry. Why are supplements, and particularly, vitamins so popular? There are probably a number of reasons, but we think some people use them as a shortcut to good nutrition.

Since these products are often marketed as natural, people assume they are harmless and must be beneficial. However, in some cases new research has shown that not only might vitamin supplements not be of tremendous benefit, but they may actually be associated with a higher risk of disease and mortality!

STICK TO AN APPLE A DAY
Since 1986, the Iowa Women’s Health Study has been observing the well-being and habits of 38,772 women who were on average about 60 years of age when the study began… About 50 percent of the participants reported taking vitamin supplements on a regular basis. Shockingly, with the exception of calcium, which showed a modest benefit, the use of all other studied nutritional supplements was actually associated with an INCREASE in the risk of mortality over the course of the study. For the most common nutritional supplement, multivitamins, there was a 6 percent greater incidence of death than in those who didn’t take multivitamins.

VITAMINS VITALITY
Now, we (and the authors of this report) freely admit that this type of study can only show a statistical association between supplement use and increased mortality: It can’t actually prove the vitamin and mineral use caused these people to die early. It may just be that vitamin use is a confounding variable, or a marker for some other unhealthy behavior, like smoking or eating too much fast food. It is certainly plausible that people who have other unhealthy habits take vitamins to compensate for bad habits. It’s like the age-old question of which came first, the chicken or the egg? But, nonetheless, the results should give us pause. Rather than reflexively taking nutritional supplements, particularly multivitamins, without a clear indication of deficiency, perhaps we should reconsider the one-a-day regimen.

WHAT ABOUT OTHER STUDIES?
This study is not the only piece of scientific data that questions the routine use of nutritional supplements in otherwise healthy individuals. In a number of other instances, when nutritional supplements have actually been put to the test in rigorous clinical trials, the results have been less than impressive. For example, for years, many people assumed that the supplemental use of antioxidant vitamins, like vitamins C and E, would decrease the risk of heart and vascular disease; in fact, it even seemed biologically plausible to some medical professionals. However, when the use of antioxidant vitamins in people at risk for heart and vascular disease was actually studied, it was found that the use of these products actually led to more heart disease than the use of placebo tablets.

THE JUMBO-SHRIMP OF VITAMIN C
Of course, micronutrients, like vitamins and minerals, are essential to good health, but, if you think about it, we are designed to consume these micronutrients in the form of food, not pills, shakes, or powders. People usually assume that since these products are “natural” they must be good for you and have no potential risks. However, in order to provide a good value to the consumer and compete with other brands, many of these supplements actually offer amounts of these vitamins and minerals that are far above the usual recommended daily allowance (RDA).

Added to that, we are still eating, and therefore getting these vitamins and minerals from food as well. As a result, many Americans are actually consuming quite large amounts of what are generally designed to be micronutrients (micro, of course meaning “small”). Does anyone really need the amount of vitamin C that would require eating over 20 oranges a day?

THE VITAMIN OVERDOSE
We think that this dose issue is critical. As a simple example, think about a commonly consumed substance like alcohol. While one to two drinks per day may be healthy (and, of course, make you the life of the party), 10 times that amount on a daily basis could land you on the liver transplant list. More to the point, we have each seen patients that developed painful damage to their nerves (called peripheral neuropathy) from taking very large amounts of vitamin B6 in the form of supplements.

When it comes to balancing the risks and benefits of taking nutritional supplements, the biggest issue is the lack of rigorous scientific study. Certainly, the mainstream U.S. pharmaceutical industry has its share of problems, however, at least the makers of prescription medications are rigorously monitored and studied. They must follow very specific guidelines and tests before they go to market. Certainly, those studies can be flawed or even biased to show a benefit. However, for anyone who’s ever watched a pharmaceutical commercial, they’re required to provide a long list of side effects, so that at least consumers can make an informed decision about the risks.

Unfortunately, in our opinion, nutritional supplements are not subject to the same requirements by the FDA. And, even when there is some data available with a specific micronutrient, there is less consistency in terms of exact formulation and dose from one product to the next.

EAT YOUR VEGGIES!
These arguments are in no way meant to imply that all nutritional supplements are bad for you and should be avoided. Quite the contrary, there are definitely specific instances, where specific products, at specific doses, have been found to be beneficial. For example, use of vitamin E was recently demonstrated to have a beneficial effect in patients with an inflamed liver due to being overweight, and fish oil certainly has been shown to effectively lower triglyceride levels. Likewise supplemental calcium and vitamin D can have a favorable effect on bone health in people at risk for osteoporosis.

Based on the data available today, we recommend taking specific supplements for specific conditions after discussing the risks and benefits with a professional health care provider. We suggest that people should be somewhat wary of a shotgun approach, where you down large amounts of supplements to maintain general good health. We certainly do recommend eating a healthy diet chock-full of essential vitamins and minerals. (Your mom was right: You should eat your vegetables!) And finally, we hope that in the future there will be more rigorous studies of the risks and benefits of nutritional supplements on health and well being.

CONVERSATION STARTER
Remembering that our goal in the ‘practice’ of medicine needs to shift from curing the sick to maintaining health, we need to have more information on what people think about their own health. Did you pop a multivitamin this morning? We want to know what you think about vitamins and supplements. Please post your comments and thoughts.

The last bone in a person’s body stops growing at 24—which basically marks a slow down-hill slide from there (as any who’s gone through a quarter life crisis can tell you). However, in all seriousness, most people make the jump from pediatrician, or “kiddie doctor,” to internist or GP for primary care around the age of 18. Taking the training wheels off of your medical care is indeed, in many ways, a transition from one type of health care to another. Put simply, pediatrics is more focused on the study of growth than illness and disease, while primary care for adults is really code for a doctor that helps with aging and prevention strategies.

NO SURPRISES HERE
Using de-identified patient records from GE’s Medical Quality Improvement Consortium (MQIC) database, we analyzed some 1 million pediatric visits in 2010 and broke out diagnosis by month, as well as the aggregate top 20 diagnoses for kids. Nothing hugely shocking here we suspect for most parents, at least.

LADIES AND GERMS
It’s no surprise, given our understanding of pediatrics, that the number one reason people take their kids to the doctor is for a routine infant or child health checkup. This represents 21 percent of all visits to the pediatrician for most of the year—except for December and January when the big reason kids need a doctor is for acute respiratory infections—no shocker there. You could also lump the five percent of appointments for flu vaccines and sports physicals into the “wellness category,” which means one in four visits are essentially geared toward monitoring normal growth and keeping healthy kids healthy.

KEEP YOUR EYE ON THE VERY SLOWLY MOVING BALL
When you’re monitoring a child’s growth and development, you’re also more likely to spot any health or developmental concerns, which means these routine wellness visits also have a valuable prevention angle. Many health and developmental issues that kids are prone to develop insidiously, meaning that they happen so slowly that it might not be obvious to the parent who sees the kid every day.

HAPPY 500th COLD
Infectious diagnoses, both viral and bacterial, account for 59.2 percent of all pediatric visits. Just below that, acute viral illnesses hold the number two spot except for January and December when they’re on top (yay, colds!). This just goes to show that the proverbial runny nose can run any month of the year. It’s been hypothesized that kids get more than 500 infections by their seventh birthday. Add to this that “allergic rhinitis,” or the non-viral runny nose, accounted for 4.2 percent of all diagnoses and it makes an almost perfect bell curve starting in spring and ending in fall.

WE’RE ALL EARS
Ear infections, or acute otitis media, occupy the number three and four slots every month of the year. This is in contrast to sinus infections, which tend to hover in the seventh and eighth slots, except for the summer months when they are nearly absent. The ear is twice as likely as the nose to become painful or infected because the tube that connects the ear and throat is particularly small in children and susceptible to troublemaking backups.

MY TUMMY HURTS
Switching gears away from ears, nose, and throat, which we expected to be high-ranking diagnoses, we were surprised to find that rashes accounted for only 4.9 percent of visits—even though it probably seems like every kid on the playground has a rash or some other itchyness. We were also surprised that only 2 percent of all pediatric visits were for abdominal pain, which, when accompanied by functional bowel issues like diarrhea or nausea can lead to time-consuming and often expensive work-up. Since kids can’t usually provide the same in-depth details about their symptoms like adults can, it’s often extremely difficult to determine normal upset stomach from more serious problems.

LUCKY NUMBER 13
Some fantastic news is that the 13th most common reason for a pediatrician visit was immunization! This shows that collectively we are making great strides in prevention. Sometimes I, Dr. Shlain wonder if the big, hidden health-care expense is “inaction.”

IT’S TOUGH TO BE A KID
Our immune system is constantly challenged as a kid—viruses bullying our natural defenses in the winter and allergies tormenting us in spring. However, fortunately, the body is an organic, physiologically adaptive organism that is constantly protecting itself from antigens and allergens. The immune system has micro and macro protective mechanisms. On the molecular level, antibodies, killer cells, and other cool sounding molecules karate-chop invaders, while on the macro level mucus-cell production creates a thick, gooey protective barrier that viruses, bacteria, and pollen can’t penetrate.

SNOT-NOSED KIDS
While it sucks for now, all these infections our kids get probably prime the immune system to avoid worse issues in adulthood—like the classic chicken pox example. It turns out that lowly snot is probably really part of the grand protection design. Remember how fast you ran away from the kid with a booger on his finger? It’s a good parallel for how the immune system works.

The bottom line is that for those kids with access to healthcare, our current system is on the right track. Parents are getting reassurance that their kids are developing normally and they’re preventing more serious illness with vaccinations, as well as sorting out bigger concerns. So, in this case, everyone gets to choose a toy from the treasure chest!

THE ONES TO WATCH
In last week’s blog, we listed out the top 20 reasons that people go to see their doctors, as well as a number of interesting, and very treatable diagnoses that pop up every month. This week, we’ll focus on a few that caught our attention when we used de-identified patient records from GE’s Medical Quality Improvement Consortium (MQIC) database to analyze some 4,264,039 doctors visits by adults 18 and older to assess the “chart-topping” reasons people are booking appointments.

THE VITAMIN D-L
To tan or not to tan? Even the medical community is taking sides: There are a few camps formed around the topic. There are the “sun is bad” camp, the “vitamin D doesn’t matter” camp, the “sun is good” camp, and the “low vitamin D is bad” camp—as well as a few splinter factions from those. Vitamin deficiency never cracks the top 10 by month, yet it does hold the 19th spot on the top 20. While the sun hasn’t changed its orbit in a very long time, one can surmise that the fear of skin cancer campaign promoted by the health industry is working. Working so well, in fact, that, according to the “low vitamin D is bad” camp, we could be creating a future population with brittle bones. Personally, when it comes to vitamin D, we throw our allegiance with the “if you have a great eat-style and lifestyle, your vitamin D will come naturally from the sun and healthy foods in its natural form and this will not be your problem” group.

BONE UP ON VITAMIN D
A recent report from the Institute of Medicine (IOM) found that we are generally on the right track. The IOM concluded that while vitamin D deficiency can be a problem for people with bone health issues, there is less evidence for its importance in other medical conditions, like heart disease and cancer. Part of what makes this a challenging issue in the medical field is it has been difficult to establish a normal level for vitamin D in the blood. The IOM basically concluded that levels of 20 or more are probably OK for most adults, however, that is substantially lower than many doctors feel is appropriate. Given the discrepancy, it’s likely there probably isn’t one right answer. We believe that in the future it will probably be determined that one vitamin D level is not right for every person, meaning different people probably require different levels of vitamin D in the blood to maintain bone health.

People who have had or are at risk for bone health issues should get their vitamin D level checked regularly and treated appropriately. For the rest of us, it’s good enough to eat right, get a bit of sun, and if you want to take a supplement, up to 4,000 units a day is probably safe based on the IOM report.

SUMMER HEAT AND SUMMER LOVIN’
In the annual top 20 diagnoses identified through the dataset, UTIs (urinary tract infections) rank number 10. There are many causes for urinary tract infections, but the overarching predisposing factor is decreased urine flow. The other two main reasons for UTIs are dehydration and the proverbial “honeymoon UTI” related to sexual activity. When looking at the yearly trends, UTIs hit the top 10 in four months. Can you guess which months? Which months are hot, have an increased predilection for alcohol consumption, and might inspire a honeymoon? Yep! June, July, and August, UTIs ranked sixth in terms of top diagnoses and in September they were eighth.

Ways to avoid UTIs include staying hydrated and perhaps drinking cranberry juice to acidify the urine, which are good ideas for any month.

IS LAZINESS KILLING US?
Taking a closer look at the top 20 diagnoses, we see that numbers 5, 7, and 20 are the only diagnoses that resemble chronic disease. However, not one of them is diabetes, metabolic syndrome, or any of the downstream effects of obesity. While we are unable to get a detailed socioeconomic context for this data, it seems peculiar that diabetes is a no show. Even if this no show is at least in part reflective of how clinicians use diagnosis codes, than all the concerns doctors and patients discuss during appointments, it does lead us to ask again whether these chronic conditions are getting the attention they need. As we wrote in past posts: why aren’t there more visits for these chronic ailments which ultimately, left untreated, lead to devastating stroke, heart attack, and death? One would think it would be compulsory to get these under control, much like it’s compulsory to get our cars registered (another idea that we had thrown out in an earlier post on high blood pressure). Of the more than four million visits, only 14 percent of them fall under the chronic condition maintenance column.

Now looking to the next generation, next week we’ll look at the pediatric trends. Feel free to post some topic suggestions because your input is valuable!

MEDICAL TOP 20 “BILLBOARD”
Is something wrong with you? What’s topping your medical chart these days? While editors at pop-culture magazines are furiously toiling away on their end-of-year, “best of” lists for movies and music, we decided to give this annual tradition our own spin: introducing the Top 20 Reasons to visit a doctor. Using de-identified patient records from GE’s Medical Quality Improvement Consortium (MQIC) database, we analyzed some 4,264,039 doctors visits by adults 18 and older to assess the “chart-topping” reasons people are booking appointments. Check it out: There are some surprising observations and interesting inferences to report based on this data set. (OK, granted there are no Grammy nods on this one.)

THE BIGGEST TRENDS:

• 29% of visits were checkups, annual physicals, and gynecological exams
• 55% of all visits were motivated by pain or discomfort
• 7% were due to joint or back pain

DECLARATION OF INFLAMMATION:
ACHY, SNEEZY, RUNNY NOSE, COUGH, SORE THROAT
Within the “pain and discomfort” group, more than half of diagnoses (about 30 percent of all visits) were specifically related to the inflammation associated with acute viral and bacterial infections and their aftermath.

We’ll use that to segway into the concept of the “inflammatory cascade” that occurs when our skin or the lining of the mouth, nose, and throat (our “mucosa,” if you want to use the sexy word) lose their immune defenses to viruses and bacteria.

Our skin and mucosa are the protective layer against the outside world. It wields molecular detectors and cellular weapons that stand-by like vigilantes waiting to pounce at the smallest sign of an invasion.

The reason for this digression is to emphasize that in our Top 20 Diagnoses, 30 percent are related to inflammation (reference numbers 3, 6, 8, 11, 12, and 13). Some scientists would suggest that we put malaise and fatigue (number 4) in this bucket as well.

When we looked at the top 10 diagnoses by month, we found one especially interesting thing: The only month when infectious causes didn’t make the top 10 was August. Apparently, those pesky viruses just can’t stand the heat. Also, with those “virus factories,” otherwise known as schools generally closed, the adults who care for children also get a break—so enjoy that summer vacation.

What is the best defense against those viral and bacterial invaders? Frequent hand washing is key and generally felt to be better than antibacterial wipes or gels. Also, get your flu shot if you are over the age of 65, have chronic medical conditions, like lung disease or diabetes, or if you work in the healthcare arena or in schools.

STATE OF THE WEIGHT
Although none of the top 20 diagnoses were specifically labeled obesity, we can infer that for many patients, weight and diet issues are key underlying causes of the high blood pressure, high cholesterol, and reflux listed. A look at the month-by-month top 10 diagnoses list reveals that heartburn only appears in July and August where it comes in at number 9 and number 8, respectively. We are going to hazard a guess that reflux jumps up on the charts due to the signing of the Declaration of Independence more than 200 years ago and the ensuing summer festivities in the form of beer, BBQ, and breaded things—not to mention all loss of reasonable portion control.

ANNUAL CHECKUPS TOP OF THE POPS
Routine general medical exams ranked first in every month except October, where it ranked second only behind flu shots. The flu vaccine ranked second in September and November, as well. The good news is: It appears most of us do get the message that influenza can be prevented.

Gynecologic exams have an interesting curve showing these visits sit in the second position from April to July and then fall to the fifth and sixth rankings in January and February. Spring has always been a time of renewal.

These routine visits promote detection and prevention. Detection, a.k.a. “nipping it in the bud,” can produce better outcomes in some cases, while prevention, falls into two basic categories: lifestyle and eat-style.

UPDATE YOUR “STYLES”
By lifestyle, we’re looking at issues, like the amount of exercise an individual gets. Do you ride a bike to work—and if you do, do you wear a helmet? How much sun do you get? Do you play videogames all day long? Do you floss and brush your teeth? Do you smoke? These are all modifiable lifestyle behaviors.

By eat-style, we’re talking how much, how often, and how healthy do you eat and drink? Are you eating half as much protein with each bite of carbohydrate? Do you drink juice or soda (er sugar)? Do you sit at the table when you eat? Do you eat fast food? Do you snack? What does portion mean to you? These are also modifiable behaviors, but the energy required to overcome years of eat-style inertia—a habit, reinforced marketing, cost subsidies, and sweet, sweet, irresistible desserts.

WHAT NEEDS TO CHANGE
How many of these visits were initiated by a doctor and how many were initiated by a patient? Where is the blinking light like the ones in our car that flash when we’re due for a service? And, at those general checkups how much time is really spent on counseling about lifestyle and eat-style? In our experience, not enough.

Next week we’ll look at trends in vitamin D, chronic disease, and urinary tract symptoms, all treatable conditions that make the top 20.

To Screen or Not to Screen – That is the Question

If you had prostate cancer would you want to know? The conventional answer is ‘of course,’ but new recommendations should cause men and the physicians who treat them to more critically examine that question.

Conventional Wisdom

When it comes to cancer screening, the conventional wisdom is that early detection can be key to a good outcome. Unlike some other types of cancer like breast cancer and colon cancer, prostate cancer in most men is relatively slow growing and less aggressive. The truth is that most men who have prostate cancer, which tends to affect mostly older men, will actually die of causes other than their prostate cancer, usually without any cancer symptoms.

Prostate Cancer – The Numbers

• 1 in 6 men in the U.S. will receive a diagnosis of prostate cancer in their lifetime (usually over the age of 70)
• 218,890 U.S. men received a diagnosis of prostate cancer in 2007
• 27,350 U.S. men died of prostate cancer in 2006

So, a large number of men are diagnosed with prostate cancer each year, but only a small minority of men diagnosed with prostate cancer die of prostate cancer.

PSA – The Screening Test for Prostate Cancer

Years ago, prostate cancer screening mostly relied on the dreaded ‘digital rectal examination’ or DRE. Yep, that’s the test you are thinking of. In fact, when we went to medical school one of our mentors was fond of reminding us that there were only two reasons not to perform a DRE – no finger or no a–hole. Given the discomfort of the DRE (for both the operator and the victim) and its relatively poor accuracy, it has slowly been replaced by a blood test measuring levels of a protein called prostate specific antigen or PSA.

Traditionally, physicians have recommended that healthy men over the age of the 50 should undergo routine yearly PSA tests. It turns out that there are 44 million men over the age of 50 in the U.S. and about 33 million of them have already had a PSA test, sometimes without their knowledge as part of a routine general medical examination. In our query of 1.5 million de-identified patient records from the GE’s Medical Quality Improvement Consortium (MQIC) database, we found that
27% of men over the age of 50 had a PSA checked just within that last year.

Interpreting the PSA Test

While the PSA is easy to obtain through a simple blood test, it turns out that deciding what to do with the results is anything but a simple decision. There is no doubt that measuring the PSA is effective in identifying patients with prostate cancer. Most physicians agree that a PSA level of <4.0 generally means there is no prostate cancer and no need for further testing.

The problem is when the level is >4.0 – some of these men have prostate cancer, but many – some studies say as many as 50% – do not have cancer. Currently, the only way to definitively determine whether or not a patient with a PSA > 4.0 has cancer or not is to do a biopsy, which while safe, is a relatively expensive and invasive procedure.

Once again, the scope of the numbers we are dealing with are well illustrated in the GE’s MQIC database. Of the over 400,000 men who had a PSA test in the last year, about 7.5% had a PSA > 4.0. In men >70 years of age, the percentage with a PSA >4.0 is actually 17%! Should all these men undergo a biopsy for prostate cancer?

Prostate Cancer Treatment – The Great Debate

The real question comes if the biopsy is positive for cancer. Treatments for prostate cancer include surgery, radiation, or hormonal treatment, all which are effective in treating the disease but can be associated with serious side-effects like sexual dysfunction and incontinence. Most, but certainly not all, prostate cancer is slow growing and in many cases will not progress to cause serious symptoms in an older man’s lifetime.

Given the risk of complications and potential lack of meaningful benefit for many men, in a lot of cases a ‘watchful waiting’ approach, rather than more aggressive treatment is recommended. But, as you can imagine, men who have been diagnosed with cancer may have considerable anxiety over this approach and opt for more definitive treatment. And, if you are not going to treat the cancer, why do the biopsy? And, if you are not going to do a biopsy, why measure the PSA in the first place? It’s like trying to solve a Rubiks cube.

New Research Challenges the Wisdom of Measuring the PSA

A recent European trial studied 182,000 men from seven countries who either got PSA testing or did not. Overall, after nine years there was no difference in death rates between those who got or did not get a PSA test (although there may have been some benefit in those men aged 55-69). A similar study of 76,693 men in the U.S. found that measuring PSA had no effect on death rates over 10 years.

To Test or Not to Test

Based on the results of these and other studies, a key government panel, the U.S. Preventative Task Force (USPTF) recently recommended against healthy men getting the PSA test. This recommendation has been harshly criticized by advocates of prostate cancer screening and treatment.

Like a lot of questions we face in medical care today, there are no easy answers. What is clear is that each man needs to discuss the pros and cons of getting the PSA test with their personal healthcare provider. Rather than just being a reflexive part of healthcare screening, men should have frank discussions about what they would do if faced with a PSA suggestive of possible cancer, and base their decision about whether or not to proceed with getting a PSA based on that discussion.

What Does the Future Hold

If you follow this debate to its logical conclusion, what we truly need is a test that gives us more information than the current PSA test provides. While most prostate cancer is slow growing, there are some patients who have more aggressive tumors. Future research needs to help us identify this important minority of patients who will actually benefit from more aggressive treatment. One more example of the need for a more personalized approach to medical care.

In the ’90s, the U.S. Department of Health and Human Services recognized that poorly controlled high blood pressure (otherwise known as hypertension) was a serious national priority. High blood pressure, known as the silent killer, puts millions of Americans at unnecessary risk for heart attack, stroke, heart failure, and kidney problems. As a call to action for this unmet need, the HHS put together an attack plan known as Healthy People 2000. For high blood pressure, the goal was to get 50 percent of patients’ blood pressure under control by the turn of the century. Sounds easy…right?

Healthy People 2000: Grade F
Well, when the data came out, we found that we missed the mark, and frankly we didn’t even come close—in the years 1999 to 2000 it was estimated that only 35 percent of the approximately 60 million Americans with high blood pressure were where they needed to be with their numbers. Why was this abysmal failure not on the front page of the news? You would think that this magnitude of failure would have led to tremendous public outcry. After all, this was a goal set by our country’s major public health organization. However, our guess is that most of our readers have heard nothing about it. That is because treatment of stroke and heart disease get our nation’s attention, while prevention is largely ignored.

Cashing in on Treatment
Here’s a disturbing reality: There is more money to be made in treatment than in prevention. However, treatment is not a sustainable strategy; prevention is. In fact, if we master prevention, we can really make a difference. As such, there is growing realization among physicians, insurers, employers, politicians, and the general public that the best (and cheapest) way to treat heart disease and stroke is to prevent it in the first place. Duh! Right?

If at First You Don’t Succeed, Try, Try, Again
So what did the folks at Healthy People do when faced with this poor performance? Well, in our opinion, they basically just kicked the problem down the road a bit. When the next set of goals came out, Healthy People 2011, guess what the target for blood pressure control was? That’s right 50 percent—again.

Healthy People 2010: Grade C-
Well it is 2010, time for the report card. And it turns out that we passed! Now before you start popping the champagne corks, it is important to note that we barely passed. In data from 2007 to 2008 the control rate of high blood pressure was a whopping 50.1 percent. That is cutting it pretty close, and I think it is important to recognize that since there are now about 68 million people with high blood pressure in this country, >33 million still have poor control and are facing unnecessary risk of heart disease and stroke.

Getting in Prevention’s Corner
If you remember anything, make it these facts:

• Heart disease is the leading cause of death in the U.S.
• Stroke is the third leading cause of death in the U.S.
• Together, heart disease and stroke accounted for more than $500 billion in health care expenditures and related expenses in 2010 alone.
• Most heart disease and strokes are preventable with better blood pressure control and managing other risk factors, such as cholesterol and smoking.

It seems high time that we start holding ourselves accountable for our own health.

Healthy People 2020: Grade Pending
So, basically in 2011, we got a C- and now the bar has been set higher, for Healthy People 2020 the goal is 61.2 percent control rates. The question on our minds, and hopefully yours is, why isn’t the goal 100 percent?!

Ignorance Is Bliss…Until a Heart Attack
In order to reach this target of 61.2 percent, we believe that we need to educate ourselves about who these >33 million people with uncontrolled hypertension are.

Hypertension’s Under Achievers
To drill down on this group of patients, with treated, but poorly controlled hypertension, we examined de-identified patient records from the GE’s Medical Quality Improvement Consortium (MQIC) database. We identified 1.5 million patients with documented hypertension. Not surprisingly, based on their access to healthcare, the majority of these patients were on treatment, but still about 25 percent of them had poor blood pressure control. . Interestingly, when we looked at the characteristics of these patients, they were actually very similar to the patients with decent control – about the same age, weight, with similar rates of smoking, and with similar other medical problems. They even saw their doctors just as much, about five times per year.

The Sicker, the Better!
The one thing we did notice is that blood pressure control was actually better in those patients who also had diabetes or kidney disease, conditions where physicians are very in tune with the importance of blood pressure control. Does this imply that both doctors and patients are more activated? That is, does high blood pressure only get our attention after an acute event? If illness is the only activator of wellness, our thinking of wellness needs to shift. We must take advantage of all acute issues to highlight the preventable next one. This is our teachable moment!

What Can You Do to Improve Blood Pressure Control?
As you know, 2020 will be here in nine short years. If we want to improve our grade, we each need to take responsibility for our personal blood pressure. We suggest the following steps:

1. Know your blood pressure! Your blood pressure will determine the quality and the quantity of your life.
2. If your blood pressure is high, make an appointment to see your primary care provider to get on a program of lifestyle changes and medications (if necessary) to get the blood pressure down.
3. If you are on blood pressure treatment, keep checking to make sure it is effective.

Help From the DMV?
Sure the lines at the DMV usually make your blood pressure go up, but what about making blood pressure checks part of car registration? We need to start thinking out of the box because the one we’re in now has no windows of consequence, only walls of ignorance. By holding no one accountable for the collective blood pressure of our nation, we‘re waiting for a national heart attack.

(1) Egan BM et al. Uncontrolled and Apparently Treatment Resistant Hypertension in the United States, 1988-2008. Circulation 2011;124:1026-1058.

How often do you drive your car with the revolutions per minute (RPM) meter in the red? The loud whine of the racing motor and the increasing vibration are usually pretty solid cues to switch gears asap. Even if you don’t know the specific consequence of not changing gears, it sounds like something is about to break and that will be bad for the car and costly to the driver.

Revving Up the Heart
Hypertension is medical-speak for high blood pressure – or in car terms, very high RPM. It means that each time your heart pumps blood throughout the plumbing of your circulatory system, it’s doing so at high pressure – much like a car being driven at high RPM. The big difference between a car and our body is that hypertension is quiet – hence the term “the silent killer.”

There is a version of hypertension that is not silent: It’s called malignant hypertension. In these cases, the loud whine and vibration of a car translate into severe headaches, stroke, and heart failure among other symptoms. But, because most people with high blood pressure never know they have it, they are not inclined to ‘do something’ unless they are adequately coached by their doctor. Moreover, even if one is diagnosed, there is a psychological barrier to take a medicine for something that you don’t feel.

Most of us want our car to last a very long time. So, we maintain it with oil changes; tire rotations and tune-ups. Our health – and more specifically our blood pressure – requires the same level of attention.

Under Pressure
Large blood vessels are not affected as much as the small blood vessels in the pathology of hypertension. Little vessels are more prone to deform under high pressure and lose their capacity to function.

All of these organs have vast networks of small vessels called arterioles and capillaries that are critical to their function. This is why untreated hypertension eventually and inevitably leads to:

People with hypertension have a stroke risk that is three to four times higher than those with normal blood pressure. Numerous studies have demonstrated that even with modest treatment of hypertension, with medications, we can decrease the risk of stroke by 40 percent with reduction in pressures. Given that 75,000,000 Americans have hypertension, this could result in tens of thousands of fewer strokes in America each year. Strokes can have catastrophic consequences on a person’s daily living as well as the economic implications for a family.

Know your Pressure!
Blood pressure comes in two numbers: The systolic, or top number and diastolic, or bottom number. The top number (systolic) is the pressure that’s created after the big chambers (ventricles) of your heart contract, similar to the pressure in your car’s motor at high RPM. The bottom number (diastolic) represents the pressure of your entire circulatory system at rest. That is, after the heart has pumped. This means that even in our resting state, our circulatory system is under pressure. This is analogous to the RPM of your car at idle. Around the time you start thinking about switching out your Subaru for a Porsche (oh, let’s say in your mid-50s), the impact of these numbers switch: In general, for younger models the bottom number tends to be the problem, and in older models it is usually the top number. Both numbers are important, and you can’t say that your blood pressure in under control unless it is <140/90 (for most people).

Nothing is that simple!

Hypertension is usually caused by genetics, lifestyle issues, or in most people with high blood pressure, a combination of the two. Being overweight, having a sedentary lifestyle, drinking too much alcohol and eating unhealthy foods are just some of the self-induced reasons that can contribute to high blood pressure. The sad truth is, for many of us hypertension is self-inflicted.

Hypertension Comes Fully Loaded

Not surprisingly, people with hypertension usually have other medical problems that are also lifestyle related.

In our query of 1.5 million de-identified patient records from the GE's Medical Quality Improvement Consortium (MQIC) database, it was found that among people with high blood pressure:
• 25% also have diabetes
• 36% have high cholesterol

Time to Switch Gears
For most people, the treatment of hypertension consists of a combination of lifestyle changes and medications. Lifestyle changes include losing weight, eating fruits and vegetables, limiting alcohol, reducing salt in the diet, getting better sleep, and exercising. But, by the time the plumbing system is messed up enough for a person to have chronic high blood pressure, we usually ask patients to make these changes in addition to taking medications. That may be sobering for some, but we always remind our patients that, importantly, making those lifestyle changes will allow us to use the least amount of medication possible.

Break the Cycle
For adults, Hypertension is the number one reason to go to a doctor, and yet some people still ignore it. According to a large-scale ongoing national survey paid for by your tax dollars run by the NHANES (a.k.a. the National Health and Nutrition Examination Survey), 80 percent of patients with hypertension are aware of their diagnosis, yet only 50 percent actually have their blood pressure controlled (that translates to about 70% of those who are aware). These numbers are very consistent with what we’ve found using data from GE’s Medical Quality Improvement Consortium (MQIC) Database, Only 73 percent of Hypertension patients have their blood pressure under control, despite the fact that these patients see their providers an average of five times per year.

Now, if I took my car to a mechanics shop five times per year, and it still wasn’t fixed, I would find a new mechanic. So, why are these numbers so abysmal? Why are we not keeping our blood pressure collectively under control?

Sounds like a subject for next week’s installment!

We need a new value proposition – so lets take a look at the numbers!

As we talked about last week, we are in the midst of a diabetes epidemic that could swallow the entire U.S. GDP if we don’t start thinking differently. Albert Einstein said it aptly: “We cannot solve problems with the same type of thinking we used when we created them.”

More than 20 million Americans have diabetes. Our medical system is designed to treat chronic ‘illness’ rather than focus on prevention and behavior change. In the last decade, the medical community has put its best foot forward to address this change in mandate. However, we must be crystal clear that our healthcare system makes money treating illness, not preventing it – and it’s here where we need to reflect on Einstein’s axiom.

IT’S NOT ROCKET SCIENCE OR BRAIN SURGERY
It’s harder – it involves changing behavior.

We’ll let you in on a secret that is too widely kept in the medical field; preventing the complications of diabetes is theoretically straightforward, it’s putting them into practice that appears to be straight backward.

The main complications of diabetes are heart attacks, strokes, amputations, kidney failure, and other wretched ailments that diminish our quality of life. So, why is it so hard? The guidelines are clear:

Although it often requires a combination of medications and lifestyle changes to make this happen, we have a tremendous number of therapeutic options available to us. Yet, whenever we look at ‘real-world’ data in diabetes management, we see that we simply get a failing grade in this country. Is our incentive structure in need of re-adjustment?

Let’s look at the numbers:
Using de-identified patient data from GE’s Medical Quality Improvement Consortium (MQIC) Database, we looked at over 600,000 patients with documented type 2 diabetes.

In their most recent visit to the doctor, patients with

To be clear and give a sense of scale, the aggregate blood sugar for a person without diabetes should be below 5.6%…and every 0.1% increase is a BIG deal. In a person with diabetes, it is ideal to keep their sugars below 7%.

Additionally, only about 45% of patients had normal blood pressure at their most recent visit. (Age and gender had little effect on those results.) Only around 30% were on any cholesterol lowering medications.

When you put it all together, you find that exceedingly few patients with type 2 diabetes are meeting optimal prevention targets. Shockingly, only 8.6% of people in the MQIC database who have elevated sugars and blood pressure are on a cholesterol lowering medication. This is fairly consistent with data that has been published by other groups.

WHY ARE THESE NUMBERS SO ASTONISHINGLY BAD?
Part of the problem is access to care – not just being able to afford care, but actually taking the time and trouble (and expense) to go and visit a practitioner. In the current iteration of payment model, healthcare is almost exclusively managed in face-to-face meetings in an office. Recent data shows positive correlation between number of visits and healthcare status. A recent article from the Harvard Medical School teaching system showed that when patients with type 2 diabetes were seen every 2 weeks, aggregate blood sugar control, was considerably faster and better than when patients were seen every 3-6 weeks.

Yet, unless diabetics feel sick, they are unlikely to see their health practitioner. Let’s face it – who wants to sit in a physician’s waiting room for 2 hours a week getting coughed on by sick toddlers and listening to smooth (or not so smooth) jazz?

Type 2 diabetes is a silent, chronic medical condition that for the vast majority of patients causes no symptoms, until it’s too late. In our query of the MQIC database, only about 50% of patients with type 2 diabetes saw their provider more than 4 times in the last year, and 22% saw their provider only once or twice in that year. Imagine if poorly controlled diabetes caused big red spots on the face…we would likely see a different pattern of prevention.

IT’S TIME FOR A CHANGE
Certainly, some practices have begun to embrace some novel methods of interacting with their patients by email and through other electronic means, and some payers are looking to pay providers based on quality as well as volume, but in general, these initiatives are hampered by the current reimbursement and medical records systems. The code has yet to be cracked – but we are moving towards a reality where your doctor will effectively be in your pocket.

WE NEED TO TAKE THE LONG VIEW
As a society, we are stuck in the ‘short-view.’ That is, those that are getting diagnosed with diabetes now, are patently unaware of the inevitable and looming longer term consequences; blindness, stroke, heart attacks, kidney failure and lower limb amputations. Having worked in the ICU, the dialysis unit and in an internal medicine clinic, it’s amazing how miserable the quality of a diabetic life becomes. Sadly, they cannot fathom such misery while they are enjoying fast food, sugary drinks and the myriad of desserts that exist in our country. Our food policy is failing us, and our healthcare system, up to now has made money on treating illness.

Diabetes and cardiovascular disease is a symptom of our sick healthcare system – and we need treatment now! The structural and IT reform will be a hard pill to swallow, yet if we all pull together, align incentives and reinvigorate a language and lifestyle of wellness…we’ll lick these lifestyle illnesses once and for all.