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Leadership Perspective: Prediabetes Tsunami — We Can’t Afford For It to Hit

Editor’s Note: This post is part of the “Leadership Perspectives” series on the Center for Total Health blog —  a collection of guest blog posts from Kaiser Permanente leaders all about why we need to take a Total Health approach.

Today’s guest author is Trina Histon, PhD, senior principal consultant with the Kaiser Permanente Care Management Institute, who shares her thoughts on prediabetes.


 

Few would deny the burden diabetes places on those who suffer from it and their loved ones who support them as they manage this disease. Estimates suggest that Americans with diabetes spend about $6,000 out of pocket per year managing their disease, monies that could be put to other use if we had more comprehensive ways implemented nationwide to prevent diabetes.

Trina Histon, PhD

Trina Histon, PhD

Many liken the next wave of diabetes as a tsunami that will hit the United States and its citizens, so let’s play that analogy through. Recent weather patterns have shown how devastating tsunamis are in the world, so much so, that efforts have been put in place to create sophisticated warning systems. So should another tsunami strike, countries will have advance warning so they are able to evacuate low-lying coastal areas and get people to safety.

In the U.S., the screening equivalent of that warning system for diabetes is an a1C test and the ADA has established a range of 5.7-6.4 as placing the individual in the “prediabetes” range. There are other tests, such as fasting blood sugar, but more and more health care is moving away from fasting blood work as it’s hard for people to fast for long periods of time. So this a1C range is our early warning system, and like most systems, it’s not perfect. In the literature this year, a few articles that discuss diabetes care and BMI have called into question the value of addressing prediabetes. These critiques are valid and perform an important function in both advancing the science and dialogue of where we want to spend our precious health care dollars.

Preparing for a Disaster We Know is on the Horizon

Kaiser Permanente today has 600,000 members with diabetes. We have also developed a cohort of just under one million members with lab values in the prediabetes range. Rather than wait for perfect science on exactly who needs an intervention, we feel ethically that if someone has a risk we should inform them and partner with them to address that risk, should they choose. One of the complexities of determining prediabetes risk is the prediabetes range has varying origins. For example, an a1C of 5.8 does not necessarily mean you will convert to diabetes, but you are at higher risk, and clearly are showing early signs of beta cell damage. What we do see is those with an a1C of 6.0 and higher and with BMIs in the obese range are most likely to convert. We are looking at our own data to see how we can further subtype the prediabetes risk spectrum and then subtype the interventions.

The Powerful Effect of Lifestyle Changes

The good news is lifestyle is the first line of treatment. The original diabetes prevention program (DPP) and subsequent translation trials show that those who lost 5 to 7 percent of their weight and increased their activity to 150 minutes/week prevented or delayed diabetes in 58 percent of participants over a three-year period – and 52 percent over 10 years. For most people, that translates to a 12- to 15-pound reduction, more attainable than the 30-40 percent of weight people might like to lose as reported on consumer surveys.
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Reducing Health Disparities in Hypertension Care for African Americans

3KeystoCombatingHealthDisparitiesMichelle, 55, an African American Kaiser Permanente member in Southern California, was disheartened when she learned that she had high blood pressure. But her outlook changed with the encouragement of her doctor who worked with her to develop a diet and exercise regimen.

Michelle was grateful for the support.

“Even in my visits when I started the weight loss, she was very encouraging,” she said. “That makes you want to lose a little more and do the best you can. I think that I started doing some of these things so by the time I came back she would notice a difference.”

Michelle has successfully reduced her blood pressure, lost over 20 pounds, and built a sustainable, healthy lifestyle.

More than 40 percent of African Americans have high blood pressure, a rate that is one of the highest in the world.

More than 40 percent of African Americans have high blood pressure, a rate that is one of the highest in the world.

African Americans consistently have lower rates of hypertension control than whites, a higher prevalence of high blood pressure, and are more likely to develop hypertension at a younger age. In addition to genetic, environmental, social, and lifestyle factors, researchers believe that disparities in health care quality are driving these differences.

A new Kaiser Permanente Policy Story from the Institute for Health Policy highlights recent measures implemented in Kaiser Permanente facilities to treat African American patients with hypertension. It discusses how these efforts have led to improved care through increased access, better patient/provider communication, support in lifestyle changes, practice of evidence-based medicine, and use of health information technology (HIT).

Another effort is a $2.55 million grant to the American Heart Association Initiative to address high blood pressure among African Americans in two U.S. cities (Atlanta and San Diego) over three years. The program will depend upon community-based efforts to track blood pressure readings between community clinic workers, volunteer health mentors, doctors, and patients to create a model that can be replicated in communities across the country.

Another Kaiser Permanente initiative known as “ALL/PHASE” – that includes the use of three low-cost medications to reduce heart attacks and strokes – is aimed at reducing disparities in cardiovascular disease among low-income diabetics over the age of 50.

“It takes awareness and community engagement, gaining buy-in from leaders, integrating disparities work into quality improvement projects, and spreading best practices,” said Murray Ross, PhD, vice president with Kaiser Permanente and director of the Institute for Health Policy. “An increased focus on health disparities will help to reduce the occurrences of health inequities and inequalities, ensuring that all patients receive high quality health care.”

Total Health, Thriving Economies, Community Health: The Connection

In cased you haven’t noticed, “total health” is a term we like to use a lot around here. It’s meant to encompass all the aspects of living that impact a person’s mental, physical and social well-being.

We link total health to a lot of seemingly disparate subjects that one might not immediately think of when thinking about health – e.g. transportation technology, zip codes, mindfulness.

So you might suggest we’re really stretching things a bit when we link total health to…the economy. But there is, in fact, a very important connection here.

Community health and an individual’s health and well-being are very intricately connected. Communities that support health and prosperity – communities with safe places to walk and ride your bike; easy access to fresh, locally grown produce; affordable housing and strong schools – these communities create the conditions that support healthy people. They are also the signifiers of a healthy and vibrant local economy.

Thriving local economies help “create conditions in communities that give rise to health,” explains Tyler Norris, vice president for Total Health Partnerships at Kaiser Permanente.

Norris sat down with Michelle Long, executive director of the Business Alliance for Local Living Economies (BALLE) to explore the connections between total health, thriving economies and community health. BALLE builds its mission on thriving local economies. Advancing what it calls a “localist agenda,” BALLE seeks to lift up the value of local community in driving a fair and equitable society. From BALLE’s website:

Localism is about building communities that are more healthy and sustainable – backed by local economies that are stronger and more resilient. It means we use regional resources to meet our needs – reconnecting eaters with farmers, investors with entrepreneurs, and business owners with the communities and natural places on which they depend. It recognizes that not one of us can do it alone and that we’re all better off, when we’re all better off.

The dynamic conversation on localism, economies, and health is captured in this recent article and podcast on Kaiser Permanente’s Share website.

When it Comes to Health Care, What Matters Most to Consumers?

Introduction from Bernadette Loftus, MD

Introduction from Bernadette Loftus, MD

Anyone who has had to choose a health insurance plan knows how confusing the process can be, even with the help of a friendly human resources professional. For the millions of Americans purchasing their coverage through exchanges, the process can be even more daunting.

Many consumers struggle to determine which plan is going to provide the best value – the coverage they need at a price they can afford. Dozens of organizations and publications – from the National Committee for Quality Assurance (NCQA) to Consumer Reports – rate health care plans each year. Some of these rankings are meant for the average consumer, but many are for industry insiders – laden with clinical terminology and detailed beyond what most people want to know.

On October 28, the Mid-Atlantic Permanente Medical Group and the Center for Total Health hosted what we hope to be the first in a series of events examining how we can translate these often technical ratings into something more consumer-friendly and how best we can get those ratings into the hands of the consumers.

Helen Burstin, MD, MPH, FACP, from The National Quality Forum, and Margaret O’Kane, from NCQA, set the tone for the day, reminding us that the patient must be at the center of all the industry does – not just care delivery. We must seek to provide our patients with the information they want in a way that is meaningful and accessible for them, while remembering that health care is a personal experience and much of what matters most cannot be measured. Dr. Burstin reminded us: Not everything that counts can be counted; not everything that can be counted counts.

Consumer Voices Panel

Consumer Voices Panel

Kaiser Permanente’s own Bernadette Loftus moderated a panel to understand what counts for consumers. Doris Peter, PhD, of Consumer Reports, emphasized that people can handle data.

“Just look at ESPN,” she reminded the audience, daring them to find a website with more data collected.

Dr. Peter and her co-panelists, Tina Reed of the Washington Business Journal, and consumer Iris Molotsky, agreed that uniform, consumer friendly terminology is a key step to making quality ratings more accessible for consumers. Ms. Molotsky, the president of Dupont Circle Village, a neighborhood association in Washington, DC, emphasized that “even well-educated, well-read, well-traveled” members of her community are confused by the complexities of standard health care language.

This sentiment was echoed by the last panel of the day, featuring the chief health officers of the District of Columbia, Maryland, and Virginia, as they lead their populations and health departments in the second open enrollment on the exchanges.

Great connections were made during the Mad Tea Party

Great connections were made during the Mad Tea Party

The Future of Employer-Based Health Care Coverage: A Conversation with Institute for Health Policy Advisory Board Member Kevin Schulman, MD

Editor’s Note:  This post and accompanying Q&A is authored by Ben Wheatley with the Kaiser Permanente Institute for Health Policy.

In a recent Perspective published in the New England Journal of Medicine titled, “Shifting toward Defined Contributions — Predicting the Effects,” Kevin Schulman, MD, discussed the increasing number of employers that are moving to defined contribution strategies in providing health care for their employees.

For employers, this move limits their financial exposure to rising health care costs by shifting the cost burden. Instead of negotiating rates with health insurance companies, employers contribute a capped amount toward their employees’ care, which gives them a suite of options for choosing coverage – along with added obligations in paying for their care as costs increase over time.

Kevin Schulman, MD

Kevin Schulman, MD

As the trend towards defined contribution grows, the nature of employer-based coverage begins to change. Institute for Health Policy Advisory Board Member Kevin Schulman, a professor of medicine in the Duke University School of Medicine and director of the Center for Clinical and Genetic Economics, discusses the implications of this shift.

Ben Wheatley: Ten years from now, will employer-based coverage as we know it still be around?

Kevin Schulman: This is one of the most interesting questions in health policy today. There are many problems with the current employer-based coverage system: it can limit flexibility in job choice, limit entrepreneurship, and, in a global marketplace, it can make American exports look more expensive next to products from countries where health care is funded differently.

The migration to defined contribution begins to break the bond between employment and coverage. Under this new approach, employees are really the ones purchasing their health benefits, and thus pay more of their own health care costs and will want to have more flexibility in their benefit choices.

Read the entire interview.
Please note: The views expressed in this article are not those of Kaiser Permanente.

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A Perfect Storm Brings Health Care, Government and Business Together for a More Sustainable DC

There was a “perfect storm” of activity in the nation’s capital last week, and if you weren’t tuned in closely, you might have missed it.

The Sustainable DC pledge awaits formal signatures from health care representatives signifying their commitment.

The Sustainable DC pledge awaits formal signatures from health care representatives signifying their commitment.

This perfect storm was not another Superstorm Sandy. In fact, one might argue that one of the aims of this perfect storm was to build resilience to any such storms in the future. This perfect storm brought together representatives from 21 different health care organizations and local government officials at Kaiser Permanente’s Center for Total Health pledging to make the District of Columbia “the most sustainable city in the United States.

So what makes this newsworthy? The health care sector is certainly no stranger to coming together under the umbrella of sustainability. Over the past 20 years, the sector has been leading its very own “green revolution,” with hospitals and health care systems of all sizes looking hard at their contributions to environmental waste and pollution and what they must do to flip the equation and support more environmentally sustainable health care approaches.

What makes the Sustainable DC effort special is its focus on a single urban community, on bringing together leaders from health care, government and business sectors in a particular place, concentrating their efforts across governance, jobs and the economy, equity and diversity with the goal that, “By 2032, the District will be the healthiest, greenest, most livable city in the nation by using sustainability solutions to address core challenges.” The Sustainable DC plan outlines specific goals, targets and actions to get there. And the plan makes it clear that health care organizations to be at the table to bring the mighty vision to fruition.

Hospitals in America contribute an estimated 8 percent of greenhouse gas emissions, generate more than 2 million tons of waste each year and draw upon natural resources like water in ways that often counteract efforts to support the health of individuals and communities. Recognizing this paradox, many health care leaders have joined efforts like the Healthier Hospitals Initiative, Practice Greenhealth and Health Care Without Harm to green their own health care systems.

Kathy Gerwig, chief environmental stewardship officer for Kaiser Permanente, chronicles this green movement in her recent book, Greening Health Care: How Hospitals Can Heal the Planet. In the book, she notes the reasoning behind why health care organizations would move to join forces with each other and government to move the needle on environmental health:

“In the final analysis, most health systems engage with their communities not because they are incented to do so by federal and state tax law, but because they are mission-driven organizations that care deeply about the health of their communities. They know that individuals’ health depends on the health of the communities in which they live, work, learn, and play, and that the health of those communities depends on a healthy environment—health-sustaining air, water, soil, and all natural resources. They strongly believe, on the basis of compelling evidence, that when they invest their dollars and their expertise in promoting healthy social and physical environments, they are benefiting their communities and contributing to the health of everyone.”

That mission-driven energy was palpable on October 23, 2014. The energy in the room was exciting, collegial and activated. There was much talk of the sustainability progress that is already converging in DC – from an extensive array of green roofs and LEED-certified buildings across DC to the build out of the Metropolitan Trail to provide safe, physical activity and active transportation options. And there was a clear conviction expressed by health care leaders who were gathered, as well as the Mayor’s office, that this coming together for a more sustainable DC was just setting the stage for a convergence of efforts that would echo progress even beyond DC limits.

We can only hope that, as DC leads the way in sustainability, so goes the rest of the country.

Representatives from DC area health care organizations gather with Mayor Vincent Gray at the Center for Total Health after the signing of the Sustainable DC pledge.

Representatives from DC area health care organizations gather with Mayor Vincent Gray at the Center for Total Health after the signing of the Sustainable DC pledge.

Kaiser Permanente applauds the Sustainable DC plan, and we are pleased to be among the pledge-signers and the hosts for this momentous step forward. We have pledged our support and look forward to working with fellow health care system leaders to advance the goals outlined in the plan.

Kaiser Permanente physician director for the Center for Total Health, Ted Eytan, along with Keith Montgomery, executive director for the Center, nicely set the stage for the day’s event in their welcome remarks. Ted offered his follow-up reflections in a blog post that summarized the vision for total health that everyone in the room intuitively if not concretely echoed that morning. He writes, the Sustainable DC plan is “not just about the environment, it’s about everything that goes into creating an ‘equitable, prosperous, society.’”

You can watch the full signing ceremony in this video.

Domestic Violence: A preventable public health problem

Domestic Violence InfographicThis month and every October, we pause to reflect on the profound impact that domestic violence has at the individual, community and national levels. It is well documented that one in four American women and one in fourteen men will be subject to domestic violence during their lifetime. We know more today than ever before about the science behind domestic violence — meaning its short-term and long-term health impacts.

Kaiser Permanente has a long track record of raising awareness and taking action on this topic for the benefit of the many lives it insures (many of whom are employees of the company). Its efforts were recognized last month by Peace Over Violence (a Los Angeles based non-profit whose goal it is to eliminate violence against women, youth and children) in the form of a corporate humanitarian award. This honor came about because of Kaiser Permanente’s leadership in partnering with the NO MORE campaign to raise public awareness about this issue via funding for programs serving survivors.

This week, the Institute for Health Policy website published an updated version of the article I authored in 2012 that highlights Kaiser Permanente initiatives and the gains over the last decade. A shining example is the implementation of an innovative approach for domestic violence prevention that was first piloted and launched in Kaiser Permanente’s Northern California region. In the words of Brigid McCaw, MD, director of that region’s family violence prevention program: “Transforming the health care response to domestic violence requires going beyond the traditional focus on didactic training for clinicians. Kaiser Permanente’s successful ‘systems model’ approach demonstrates that domestic violence prevention can be effectively incorporated into everyday health care services.”

You can read the story in its entirety at the Institute for Health Policy site.

Leadership Perspectives: Good Health Starts Where You Are

Editor’s Note: Today, we launch a recurring feature on the Center for Total Health Blog. “Leadership Perspectives” is a collection of guest blog posts from Kaiser Permanente leaders all about why we need to take a Total Health approach.

Today’s guest author is Elisa Mendel, national vice president of HealthWorks & Product Innovation for Kaiser Permanente, who shares her thoughts on place-based health.


 

How much time would you guess you spend at work each year? Would you be surprised if I said it’s something like 2,000 hours?

Elisa Mendel, VP of HealthWorks & Product Innovation for Kaiser Permanente

Elisa Mendel, VP of HealthWorks & Product Innovation for Kaiser Permanente

Compare that to the time we spend with our doctor — maybe 15 minutes once or twice a year? That’s why place-based health is so important. At its core, good health starts with us — where we live, work, learn, and play.

That’s one of the reasons Kaiser Permanente partnered with leading national organizations to launch Thriving Schools. The idea is that schools are the hub of every community. Our work in schools focuses on four key areas: healthy eating, active living, school employee wellness, and a positive school environment. One of the active living programs is called Fire Up Your Feet. Fire Up Your Feet’s fall campaign launches October 1, and it encourages kids to walk to school with their parents, giving them much-needed exercise and some quality time together.

Another initiative I really love combines the childhood enthusiasm for play with the workplace. It’s called “Instant Recess.” A manager or wellness champion schedules time with their team —usually about 10 minutes. Everyone stops what they’re doing, and one of the team members leads the group in dancing and exercise. People are moving, getting their blood pumping, and laughing together. It’s had amazing results, because when you’re doing the chicken dance with your supervisor, suddenly things feel a little less stressful.

Kaiser Permanente piloted this in various work settings — call centers, IT, and even the ICU. One of the ICU patients heard the staff doing this Instant Recess every day on the floor and she was determined to get out of bed so she could be wheeled out to participate in the fun.

There’s no limit to the benefits of healthy living. It can lift spirits and deliver real business results. One study in the Journal of Occupational and Environmental Medicine showed that employees who ate healthy and exercised regularly were up to 27 percent less likely to be absent from work for health reasons.

Good health is becoming a national movement. Find your “healthy,” and start to share good health close to your home.

Exercise is the New Vital Sign!

Since the dawn of the doctor’s visit, taking vital signs has been a mainstay. Height, weight, temperature, heart rate, blood pressure. It’s a routine process that we participate in almost without thinking.

But at Kaiser Permanente, after the blood pressure cuff comes off, you’ll get questions that might surprise you: how many days a week do you exercise moderately or strenuously? How many minutes a day do you exercise at this level?

Come again? At first thought, asking about physical activity levels might seem unorthodox. Unlike other vital signs, it’s measuring a behavior, not a body part. But conventional thinking about health and health care has changed, and systems like Kaiser Permanente recognize that addressing personal behavior and lifestyle is just as important as addressing biology.

A new KP Policy Story from Benjamin Wheatley of the Kaiser Permanente Institute for Health Policy highlights our “Exercise as a Vital Sign” (EVS) initiative. Since 2009, Kaiser Permanente providers have asked patients about their exercise habits during routine office visits. Taking this “vital sign” encourages ongoing conversations between patients and providers about physical activity, and serves as a gateway for referring patients to activities such as yoga, Zumba classes or hiking clubs. Recent research shows positive results of the EVS initiative: in 2013, we found that asking about exercise habits is associated with modest weight loss in overweight patients and improved glucose control among diabetics.

You can read the story in its entirety at the Institute for Health Policy site.

The Best Community Spaces come from the Community

Artistic rendering of 11th Street Bridge Park courtesy of Ed Estes, Washington, DC Office of Planning

Artistic rendering of 11th Street Bridge Park courtesy of Ed Estes, Washington, DC Office of Planning

Editor’s Note:  We have invited Scott Kratz, director of 11th Street Bridge Park to share with us some of his experiences as he takes this vision of a shared community space that supports health from concept to reality.  This is his second post with us. You can see his first post here.

Walking in a city park, have you ever experienced that frustrating moment? Maybe there’s no place to sit down. Or no shelter from the sun. Or there’s no family-friendly restroom in sight. The best civic spaces respond to the needs and desires of the community, but too often residents are left out of the design process. At the 11th Street Bridge Park, we’re working to change that with our new civic space in nation’s capital.

Together with the Washington, D.C. city government and a local non-profit organization “Building Bridges Across the River at THEARC” we’re transforming an aged-out freeway into a new park over the Anacostia River. After an extensive community outreach effort with more than 350 community meetings to date, we have created an amazing list of ideas for our park that were incorporated into a nation-wide design competition.

A primary goal of the 11th Street Bridge Park is to improve public health with this iconic new space. It will offer a safe place to play in a neighborhood that has the highest rates of obesity, and will incorporate healthy edible landscapes that can serve as a backdrop for farmers markets and planting/ harvest festivals for residents that have the lowest access to fresh fruits and vegetables in the region.

The design competition jury shortlisted four teams earlier this year, made up of the best landscape architects, architects and structural engineers in the country. After working all summer and meeting repeatedly with community stakeholders, the four teams submitted their renderings last week.

Now we want to hear from you. After reviewing the concepts here, tell us what you think! Take a short survey evaluating how each design meets our four key project goals. The results will be shared with our competition jury as it makes the final selection. We’ll announce the selected team on October 16. Stay tuned!

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