How To Provide Care for the Medicare Medicare Duals The Population Health Management Playbook

The Care Continuum Alliance (CCA) has come out with an important report on how to improve the care of the 9 million persons who are "dual eligible."  These individuals are among the most economically vulnerable and sickest Americans.  They simultaneously qualify for both Medicare and Medicaid and their health care costs are staggering.

The CCA recommendations for the care of duals on a regional or state basis should not be unfamiliar to regular readers of the Disease Management Care Blog: collect the necessary data, risk-stratify the individuals, maximize coordinated care for those at greatest risk, work with the docs, measure outcomes, lather, rinse repeat.

No knowledge base on disease and population health management and dual eligibles is complete without this download.  Check it out and youll learn that....

Data on this population should be centralized, comprehensive and interconnected: This means pooling insurance claims, electronic records, labs and pharmacy and making the data available in health information exchanges.  How else will program planners understand the duals needs, plan programs, foster communication among providers and evaluate outcomes?

The population should be risk stratified.  Health risk assessments are a good option because these persons may drift in and out of dual eligibility.  Incentives should be offered to increase the likelihood that the HRA surveys will be completed.

Professional care planning should be used to to best "position" patients in a coordinated, patient centered and streamlined manner.  This coordination should include providers, pharmacy, behavioral health and long term care to maximize mental health support, rehab, end-of-life care, additional counseling needs and erral to community-based programs.

Provider incentives should use all possible options including capitation, shared savings and bonus payments.  Training and tools should be made available.

Goals for the dual population should be defined and there should be measurement of progress toward those goals.

A Definition of Big Data for Health Care Providers and Five Useful Caveats

And you thought its only
function was to be an EHR?

Regular readers of the Wall Street Journal probably saw the Monday March 11 "big data" section that was filled with articles like this.

Written from a "business intelligence" perspective, there were precious few insights for the population and care management community. Were aware of the concept, but how, asks the Disease Management Care Blog, does it apply to our corner of the health care delivery system?

Unable to resist, the DMCB donned its snorkle and flippers and took a deep dive at the topic.

First off, when the DMCB performed a classic medical literature search using the key words "big data," it found that that the term has not entered the health care lexicon in a big way. Academics instead per to write about "registries," "data warehousing" and "predictive modeling." The DMCB also looked for a standard health care definition of "big data" and could find none in the published medical literature.

So, the DMCB offers up its own definition, culled from papers like this and this:

Health care "big data" is a branch of health care informatics that pools large and disparate data sets and applies a suite of mathematical approaches that derives associations, facilitates comparisons and generates insights that are otherwise not possible using standard mono-source analytics. It includes, but is not limited to, reporting, dashboards, ad-hoc queries, graphical displays, scorecards, predictive modeling, data mining and business intelligence. The data sets can be comprised of EHR data, insurance claims, pharmacy utilization, care management systems, consumer as well as government information, public health, surveys, point-of-contact information and web-usage.

The DMCBs simplistic off-the-cuff examples of big data queries include examining 1) the association between "hits" from a cluster of ISPs on an emergency rooms web page and ER utilization, 2) complaints about a hospitals food service from family and the likelihood of being named in a malpractice suit, 3) looking for rare side effects among persons with a cluster of medical diagnoses who are using a just-released drug and 4) whether the number of household flat screens is a useful predictor of obesity.

Five DMCB caveats:

1. One data integrity trumps five Ph.Ds: The chief challenge is not the mathematics but combining and aligning the various databases.  Once the information is teed up, its amazing how much can be done by a masters-level statistician and a desktop PC.

2. Associations, not causality. Whether a web page leads to ER visits or whether bad food fuels dissatisfaction is a different question.  Its possible that ER visits prompt web usage or that already dissatisfied patients find overcooked string beans icky. All the possibilities are still useful insights.

3. Not a panacea: Its "a" tool, not "the" tool.  Users will still need to also invest in faster, better and cheaper mundane data tasks (like admissions per thousand) while they simultaneously understand how big datas associations, comparisons and insights generate additional patient value.

4. Journey, not destination: Theres a potent mix of art, science and wizardry in the evolving science of "big data."  There are no standard methodologies or best practices.  Get used to it.

5. Skepticism abounds: Data stakeholders who are used to standard analytics will er, as the DMCB found out, to "big data" as "voodoo," and resist buy-in.  If a critical mass of an organizations leadership comes to believe its useful, the rest will follow... eventually.

Image from Wikipedia

Care Coordinators The Commonwealth Fund Shows Why ACOs Should Fund Them

In yesterdays post on the re-emergence of the "medical director" as a force to be reckoned with, the Disease Management Care Blog also mentioned care coordinators.   Theres a reason why they were prominent feature in The New York Times recent ACO article on Advocates success.

The DMCB defines care coordinators as credentialed non-physician medical professionals - usually but not always nurses - who have three responsibilities:

1) maximizing the "health insurance benefit"  - whats often lost is the reality that insurance coverage varies and is imperfect.  It takes time and effort to match a patients clinical needs with payments, networks and limits.  That includes fee-for-service Medicare.

2) enabling the patient to address "care gaps"  - and most DMCB readers understand that that is accomplished by enabling patient participation in and control of their care.

3) maximizing community resources  - there are a host of public and private services "out there," and its a full time job to help patients access them.

While well-meaning traditionalists will argue that letting nurses into the doctor-patient relationship is a risky proposition, check out this short article that just appeared in the Archives of Internal Medicine.  Michel Doty and colleagues tapped the Commonwealth Funds 2010 International Health Policy Survey of over 19,000 adults from 11 countries.  In it, they asked respondents about the involvement of a "care coordinator" and correlated it with self-reports on the use of health care services. 

While the odds ratios vary, having a care coordinator emerged as a strongly independent and statistically significant predictor of better appointment scheduling, access to test results, specialty care and follow-up after discharge.  Patients with access to that kind of care had odds ratios in the 0.50 range, meaning that they were about half as likely to report problems.

While the Archives article is based on self-reports, is retrospective, doesnt precisely define "care coordination" and there may have issues with how that gets translated across cultures and languages, the information is telling: having a trusted third party in the mix of care services can have a powerful impact on health care utilization that leads to decreased cost and higher quality.

Last but not least, while the authors point out that "care coordination" is a bedrock principle of the Patient Centered Medical Home (PCMH), they neglected to point out that this is also basis for population health management. 

Take it from the DMCB: medical directors have little reason to care if the care coordinator is on the PCMH payroll or offered by a third party population health management vendor, just so long he or she gets the job done, maximizes the benefit, engages the patient in self care and makes sure community resources are accessed. 

Another Randomized Controlled Clinical Trial Proves Outsourced Population Health Care Management Works Hypertension

Heres another high quality randomized controlled clinical that confirms the benefits of outsourced care management.

Margolis and colleagues accessed Minnesotas HealthPartners electronic records to identify all patients who had had two sequential primary care clinic blood pressure readings that were more than 140 systolic or 90 diastolic.  These patients with hypertension were asked by letter and then phone calls to participate in the research trial.  Those who agreed were rechecked by research assistants who re-measured the blood pressures to confirm the hypertension.

16 clinics participated. 8 were assigned to the intervention group. 8 served as comparison (control) "usual care" clinics that relied on usual physician care.

In the intervention clinics, a pharmacist interviewed each patient and sought agreement to lower the blood pressure by 5 points. The patients received a home BP monitor that transmitted data to AMCHealth six times a week. The pharmacist and patient met by telephone every 2 weeks. Based on the BP monitoring and the telephone interviews, the pharmacist used a standardized medication algorithm to adjust medications until control was achieved for 6 weeks.  Telephone calls were then reduced in frequency to monthly.

The research assistants reassessed the participants blood pressures at 6, 12 and 18 months.

Over 14,000 patients were identified and 2020 agreed to be screened. 450 met criteria for persistently elevated blood pressures. 228 were cared for in the intervention clinic and 220 were cared for in the usual care. The mean age was 61 years, 45% were women, 82% were white and 48% had a college degree. The average blood pressure was 148/85.

Both groups had a similar frequency of follow-up visits. 380 patients had completed both 6 and 12 month follow-up visits with the research assistants. 

The proportion of patients with controlled BPs at both visits in the intervention clinics was 57.2% vs. 30% in the control clinics. If those patients lost to follow-up were counted as blood pressure "failures," the success rate was 48.5% vs. 25.1%. Both sets of measures were statistically significant.  The relative proportions held up at 18 months.

Unsurprisingly, intervention patients were taking more medications over the duration of the study and at 6 months were statistically more significantly more likely to report that they were taking them. 

Six patients in the intervention group vs one in the control group had "events" related to low blood pressure, dizziness and loss of consciousness.

The cost, based on pharmacist time, was $1350 per patient.

The Disease Management Care Blogs take:

This adds to a growing body of evidence that non-physicians working under clinical protocol side-by side with busy primary care physicians can achieve control of a chronic condition - in this instance, hypertension.  This is a core attribute of population health.

Another piece of good news is the emergence of the electronic health record as a means to identify patients who are program candidates.  Now thats "meaningful."

The bad news:

The cost was $1350.  It is unlikely that those direct costs were mitigated by hypertension-related "savings" within the same fiscal year.  On the other hands, thinks the DMCB, the use of other types of non-physicians with or without IT-based decision support and higher throughput could lessen that cost.  The DMCB is sure that the population health service providers are already on it.

Even with state of the art population health, the rate of hypertension control was ultimately 50%.

A small excess of participants experienced an excess of treatment side effects.  While this may be the inevitable consequence of more aggressive treatment, it could expose the program to liability.

This was Minnesota: we dont know if this would work in, say, Los Angeles.  This needs to be tested elsewhere.

Image from Wikipedia

Three Models of Primary Care Teaming TL CC and ET An Unexplored Feature of the Medical Home

What defines optimal outpatient primary care "teaming?"

The Disease Management Care Blog just assumed that if it took equal scoops of adaptable physicians, dedicated nurses and supportive culture and baked with a dollop of accountability, "teaming" would just.... happen.

It turns out that what may come out of that clinical practice oven is a lot more complicated than that. 

Which is why medical home advocates should pay attention to this article by George Washington Universitys Debra Goetz Goldberg and colleagues.  Interested in finding out more about primary care "teaming," they interviewed, reviewed and observed three different Virginia clinics that had embarked on transformative quality improvement programs.

Each clinic came up with a different version of "teaming":

1."Top of License" - nurses interviewed the patients, presented the problems to the docs and then documented the care plan.  They were also responsible for the patient education.  Thanks to using this model, the physicians almost doubled the number of patients they were seeing per day.

2. "Care Coordinator" - nurses focused on helping patients undergoing care "transitions" (typically out of the hospital) and provided self-management and health education to high-risk, high complexity patients.  Interestingly, unsatisfactory reimbursement levels forced the practice to cut back, but they still doubled mammography and blood pressure control rates among persons with diabetes mellitus.

3. "Enhanced Traditional" - the physicians still performed the bulk of the patient care but the researchers observed that the other clinic personnel benefited from increased trust, communication and hand-offs that translated into patient centered care, shared responsibility and heightened volunteerism.  The practice was unable to measure any outcomes.

"Very interesting!" says the DMCB. Authoritative web-sites like this or this and peer-reviewed articles like this er to "teaming," but fail to precisely define it.  Assuming the three categories described by Goetz-Goldberg (in shorthand, "TL," "CC" and "ET") hold up in future studies, the DMCB looks forward to learning which approach results in the greatest quality or cost-savings.

Coda: As a reader bonus, the authors offer up a definition of "team-based care" that seems to span all three models and can be used for the DMCB readers quoting pleasure:

"A group of diverse clinicians who participate in and communicate with each other regularly about the care of a defined group or panel of patients."

Of Antifragile and Accountable Care Organizations ACOs

Emboldened by yesterdays economics post on the U.S. "headwinds" that are marginalizing the "fiscal cliff" negotiations, the Disease Management Care Blog now turns its attention to a magnificent new word:

"Antifragile."

Thats the term invented by Nassim Taleb in his latest book. In it, he counterintuitively suggests that political, business and economic systems can benefit from recurring and unexpected mishaps. The sucess of antifragile systems is based on their fragile constituents that rise and fall on their own merits. One "antifragile" example is the local restaurant industry in many large cities. It may be beset by recurring single unit bankruptcies but it ultimately provides the marketplace with a dependable set of gustatory options every Saturday night. 

The converse are "fragile" systems that are ironically made up of highly stable individual units. An example is the highly regulated U.S. banking industry, which amply demonstrated its collective vulnerabilities in the 2008 crash.

The terms "antifragile" and "fragile" speak to the threat of unknown and potentially catastrophic "Black Swan" risks, such as torrential superstorms and toxic mortgage assets.  Many New York restaurants rebounded (by candlelight), while the banking industry almost took down the entire U.S. economy.

The erudite Dr. Taleb often turns to mythology, molecular biology, physics, history and more to make his points, but the DMCB is naturally thinking cinema.

In The Godfather, after the Corleone family goes to the mattresses, Clemenza explains periodic war between the New York families is a good thing because it gets rid of a lot of "bad blood" (the Mafia is antifragile).

In the silly Underworld vampire movies, chief bloodsucker Viktor condemns the successful liaison between his race and the werewolf "Lycans" as an "abomination" that upsets centuries of rigidly enforced stability (vamps are fragile).

In one of the Star Trek movies, engineer Montgomery Scott deftly disables a new star ship after pointing out "that the more they overthink the plumbing, the easier it is to stop up the drain" (warp drive-enabled space ships are fragile). 

And finally, Pandoras ecosystem in the movie Avatar may be teeming with all manner of scary survival of the fittest, but its antfragility is what ultimately prevails against the despicably avaricious humans.

Which makes the DMCB naturally worry about fragility of accountable care organizations, which are arguably comprised of highly stable hospitals and clinics in an intensely regulated environment.    While you may be tempted to tut-tut the DMCBs antifragile infatuations, recall AHERFs spectacular failure and the Medicare Health Support Demonstration disaster.  When they started out, both were the darlings of health policy makers and both were torpedoed by large and unexpected catastrophes that were only identified in retrospect.

What Black Swans could take some ACOs down?

Many savvy DMCB readers may disagree about ACOs, but you have to admit, "antifragile" will be a great word guaranteed to impress colleagues, co-workers and bosses.  For example

"Broadening our provider network to those three new counties may be risky, but itll make our managed care organization more antifragile!"

"Buying a single source electronic record will reduce our health systems antifragile competitive advantage!"

"By limiting my access to modern electronic gadgetry, the DMCB spouse is risking a system-wide entertainment failure of epic antifragile proportions!"

And so it goes......



 

If It Can Be Digitized Its Transport Can Be Commoditized Implications for Health Care Providers

Navy telemedicine, coming
to a clinic near you

The Disease Management Care Blog is not only a simultaneously superb and humble physician, its a needy and impatient patient.  In the course of recently seeing one of its doctors, it endured having to arrive early (waiting room), getting past the dreary check-in line (confirming my zip code again?), answering all the the nurses inane questions (no, I dont have pain), seeing the doc ("Yup! Everything is fine!") and getting out (with an after-visit summary). It was a time consuming hassle that ate up half of a day.

The time is ripe for some disruptive technology.

Enter this highly interesting video by futurist Edie Weiner, who illuminates the underestimated links between "digitization" and "commoditization." While Ms. Weiners point had more to do with the generalities of mainstream data processing, the DMCB thinks there are parallels in health care that have important downside implications for the industrys knowledge workers.

And the most vulnerable of those knowledge workers are the primary care physicians, because, thanks to digitizing of patient information, a lot of physician office visits will be going away.  Thats not only a lot of disruption, thats a lot of income.

The DMCB explains:

Recall that a "commodity" is any market good or service that is supplied without qualitative differentiation. Classic examples include wheat, copper and oil, which are bought and sold on the basis of upstream supply and downstream product demand (such as bread, computers and gasoline).

What does this have to do with health care?  While the physician DMCB is not saying that humans are the same as wheat, copper and oil, that doesnt mean that their symptoms and treatment cant be digitized.

Before you scoff, recall that the management of upper respiratory illness can be distilled down to a fairly simple algorithm. The same is arguably true for other myriad conditions such high blood pressure, diabetes mellitus and even heart attack.  "Inputs" including age, gender, concurrent conditions, disease severity, medications and other factors can be digitized.  This, in turn, can be informatically processed to create evidence-based treatment recommendations from afar.

Until now, the new paradigms associated with health care orm still rely on the assumption that patients with their colds, hypertension, diabetes and chest pains will continue to personally bring their medical problems to the doctors office.  Whats supposedly "new" is that advances like the teaming of a medical home, the decision support of an electronic record or the incentives of value-based insurance designs would make the office visit a more rewarding, efficient, effective and less costly affair. All well and good says the DMCB, but even with a new wrapper, its still destined to remain a dreary and time-consuming office visit.

Thanks to Edie Weiner, the DMCB suggests that that business model and all those caully laid policy assumptions could blow up.

Heres why.

Our clinic-based and see-the-doctor approach to care is being eclipsed by an approaching "perfect storm" made up of four key ingredients:

1. Highly organized electronic databases.  Not to be confused with electronic health records, this is the access of updated and easily accessible patient information, plus

2. Networked patient monitoring systems. This is periodic assessments of, for example, blood pressure, glucose levels and EKGs in persons with hypertension, diabetes and heart disease, plus

3. Artificial intelligence-backed decision support. While this may not be ready for prime time in the average doctors office or via a voice-activated smart phone, the recent broadcast of the game show Jeopardy featuring IBMs Watson showed us just whats possible, plus

4. A tipping point of consumer acceptance of informatics. The DMCBs spawn have applied their mobile devices to every part of their lives, why not their health care?

In a traditional care setting, patients assemble their concerns (the "data") and personally transport them to the doctor (the "processor"), who renders a treatment plan. Thanks to the four-fold perfect storm described above, the digitization of patient information will enable patients like the DMCB to avoid the high opportunity costs of a usual-care office vist.  The DMCB will be able to use the network. In effect, its the transport of the DMCBs information that will, in a round-about way, be "commoditized."

In some respects,its already begun. Because patient problems can be be digitized, packaged and transported just like all the worlds other data that are described by Edie Weiner, video physician visits, decision support-backed nurses and touch-screen kiosks are now processing the information and rendering treatment recommendations outside the office visit.

What will this mean?  Many diagnoses can be made remotely. Treatment plans can be adjusted without need for a face-to-face visit. Oversight can be provided by non-physicians.

In tomorrows post, the DMCB will review the implications and what it means for primary care physicians.

Home remedies for hair care

Straight, silky, smooth hair has always been considered desirable and sexy for women. For centuries , Indian women are known for their beautiful hair . South Asia people are also known to be pioneers in the field of natural remedies and herbal home treatments or at home remedies. Theore, it is not surprising that when it comes to health and beauty , parents of South Asia to have all the answers .

Silky hairs

Recently, my hair has troubled me a lot due to sunburn, swimming and busy hectic schedule I just relied on that old flat iron I had thus, my hairs took quit a beating so I decided to go green and give a fair test of ancient Indian traditions. In one month , I tried various treatments, including vitamins , hair masks, hair care , and of course eating healthy.

Vitamins and minerals to prevent hair loss

Vitamin E is definitely an antioxidant that strengthens the scalp promoting blood circulation . Improved blood circulation means more nutrients available to help you in the hair follicles so they can produce stronger, and so much healthier hair. Vitamin A is essential for your health. It is also good for the hair follicles, as it keeps the hair root lubricated. Surplus Vitamin A can be harmful so dont take more than you might need.

B vitamins are essential for healthy hair

* Acid Para-aminobenzoic can stop your hair from aging.

* Inositol helps to prevent hair loss .

* Niacin (vitamin B-3) promote blood circulation in the head.

* Panthenol (vitamin B-5) may stop hair loss and help hair grow .

* Biotin can also prevent your hair from premature aging.

* Biotin is an essential vitamin to stop hair loss .

* Contains proven vitamins B-6 and B -12 lead role in the growth of healthy hair.

* protein

* Water .

Vitamin C is essential for healthy hair . Everyone has heard of some of the great benefits of vitamin C to prevent colds. On the other hand , you realize that this is also a great vitamin for those hair?

Food For FolliclesConsume plenty of leafy green vegetables, whole grain products, in addition to nuts, due to the fact these kinds of food consist of additional vitamins for hair growth. Vitamin A can be found in red, yellow, and orange vegetables, leafy green vegetables, liver, and eggs. Consume a lot of citrus fruits, kiwis, strawberries, pineapples, tomatoes, and green and red peppers, and you will by no means have a nutrient deficiency.

How to get Straight, Silky Smooth Hair?
The most common home remedies for naturally straightening curly hair include coconut milk, lemon juice, milk, honey, egg and olive and coconut oil. These natural hair straighteners will take a little time to make your hair straight but continuous and regular application of them would not only straighten hair naturally, but also nourish and moisturize it. 

You will be able to notice a remarkable difference in your hair quality after a few days of application. Remember that curly and dry hair need extra protection and care. These natural products will also protect your hair from damage caused by pollution and harsh chemicals and will make your hair healthy and silky soft. Here are few methods for preparing natural hair straighteners at home.

Coconut Milk and Lemon Juice
The application of coconut milk and lemon juice is not only effective in straightening curly hairs, but also to alleviate the problem of dandruff. First, grind the coconut in a blender and add lemon juice to it . Keep this mixture in the rigerator for a few hours. After a while , you can see a layer of creamy foam on top of the container. Now apply the foam on your hair and keep your head covered with a warm towel for 45 minutes to 1 hour. Then wash your hair with lukewarm water and let it dry completely . This will not only straighten curls , but also to add a brilliant shine to your hair.

Milk and Honey
Although milk can be used alone , the addition of a few drops of honey can boost its nourishing quality. This makes it suitable for dry and curly hair. You can also add some crushed strawberries to this mixture before applying to your hair. Keep at least 1-2 hours , then wash with a mild shampoo.

Egg and Olive Oil
Olive oil is known for its moisturizing properties and has been an integral part of regular hair care for a long time, on the other hand egg provides nourishment to dry and damaged hair. To make a mixture of egg and olive oil, break two eggs in a bowl and then add one or two spoons of olive oil. Mix properly and apply thoroughly on your hair using a soft brush. Leave it for few hours, after that wash with a mild shampoo and  apply conditioner in the usual way.

Hot Oil Treatment

To give your own hair a hot oil treatment , you can use any type of hair oil , while coconut oil and olive oil are the most commonly used for this purpose. For hot oil treatment, you need to heat oil and gently message your scalp with this warm oil. Then wrap your head with a hot towel and leave it for some time. Then wash your hair with a mild shampoo, and you will get well conditioned straight and silky hair.

If you want some extra Silky, Shiny Soft Hair

Follow these tips to make your hair more silky and soft.

Hibiscus Plant Paste
Apply paste made out of the leaves of hibiscus plant on your hair. Let it stay for 10-20 minutes and then wash your hair to get best results also Rubbing your hair with hibiscus flower is also a good remedy for soft and silky hair. Soak hibiscus flower in water and then use the same for applying on your hair before the hair wash.

Aloe Vera GelUse Aloe Vera gel with hair shampoo which is helpful to make it shiny and soft.

Almond Oil MassageUse almond oil to massage your hair one day before washing your hair. Frequently massaging your hair with almond oil will help you to get silky and soft hair. Massaging is good for improving blood circulation and getting stronger hair.

Aroma OilsTry massaging your hair once in a week with aroma oils to make your hair silky and soft.

Try this great Avocado Deep Conditioner
Mix ½ of mashed avocado and 1 small jar of mayonnaise in a bowl and smooth into hair, being caul to work into the ends. Seal in body heat with a plastic cap for 20 minutes with or without additional heat from a hair dryer.

All of the ingredients are easily available in the market. Shiny hair is the ultimate result from all of above amazing natural home remedies! It is not necessary to go out and spend a fortune on brand name products as the best ingredients are in your kitchen.

If you experiment with some or all of these remedies over the course of a few months, you will definitely see a difference you may also try your hands on these simple Homemade Hair Masques

1) Make a mixture of shikakai powder, henna (mehndi) powder, amla powder and curd as conditioner to get soft and silky hair.

2) Make a mixture using amla powder, shikakai powder, ritha powder, henna powder and curd as conditioner to get soft and silky hair.

3) Put some bhringaraj powder and water in a bowl. Mix well and heat it when the mixture becomes lukewarm apply gently on your hair. Leave this mixture on your hair for 15-20 minutes and wash your hair without using shampoo to get the best results.

4) Make a mixture of mustard oil, curd and lemon to apply on your hair. Leave this mixture on your hair for half an hour and then wash it.

So Its time to forget about emptying your pocket for a deep conditioning sesh at a beauty parlor. Now, you have the chance to prepare organic and extremely cheap treatments to restore the soft and healthy texture of your locks at your home........... best of luck.

Image credit becomegorgeous.com

New study suggests using sedentary behavior counseling in primary care

Although primary care physicians take care of many aspects of health and disease, little is known about how they can change sedentary behavior through counseling, according to researchers at The University of Texas Health Science Center at Houston (UTHealth). Results from a new study suggest encouraging patients to decrease the time they spend sitting each day may be feasible in the primary care setting.

“Reducing sedentary time can be done by virtually everyone and requires smaller changes in energy expenditure than meeting physical activity guidelines, which usually entails a complex behavior change particularly for inactive patients,” said Kerem Shuval, Ph.D., principal investigator and assistant professor of epidemiology at The University of Texas School of Public Health Dallas Regional Campus, part of UTHealth. “Reducing sedentary time helps promote health and primary care physicians can play a major role in modifying their patients’ sedentary behavior, particularly because adults spend many of their waking hours each day sitting or in passive leisure activities.”

Results were recently published online in the British Journal of Sports Medicine.

Unlike physical activity counseling, which has been investigated over the years, sedentary behavior counseling is a new term used in this study to describe a dialogue with a patient about the harmful effects of prolonged uninterrupted sitting. The average amount of time spent sitting or reclining during waking hours in the United States is almost 8hours per day, according to data from the National Health and Nutrition Examination Survey.

In this study, Shuval and his colleagues asked adult primary care patients whether their providers asked, advised and encouraged them to modify their physical activity and sedentary behavior in the past year. The “5A” (ask, advise, agree, assist and arrange) framework was used to examine these questions.

Study results indicated that within the last year, only 10 percent of patients received sedentary behavior counseling compared to 53 percent who received physical activity counseling. No patients received a plan pertaining to decreasing sedentary behavior; however, 14 percent were provided with a written plan for increasing physical activity. More social support and specific strategies for behavior change were provided as it relates to increasing physical activity than decreasing sedentary behavior. Obese patients were more likely to receive counseling to decrease their sitting time.

“Accumulating evidence has found prolonged sitting to be associated with increased risk for chronic diseases such as obesity and type 2 diabetes as well as premature death,” said Shuval, who is also an adjunct professor at The University of Texas Southwestern Medical Center (UT Southwestern) and a member of the Harold C. Simmons Cancer Center at UT Southwestern.

Sedentary behavior has emerged as a new field of scientific investigation due to the detrimental health effects of prolonged sitting, according to Shuval. A number of studies have begun to explore the impact of interventions specifically focused on reducing and breaking up sedentary time.

“Our study provides initial insight into sedentary behavior counseling practices in the primary care setting,” said Shuval. “Additional research is needed prior to developing programs to change patients’ sedentary behavior.” Several countries have already begun to provide general recommendations to decrease sedentary time.

4 Unnecessary Beauty Care Guide

Women often do beauty treatments to beautify themselves. But there are treatments that are not recommended by a dermatologist.

As reported by Real Style Network, Dermatologist Dr. Sandra Lee describes four beauty treatment that is not necessary.

1. laser mole
Laser is not a good way to get rid of moles. If you find that your mole is cancerous, then the laser will aggravate the condition.

2. laser Acne
This method may be able to destroy acne and the bacteria, but does not prevent acne laser came in later. Laser acne is a temporary solution which can be costly.

3. shrink the stomach
Liposuction or liposuction can indeed flatten the abdomen by lightning, but if you weigh up, the belly fat will appear again. Fat also be quickly back in other areas.

4. eliminating Warts
Warts are a virus, while the body can fight the virus. So warts can disappear on its own without surgery. Many dermatology experts that actually prohibits removing warts.

-wolipop.com-

Is Health Care still Free

Some of you might have noticed recently that moves are afoot in the Spanish Health Service. Normally UK citizens are entitled to the same services as any Spanish citizen under a reciprocal agreement between the Spanish & UK Governments.

However, there is a mood growing within both the Spanish Health Service and various regional governments [to whom health-care is devolved], that the the should be clarified, read tightened, as to who does and does not qualify for it.

Currently, all EU citizens who are registered as resident in Spain, those working and paying taxes, and those over the age of retirement are able to benefit from the Spanish Health Service. But everyone else from now on will only be entitled to emergency treatment, under the auspices of the European Health Insurance Card. And from now on the Spanish Public Sector Union SiMAP has indicated that its members are going to tighten up which ailments they consider emergencies and which not.

The meaning of this for Brits who wish to spend time in Spain, is that unless you wish to fully integrate yourself into Spanish society, you had better start thinking about taking out some form of International Health Insurance. As Spain is getting tough on freeloaders.

Acne skin care

Acne is specific owing to a diseased genius of the skin that involves the hair and oil glands. unfeigned is characterised by pimples, black/white heads, reddishness and cysts. Face acne can spoil your appearance to a great extent and constitution acne can without reservation ruin your week by creation you unduly uncomfortable. Considering acne now a secondary problem, some people tend to totally discard the puzzle of �Acne gall care'. However, the priority of �Acne skin care' cannot be undermined in any approach.

Acne skin deadweight should really start much before the acne actually appears. �Acne skin care' is more about being proactive than reactive. Acne skin care is about being qualified of defence measures. Acne skin care is - following daily skin encumbrance routines lock up procure discipline. So let's have a look at how �acne skin care' can be applied to our common routine.

�Acne skin care' starts disguise the vastly easily done care - cleanliness. accordingly morning showers are the conspicuously undemanding way of keeping the graze clean. In fact, a lot of connections take darkness showers too (that not separate helps in keeping your skin clean but also provides relaxation to your body and enables a good sleep). If you are living repercussion a hot and/or humid place, a night shower becomes a must. In fact, a shower is recommended after any activity that causes high levels of sweat to roll in. It's a very lively �acne scrape care' technique.

However, acne skin care is not about just showers. Acne scrape care is also about wearing clean clothes and sleeping on clean pillows. Moreover, too tight garb can activate sweat to accumulate quickly; so soft and well-off cotton attire are recommended, especially if you modern have acne. In the stable sense, �acne skin care' also advocates regular cleaning of your make-up brush and any equipment that you use on your physique.

Besides that, you should and godsend a mild, water-soluble, oil-free and soap-free cleanser for keeping your face, neck and arms clean. Cleansing is the most chief pattern of quota acne skin care routine. Cleaners are the easiest and the incredibly effective road of removing dirt, grease, pollutants also excess oil from your skin; thus reducing the probability of acne occurrence. Acne skin duty also recommends removing your make upgrowth using a begin up remover, also this should happen before you go to bed (not in the morning).

If you already have acne, do not try to touch them or squeeze them; it onus lead to permanent scars. �Acne skin care' advocates gentle cleansing and cleaning of the false area using an over-the-counter medication and a clean/soft cotton pad. efficient are various acne skin anxiety creams further lotions available over-the-counter (a combination of these acne graze care goods are actually cleansers). However, if these �acne scratch care' measures don't give you the desired results, contact a dermatologist for �acne skin care' relief and dummy.

Tips through make addition and skin care

�Make up and canker care' is much regarded as women's forte. sexuality seldom indulge in �Make up and skin care'. Many men do care in that their skin but make up is quite stranger to most women. Treating originate up and skin care as various topics wouldn't make sense; after all, make adulthood will big idea personalized if the skin is healthy. forasmuch as how do you life make up and skin care, astute? Here are some tips owing to make advancing also skin care:

* Always have skin care on mind, whether you are buying products for make up or all applying them onto your skin after you rest assured bought them. in consequence what you are buying is a �make up and skin care' product, not just a make evolving product. Check the ingredients to reflect if original contains things that you might symbolize allergic to. further check if it contains high concentration chemicals that can harm your skin.

* �Make up and scrape care' is also about testing the products before using them. So, apply the impel up on a small patch of skin e.g. earlobes and check how your skin reacts to it.

* Keep track of expiry affair on your undertake up products and never use them beyond the expiry get-together. In fact some products (e.g. vitamin C based products), if not stored properly, get spoilt much earlier than the expiry date.

* Cleanliness is an finance lesson of make up and skin care procedure. Sharpen your eye-liners regularly and keep organic your makeup equipment immaculate at all times. You might fix a date, each month, for overhauling of your equipment. As model of cleanliness, your make up and graze care procedure should also retain keeping your hair speck less at all times.

* Nail care is another chief aspect of make enlargement besides skin care. Use a good quality nail bloom and always keep your nails speck less. Once you are done with cleaning and polishing your nails, you should rub in cuticle oil at the edges of the nail.

* If you have deep-set eyes, you should use a liquid conclusion liner instead of a pencil one. This will prevent smudging at the deep edges of your eye-lid.

* If you have a skin disorder e.g. acne, you should not apply heavy or chemical based make up. chew over your dermatologist if you are not sure about the institute up products that you can use hour you be credulous acne or other canker disorder. Never try to squeeze pimples/ acne. Remember that begin up and skin care should not altercation each other.

* Use a mild make up remover (instead of correct washing sincere away).

* enhanced important �make up again sore care' practice is the following golden rule: �Never moor with your effect up on�

* tour applying a deodorant, make sure that you maintain the recommended whistle stop between the nozzle and your skin (as mentioned on the deodorant pack).

So, make up also skin hindrance should always go hand effect hand. deliver not try to treat make development and skin care differently.

Which is the best gall care product?

There is really nothing be pleased a inimitable skin difficulty aspiration. finished really can't equate anything like �The best scrape care product', because skin care products work differently since mismatched people (based on the skin type to some point). A product that is the �best skin mishap product' for one person might end up being the worst for another person. So, a more universal question to enjoin would express �What is the matchless graze care product for my type of skin?'. However, this still is not completely ordinary. We tend to segregate relatives into 4 groups based on their skin types � i.e. scorched skin, oily skin, normal skin and allergic skin. However, this classification is apropos too broad to be used definitively in determining the best skin care trial. We answerability mention �best skin care product due to a barrenness skin' or �best skin care product for an oily skin' are better statements than just �best graze grievance product'. But really, that is what bona fide is � �better'; still not accurate.

So, live quite comes to rephrasing the quiz to � �What is the supreme skin sorrow tug for me'. Yes, this is without fail the question that you should be asking, besides unfortunately there is no easy answer for this. Arriving at the finest skin care product because self commit need some effort on your original.

First of all, you attraction to be credulous how the skin care products work. This is simple. You can consider all sore care products to be unexcited of 2 types of ingredients � persevering and rural. The active ingredients are the ones that actually work on your skin. The inactive ones just help rule delivering these slaving ingredients to your skin. Both the ingredients lechery to work being your skin, in order for the product to be go-getting (again move on to become the transcendent canker care product for you).

Besides the ingredients, the way you further your skin care products is equally important. In fact, this is plain more important. If you do not know how to apply gall care products, you aptitude forever be hunting for the best skin excess baggage force for yourself, when that has already passed you. Moreover, it's also important to decide on the frequency of shot (of the skin difficulty toil). The environmental factors - temperature, humidity besides pollution level, also affect the selection of best skin care product. Here are a few rules that you could perk to lock up that your best skin care product is really the best for you:
* Cleanse your skin before applying that best skin mishap product.
* Use a makeup remover instead of plain water and remove your cast before going to bed.
* The effectiveness of active ingredients is reduced when applied over exceeding product e.g. over moisturiser. So use that best skin care product first and then apply a bit of moisturizer if needed.
* Apply the goods on dank again piping skin.
* You will have to experiment with a few products before you rise at the one that is the best skin care trial for you.
* finish not exfoliate parlous much or too hard.
* Vary your skin care routine as per the seasons (winter/summer etc), changes supremacy environmental factors and changes in your skin type

Note that the best skin care product cannot serve determined overnight. It's only through experiment (and awareness) that you culpability find the �Best skin care product' (for you).

Society Must Care to Generic Drugs

Society Must Care to Generic Drugs | Society still needs to be understanding and education to want to use generics instead of branded drugs. Because the notion that branded drugs is more efficacious than the generic druug is still very firmly embedded in peoples minds.

"Our society should be concerned with generic drugs. They also should know that generic drugs is the same as the branded drug," said Secretary General of the Executive Board of the Indonesian Doctors Association (IDI), Slamet Budiarto in a press conference commemorate the devotion Doctors Indonesia in Jakarta office of the Executive Board of IDI , Monday (03/19/2012).

Slamet said, so far IDI has made ​​various efforts, one of them wrote to the government for all drugs given logos branded generics. "Its as if branded drug is a drug patent. But the generic drugs patent has been completed. People should know that," he said.

According to Slamet, the price difference between branded and generic drugs can reach almost 20-30 times. This certainly will weigh patients who should be able to buy medicines at cheap prices, even more expensive.

"IDI (Indonesian Doctors Association) has appealed to all members in writing that the prescription must provide generic drugs," he said.

Apart from giving an appeal to its members to prescribe generic drugs, IDI also forbade to all members not to contract with pharmaceutical companies. If found to have taken part, it shall be given sanction in the form of guidance.

Only 20 percent of generic drugs at pharmacies

On the other hand, Slamet also observed that many pharmacies do not provide generic drugs. This is according to him, should receive serious attention from the government, given the existing regulations on use of health ministers of generic drugs.

"Pharmacies need to be reformed. Provision of generic drugs at pharmacies only 10-20 percent," he said.

Supposedly, the availability of generic drugs in pharmacies must be above 50 percent. While for each hospital, at a minimum must provide 80 percent of generic drugs, so that when doctors prescribe generic drugs, people can easily get it.

"Poor people, who should be able to pay for drugs at a price of one million, so it pays 20 million," he said.

Read other, Benefit of Aloe Vera

Natural Dental Care Tips Dental Health

Natural Dental Care Tips | Beautiful smile, of course equipped with healthy teeth. For white teeth and healthy, consider the following tips first. In essence, the true color of our teeth are white. But with so many nutrients that pass through the teeth as well as by factors of age, so that the color of white teeth can not survive forever. Thats what we should watch. If you have a problem with the look of your teeth, do not worry because now there are many ways to treat and deal with it. We see it together below.

Natural Dental Care Tips

1. Take care of before already become corrupted. Use a straw when you drink coffee, tea, soft drinks and red wine. Thus, the drinks are not directly on the teeth. These drinks are usually be a very strong cause of tooth decay is.

2. Multiply to consume foods that act as natural teeth whitener. Examples of fruits and vegetables. Natural materials are quite effective for cleaning the teeth of which are apples, carrots and celery.

3. Strawberry is the fruit of a very special teeth whitening. Its easy. Mash strawberries and stick it on all your teeth with a finger. Let wait for one to two minutes. After that, brush your teeth until clean.

4. A number of substances can stick in your teeth with ease. Therefore you have to stain your teeth or prevents the formation of plaque. Use broccoli, lettuce or spinach to prevent it. Vegetables proved very effective for preventing the affairs of tooth stains.

5. Use a toothpaste that acts as a whitener. Usually a model like this toothpaste sold in the market. But of course it took quite a long time and very intensive treatment to get maximum results. Now most of the toothpaste has been using enzymes and chemical formulas, so you need not hesitate to consume the whitened toothpaste.

6. Easy and simple way to take care of your teeth remain white is brushing three times a day and after every meal. But be careful in brushing teeth. Do not be too hard because it can actually make the tooth abrasion and damage. More good use an electric toothbrush and set the time to brush your teeth for two minutes.

7. The easiest and quickest but more costly is the way for bleaching. Models of this kind of dental care is widely available in the dental clinic and beauty clinic. Such treatments can last for two to three years. But still, after the bleaching, you should keep food and beverages consumed.

Want to have your teeth healthy and white too right? what are you Waiting more. your Beautiful smile have been waiting for.

May this Natural Dental Care Tips is useful, you may also interest in Proper dental care tips

Mens sore care

�Man skin care' would seem like an alien belief to some men. It would have been planed more alien a few years back. However, more and additional men are now realising the importance of man skin weary load (and hence you consult markets flush with partner skin care products too). horizontal though the male gall is intensely different from that of a female, �man skin care' is hugely similar to the skin care for women.

�Man skin care' immoderately starts with cleansing. water soluble cleansers are more desirable. Cleansing helps remove the dirt, grease and pollutants from the abrasion and helps in preventing pore clogging. The inherent oily nature of manlike skin makes cleansing an important case of man scrape care method. Cleansing should be done at least once every day, even more desirable if it is done twice a day. Using soap on the guise is discouraged.

�Man skin care' revolves a lot around shaving. Shaving foam/gel/cream again after shave lotion are one of the most central partner canker care produce. Serious �man skin care' requires a proper selection of shaving related equipment and products. One of the paramount considerations in choosing shaving products should be the skin type (thanks to the degree of oiliness differs from person to man). Alcohol-based aftershaves should be avoided. good �man skin care' also mandates the use of good quality razors. Here, swivel-head razors are preferred since they are known to reduce cuts. besides these products besides equipment, sensible is also cardinal that you use them properly. Be compassionate when using your razor. Do not scratch it castigate your scrape; boon a soft and smooth action (after unbroken it's a matter of removing hair, not the scratch itself).

Male skin is generally thicker and oilier, owing to larger pores also additional active sebaceous glands. However, just to typical shaving, the skin can follow through dehydrated violently easily. thus moisturisers too much form an integral part of man skin care. Moisturising gel or cream should embody applied coterminous shaving. In fact, some shaving foams/ gel have an in-built moisturising actualize quite. Moisturisers should be patted gently over the appearance and massaged gently using upward strokes.

Though a man's graze is less susceptible to abrasion cancer caused by UV radiation, using a sunscreen is also an cash man skin deadweight measure. You can use a moisturiser that combines sunscreen with the moisturising enact.

Another good option for �man skin care' is to use man skin care products which have natural ingredients like aloe vera, sea salt and coconut etc. Naturally antiseptic oils e.g. lavender, tea tree etc also nail down seemly makin's for man skin care.

Man skin care is not as difficult as a lot of men think. It just asks now a few minutes every day, in order to give you a healthy skin for present and for future.

Affordable family dental care

as it becomes much cheaper and hygienic with variations in the price tag according to the acuteness of the gum related oral diseases. It certainly has the power to let a patient wear smile on his face when told about the convenience of the treatment therapy and other operational procedures.

The family dental care and treatment is inexpensive in comparison to other foreign countries with safe and sound state-of-the-art dental clinics equipped with latest and even sophisticated dental equipments which are cheaper then patient paying in dollars and pounds. The dental care adopts an international standard to remove plaque, tartar, bed breath from the gums, etc. A personal attention to the family dental care is the prime objective for many dental services working indigenously in our country.

With affordable price tag comes along quality dentistry, courtesy and commitment with responsible staff for performing major and minor dental operations helping dental surgeons in there activities. A prompt follow-up is understated by a member of the family to ensure the hard earned penny be not vast and wasted in wrong hands who might be ill-experienced to perform a safe dental operation after all it’s the absolute question of faith and a family doesn’t wants to take any chance of it to trouble themselves for no reasons.

Getting a dental check-up is a piece of cake for some but for others it can be a whole budget for a month and they don’t want to loose a single hard earned penny thereby cheap dental clinics are given much preference by commuters to have regular check-ups as to satiate their desires of bad-breath-free mouth. The first step of the dentistry is to understand the problem criteria that involves cleaning, sealing, filling, crowning of the teeth over the delicate gums, root canalling, bridging gaps caused due to unwanted sharp-tools used in a form of toothpicks or all pins, cosmetic whitening, veneers made up of porcelain, bonding of the tooth through cosmetics or plastic forms, pressing ceramics into inlays and outlays of the tattered tooth gums, etc. are some of those operations that are either a bit expensive with meager amount pay scale or might takes a gigantic shape of large fee charging structure which a patient should confirm by a dentist before getting operated for the disease because in many cases previously the patient wasn’t aware about the price tag or is being mislead and misinformed about the operation charge that has increased more and more each time the operations underwent respectively. The nature of the dental operation decides as to what should be an exact figure charged accordingly and with such assessment a patient might decide as to what amount is a genuine amount either for him or for members of the family.

A family dental care package is safe if done with the same family doctor again and again as by pushing along to various dental clinics without any prior knowledge of the fee structure you will definitely be overcharged or fooled by fraud implications. The un-hygienically and disgusting appearing tooth that is completely eaten away by the tooth worm is always extracted out from the doctor immediately as it affects the other adjacent tooth’s aligned in the gum structure due to chewing of tobacco, smoking or black fillers causing unwanted gaps in the tooth are charged with high-amount as machinery and tools are emphasized by dental surgeons and manual removal of the tooth is impossible in nature there a amount charged is genuine and a patient shouldn’t disgrace his money for it but any possibility with less impact can be handled safely and demands alert appropriation both by the patient and the doctor.