Last evening the students in the EMPH program had the pleasure attending the Steven Rosenberg Lecture on Healthcare Quality. The lecture featured Bruce C. Vladeck, Ph.D. of Nexera on Putting the Patient in Patient Centered Care. Dr. Vladeck gave an overview the history of the patient-centered care concept. The lectured then focused on different definitions of patient-centered cared used in the health care industry as well as current trends. The evening ended with an informal question and answer session with Dr. Vladeck, Columbia faculty and practitioners and EMPH students.
Ingrid Edshteyn is a Preventive Medicine physician, PGY2, at Yale-Griffin Hospital and has recently been elected to the Executive Board of the American College of Lifestyle Medicine. She has embraced Preventive and Lifestyle Medicine as it encompasses both disease prevention and health promotion for individual patients and populations. Her commitments include the Yale-Griffin Prevention Research Center and Griffin’s Weight Management and Wellness Center, where she is developing a model for the clinical integration of a scalable lifestyle program. The EMPH course on Health Policy enabled her to identify the salient needs and opportunities within the changing healthcare system and the Management coursework empowered her to effectively lead the multidisciplinary committees involved within the hospital and professional societies. The EMPH program has had a substantial and direct impact professionally, enabling a broader and more cohesive understanding of our healthcare landscape.
This past Thursday right after classes we were treated to a wonderful evening presentation and discussion by Christopher Koller, President of the Milbank Memorial Fund on “Linking Evidence to Practice to Improve Population Health – Lessons from the States.” Chris, previewed for us the presentation that he is making to governors around the country on the impact that they can have in reshaping health care outcomes and lowering health care costs in their state by “going big” into revamping their health care systems. He presented extremely interesting results from both Vermont and Oregon and discussed new changes from the State of Arkansas. After the formal presentation Chris held an open and candid discussion on the trends that he is seeing in healthcare systems in different parts of the country. The seasoned EMPH students engaged Chris in a lively discussion. Another intellectually stimulating in person event with an industry thought leader which is what makes Columbia’s EMPH program so special and unique.
I have been a fan of Lean production and management practices for over 25 years (a big fan William Edward Deming) and have used these practices in many of my own professional services organizations. In our recent EMPH class in Managerial and Organization Behavior taught by Dr. Thomas D’Aunno, we have discussed the use of Lean practices in health care settings. A very important and current issue at a time where all health care providers are carefully looking at increasing quality and operational efficiency. A recent article I came across by Mark Graban which you can find here, discusses the use of Lean practices for all types of knowledge based work.
One of the best parts about the Columbia EMPH program is that it is not an online program but a diverse cohort of seasoned professionals who get together each month to have classes, socialize and network. This in person experience allows us to bond as a group and celebrate important personal events and milestones in our lives.
It is my please to introduce the latest member of our EMPH family Alexander, son of our classmate Kristin Meyers. We had a baby shower for Kristin during one of our lunch breaks which was truly a lovely event. Congratulation to Kristine and all of her family! We are looking forward to meeting Alexander in person when the weather is perhaps a bit nicer and welcome him into our EMPH family. He looks like he is ready to create health care policy that will change the world!
One of the best aspects of the EMPH program is that it provides us with the opportunity to have industry leading guest lecturers. This weekend we were fortunate to have Richard A. Barasch the Chairman and Chief Executive Officer of Universal American Corp. who lead an interactive discussion with our cohort on the rapidly changing world of healthcare under the Affordable Care Act and how his company is taking advantage of opportunities to be a leader in delivering very cost effective high quality health care. Universal American is a specialty health and life insurance holding company with an emphasis on providing a broad array of health insurance and managed care products and services to individuals covered by Medicare and Medicaid. The company has joined with primary-care provider groups, hospitals, integrated delivery systems, and a variety of other health care providers to form thirty-one Accountable Care Organizations (ACOs).
To public health enthusiasts beyond the EMPH class of 2013, here’s a note from classmate, Ellen Coleman, who hosts a lovely public health salon…
“EMPH 2013 has been conducting a bimonthly public health Salon which we would like to open up to other EMPH students past and present. The Salon is an informal gathering where we debate and discuss public health issues over food and drinks. The September Salon will be held on Wednesday September 11 from 7pm – 8:30pm on the Upper West Side. Please contact Ellen Coleman firstname.lastname@example.org if you are interested in more details or attending. “
We have had various topics from access to medicines in Sierra Leone to gun violence in the United States. It’s always been a way to combine interesting dialogue with food & vino in a relaxed, informal setting. I highly recommend you check it out!
About a year ago, in a context I’ve now forgotten, one of our classmates, Selim Arcasoy, mentioned the fat paradox during a class discussion. He explained, “Overweight people may have a lower mortality rate.” It momentarily registered in my brain, but I quickly filed it away as “statistical noise.” Since then, I heard about it again in a conversation about how the public health community sometimes ignores data, especially if it contradicts our popular conventions (like “being overweight is bad”, for example). The issue raises questions about interpretation of data that conflicts with widely held beliefs and how such findings may not impact practice. To better understand the fat paradox, I decided to go to the source…
Flegal and team, from the National Center for Health Statistics, published a meta-analysis in JAMA in 2013 entitled, “Association of All-Cause Mortality with Overweight and Obesity Using Standard Body Mass Index Categories.” They found that overweight participants had a lower hazard ratio for all-cause mortality compared with normal weight participants. To come to this conclusion, Flegal’s team reviewed 97 studies that included more than 2.88 million participants and over 270,000 deaths conducted in numerous countries (mostly the U.S. and Europe) through September 2012. They included studies that were adjusted for age, sex, and smoking but, interestingly, not for diseases that are part of the “obesity mortality pathway” such as hypertension because this would lead to “over-adjustment”. The meta-analysis found that relative to those with normal weight, grade 1 obese participants (see definitions below) had a similar mortality hazard ratio (HR) while those who were grade 2 or 3 obese had an increased mortality HR. In contrast, those who were overweight had a lower mortality HR (0.94, 95% CI, 0.91 – 0.96) compared with those who were normal weight.
Standard Body Mass Index (BMI) Categories
Underweight: < 18.5
Normal weight: 18.5 – < 25
Overweight: 25 – < 30
Obesity grade 1: 30 – < 35
Obesity grade 2: 35 – < 40
Obesity grade 3: < 40
In case you’re curious about your BMI, you can check here: http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.pdf
One of the major criticisms of the analysis is that the normal weight group contained people who may have had mortality risks including heavy smoking, advanced age, serious illness or infectious diseases that weren’t adequately controlled for and therefore served as confounders. Critics say that the researchers should have removed smokers altogether, though Flegal argues that this would eliminate a substantial amount of key data. Last, among over-weight patients, results were similar in adjusted and over-adjusted groups, thus demonstrating that diseases like hypertension were less likely to be confounders.
When looking at subgroups, the relationship between obesity and increased mortality decreases as people age. In a paper by Virginia Huges published in Nature in 2013, a U-shaped curve describes the relationship between mortality and weight among older populations. Interestingly, this curve was originally described by the National Institute on Aging based on actuarial tables decades ago. They found that the lowest mortality rate for 30 year-olds was among those with a BMI of ~20 but for 70 year-olds, the rate was lowest among those with a BMI of ~27.
What could explain all this? One theory is that among people with serious diseases (e.g. diabetes or heart disease), those who are overweight have more energy reserves to fight off illness. Others think that excess weight might help protect people during trauma and falls, particularly among the elderly. Still others believe that the underlying issue lies in what we are measuring…
What got David Lederer, a pulmonologist and lung transplant doctor at Columbia University Medical Center, interested in these weighty issues? He noticed a trend. Patients with a BMI greater than 30 were being turned down for new lungs. Why? Because there was a smattering of smallish, single-center trials that consistently showed the same trend – obese patients had high rates of early mortality after getting new lungs. David wondered why we were looking at such small studies so he tapped into the United Network for Organ Sharing (UNOS) database to learn more. After analyzing this immense data set and controlling for other variables, David still “couldn’t make the association go away” and found that obese patients had a 10-70% increase in mortality in the first year post-transplant (the wide range is partly due to co-morbidities).
Though he doesn’t consider himself an “obesity person” he forged ahead to better understand what was behind all this by assembling a multi-site team of scientists and clinicians. They’re now embarking on a prospective study looking beyond BMI to better understand how obesity is related to outcomes in lung transplant patients. Specifically, they’re investigating relationships among imaging, inflammatory mediators in fat tissue around lungs, and biomarkers in the blood like leptin (which regulates appetite), adiponecin (a protective hormone), and ghrelin (which stimulates hunger)…believe me, there are more… After better understanding these relationships, the idea is to find a variable more specific than BMI to predict lung transplant outcomes.
So how does this all relate to the original question: do overweight people have a decrease in mortality and if so why? David thinks it’s an interesting question, but suggests we should step back and define terms. “BMI is wonderfully useful at the population level. But on the individual level it’s less clear.” BMI is just one method of measuring body composition. He shows me a slide from a presentation listing others, including hydrometry, CT/MRI, ultrasound, and even dual-energy x-ray absorptiometry (or DXA-scan) – yes, the thing that measures bone density turns out to be a safe way to measure body fat. Preliminary findings of his study indicate that BMI does not correlate well with total body fat in lung transplant patients. It lacks specificity partly because of fluid and muscle mass. Remember, body builders like Schwarzenegger (back in the day) would be classified as morbidly obese because of weight. Whether it’s from muscle, fat, or fluid, BMI doesn’t know. Last, David wonders if the “normal weight” patients in the Flegal meta-analysis did worse because they might be actually losing weight (unintentional weight loss is a marker of disease), which is why a longitudinal study might be of use. He does agree, however, that having a little fat can be protective before a big surgery or during falls or trauma. His explanation of the limitations of BMI shed light on the issue and we look forward to reading the findings of his study.
After talking to David Lederer, I began to wonder if misclassification is the root of the controversy. While I think it may be contributing, I don’t think it’s the full answer. Part of the problem is that it’s a very difficult thing to study. We simply cannot replicate a single individual, keep everything constant (in terms of disease, exercise, social interaction) and give one double the calories (of the same food) to see what happens. We have to rely on studies in spite of their limitations. As a result, people combine study findings like Flegal’s with their own personal experiences to come up with a perspective on reality. Perhaps we should focus on what we do know: that a diet rich in fruits and vegetables, low in sugar and processed foods plus a lifestyle filled with exercise and activity prolongs life. These ideas are consistent with the work of Steven Blair (exercise scientist with University of South Carolina’s school of public health) who writes that focusing on the right behaviors (such as diet and exercise) leads to health irrespective of weight. He recommends at least 30 minutes of moderate intensity exercise on five or more days per week. I think his work reorients our focus – not solely on weight – but what’s beyond the weight. If eating kale for dinner decreases one’s blood glucose and walking in the park increases life expectancy, shouldn’t we give proper accolades to the kale – and to attractive walking shoes – as opposed to putting it all into one number?
Special thanks to Catherine Dentinger for edits and contributions on this blog post!
The Art of Asking a Question: My Interview with Disease Investigator and Adventure Traveler, Catherine Dentinger by Monica Mehta
There’s always one person in a room filled with vocal people who quietly listens and then asks the right question. In our class, it’s Catherine Dentinger. She has a unique way of injecting humor, introducing a novel thought, and probing others with one simple question. If you think about it, it’s not that surprising. This is the skill of an epidemiologist, to disarm and listen without coming across as intrusive. Since I’ve noticed this about her, I’ve been jonesing for an interview, so here goes…
Catherine Dentinger has a cool job. She’s an “epidemiology field officer” for the Centers for Disease Control and Prevention (CDC). Historically, this particular position came about post 9/11 when the U.S. government became increasingly worried about bio-terrorism (and rightly so after the 2001 anthrax letters). Tommy Thompson, secretary of Health and Human Services at the time, wanted CDC personnel in every state, thereby bolstering health department resources. Catherine explains, “Our goal is to detect communicable diseases, understand who gets them, and help prevent transmission.”
Epidemiology Field Officer is definitely an alluring title. “But how would you describe your job at a cocktail party?” I ask (partly because I have the same problem when describing my job). She pauses and thinks. She recalls a recent norovirus outbreak on an HBO set where she had to call and ask the affected individuals questions about symptoms and exposures. She told them that she’s a “nurse with the health department.” Sometimes she says, “disease investigator.”
I wonder how it all started. Catherine was always interested in health and in being outdoors. She knew clinical work was an option, but the thought of working in a hospital seemed depressing. And ironically, she describes herself as squeamish. When she said this, I recalled her telling me a few months prior about an investigation she conducted of a hepatitis A scare involving a pastry chef at a popular West Village restaurant. And how she “really wanted to try the food there” afterwards (which also a testament to vaccination!).
After studying environmental studies as an undergrad at the University of California at Santa Barbara, she joined the Peace Corps and went to The Democratic Republic of the Congo (which was called The Republic of Zaire at the time) to teach in a high school.
She lived in Lisala, a small town next to the Congo River. “You can actually find it on Google Maps, which blows me away because when I was there, we didn’t have electricity or running water.” And in fact, they still don’t. She notices my surprise and adds, “The Congo is a mess.” After her two-year stint, she actually stayed on to do administrative work in Lubumbashi, a larger city the border with Zambia. It was there in 1962 that Congo’s first elected prime minister (and independence leader) – Patrice Lumumba – was assassinated.
It takes a very hardy and driven person to spend three years in the Congo. “What were you looking for?” I asked. After growing up in the suburbs and wanting to make an impact in health and development (but also avoiding hospitals), she found fulfillment and adventure there. In spite of a lack of electricity, there was comfort in her work. She learned Lingala (the local language) to speak to fish farmers and also French to speak to schoolchildren. During her time there, she had a lot of students who lost family due to disease. A couple students had been crippled by polio (the preventable diseases really bothered her the most).
She recalls a young student of hers who was bit by a snake. She took him to the town hospital where the local doctor said that there was nothing he could do; the only option was to amputate. Catherine was stunned and turned to the Belgian nurses for help. They responded something like…leave it to an American to fly in and try to change the system. Catherine held the boy’s hand during the amputation and then took him home to live so he had proper rest and nutrition. One day, she came home to find he was gone. Later she learned he had gone to a traditional healer and returned home with what looked like mud and leaves on his amputation site. To her amazement, it healed nicely. The entire experience hit home for her, reminding her of the time her youngest brother lost his thumb by way of hedge clipper during a childhood accident.
Could they have saved the finger? She wonders about the Congolese boy.
Back stateside, Catherine went to nursing school on the east coast (George Mason University) and then back to Cali for her nurse practitioner (NP) degree (at University of California, San Francisco). Her nursing work post-school was limited – partly, she believes because of lack of residency training for NPs (a topic she is now passionate about and the subject of her policy class paper). Most new NPs got jobs in jails, county clinics, and the like until they gain experience). She was hired by a county clinic for uninsured adolescents, providing primary care, immunizations, birth control, and teaching nutrition and exercise. She commented that many teens were obese because of lack of education around these issues.
After three years, she applied to CDC’s Epidemic Intelligence Service (EIS) and ended up matching in the division of viral hepatitis. After some time in Atlanta, she went to Florida to work on a hepatitis A seroprevalence study in Okeechobee among children of migrant farmers. Essentially, she found that by 10 years of age, 75% of kids had hepatitis A antibodies. “Kids can be little vectors,” she explained. She published her work in 1999 and the Advisory Committee on Immunization Practices (ACIP) recommended that children of migrant farmworkers be routinely immunized. Seven years later, the ACIP recommended that all children receive hepatitis A vaccine. After that, she worked in Romania to better understand the association between hepatitis B and healthcare associated injections.
After completing EIS in 1999, she went to India for three months to work on the Stop Transmission of Polio (STOP) program, the global polio eradication initiative.
As you may recall, India eradicated Polio in 2011. (more here: http://www.polioeradication.org/Infectedcountries/India.aspx)
After her training, she moved to Alaska and stayed on with the CDC as a nurse epidemiologist. She was always intrigued by Alaska and loved nature, so it was a good fit (and also fed into her adventurous nature). During her five-year stint in Alaska, she studied infections that have a high prevalence among Alaska Natives like pneumococcus, S. aureus, H. Pylori, and more). She also conducted a 20-year follow up of hepatitis B vaccine recipients to understand the effective duration of the vaccine. And then she transferred to NYC…
How did she end up here at Columbia, perusing an MPH? Some of her NYC epi work (like antibiotic resistance work in local hospitals) lost funding so she wanted to expand her repertoire. And “jazz things up” she tells me.
And perhaps think about becoming more of a leader in nursing. Prior to joining, at a Mailman EMPH open house, she heard from a nurse who did the program and said that the program was the most interesting thing she’s done.
The future? Perhaps work around women’s health in developing countries. But then again, she’s become inspired to think about other things during school. Like health information technology. Or teaching public health to nurses. In any event, I’m confident that Catherine’s adventures will continue and that she will pay it forward. And always…ask the right question.
I’m now reflecting upon the recent annual Mailman Health Policy & Management Conference. It was great to see generations of EMPHers: my classmates milling about our predecessors and successors, sharing stories, and getting updates. I realized at one point that I really must put some time into creating the all-essential one-liner to describe my work and path. Somehow “clinical pharmacist transitioning into public health” doesn’t seem to fit anymore…and that’s when I ran into Rami who had the best one-liner ever. When asked what he was up to, he told me, “I now pay people to exercise.”
Rami Rafeh (c/o 2012) surprised me with his update. Since his graduation just six months prior, he has done what many of us aspire to…give birth to a project based on an idea. He started a company. He named it spott3r. And they pay people to exercise. Yeah, that’s right.
I was curious about all the steps leading up to it, so we chatted in Columbia Club’s plush leather foyer while I got the back-story. After studying biology (undergrad) and biomedical sciences (for a masters), Rami became a young, up-and-coming wiz at Pfizer working in drug safety. He quickly grew more proficient at the biz side of drug development and considered going back to school to pursue an MBA. His boss and mentor, an epidemiologist by training, encouraged him to pursue an MPH instead. This ended up becoming what Rami now reflects upon as being a great decision at a critical crossroads (yet another reason we should all have mentors). Rami came to Mailman with the ultimate goal of being a consultant, specifically at Mckinsey or Booze.
During the program, Rami proved himself to be quite the multi-tasker. At Pfizer, he transitioned to the Worldwide Business Development & Innovation team, took a health information technology program also at Columbia (a 7-month certificate program), became a limited partner for a healthcare start-up accelerator (more on this later), and an advisor to startup incubators. He was layering his skill set (science to business to technology and public health) in order to become an “out of the box” thinker and an asset to employers. And with this, he was able to beat out the MBA competition in an emerging niche. As superhuman as it all sounds, it turns out it was. Rami confessed to getting maxed out at one point, realizing he was possibly doing too much. Nonetheless, “it carved the path to entrepreneurialism” as he puts it.
Aside from a flashback to Back to the Future, I was unfamiliar with the term accelerator, so Rami set me straight. Essentially, they grow viable companies out of fledgling ideas. Good ideas. Or perhaps a cool solution to an existing problem. The accelerator (Blueprint Health, for example) provides space (co-shared with other innovators) + seed money + marketing assists + the proper mentors in exchange for part ownership. As a limited partner, Rami was surrounded by people converting ideas into companies, a contagious phenomenon. Combined with MPH classes (like strategy, marketing, social entrepreneurialism), Rami started brainstorming. At school, we spend countless hours discussing problems with the system. He simply thought of one solution. Spott3r grew from a school project. When he realized it was actually a good idea, he patented it.
How do you pay people to exercise, I wondered. And how is this a viable business model? He told me that people like to exercise – it makes them feel good and look good, but that’s not always enough to keep them going to the gym. Money might be the necessary boost. Furthermore, many health insurance companies recognize exercise as an investment and cut checks to customers who submit gym logs. In spite of that, many people don’t bother to make claims. And that’s where spott3r fits in – by partnering with gyms and insurance companies with consent by customers to create a win-win-win situation.
Why don’t people just make the claims themselves? The typical process is multi-step: providing a gym agreement, proving payment, sometimes showing evidence of cardiovascular equipment, filling out insurance reimbursement requests, and submitting them by mail. With spott3r, the customer simply fills out an online form and sits back while receiving checks. Rami’s company does the backend work and in return, takes a small percent from the customer’s reimbursement.
Rami still works at Pfizer. He also recently joined the Startup Leadership Program in NYC, which connects him with over 900 entrepreneurs worldwide to share best practices. Apparently approximately half of the NYC folks are alums or current students of Columbia University (news to me!).
As far as his dream of becoming a consultant? He tells me, “Nah, not for me anymore. Not to bash traditional careers, but I think I’ve found a way to make an impact while pursuing a passion.” He went on, “coming out of a program like ours with insights into healthcare delivery inefficiencies begets a lot of opportunity.” He wants this to be a call to action to other students…to partner up, mentor a start up, invest in projects, or do it oneself. There’s gratification in knowing that you are applying class work to the real world. Ultimately, Rami wants to tie the company’s efforts to health outcomes (obesity rates, cardiovascular disease, etc).
Next moves for spott3r? To partner with gyms and run pilots. They plan to launch widely late summer. Rami’s research indicates that there are over 25 million Americans who might be eligible. And the name spott3r? He reminded me that a spotter is the person who assists and protects when lifting weights. And the 3 for the e stands for “sign up, work out, and cash in.”
Sometimes the simplest ideas are the most elegant and perhaps even most impactful. Partly because simple translates into doable. Rami’s story makes me wonder about what walls we put up between change and us. It’s not really about the one-liner, is it? Perhaps the idea comes first, then the action, and the one-liner organically follows. Stuff to ponder…
Check out the spott3r video here: http://bit.ly/spott3rlaunchvideo