Category Archives: research

Improving Maine’s health, MaineHealth stays focused on data

This is a Guest Post by Tim Cowan, Director of the MaineHealth Index, an initiative of MaineHealth that monitoring Maine’s most pressing health priorities. Launched in 2008, Health Index uses data to inform the needs and opportunities for improving health across the state.
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Sit down at the counter in one of Maine’s smoke-free diners and talk to the typical Mainer next to you about healthier living, and more specifically smoking.

Odds are you’ll be talking to someone around 44 years old. Compared to his fellow Americans, he will be more likely to die from smoking, including cancer related to tobacco use, especially lung cancer. There’s just under a two-in-three chance he’ll have a weight issue, including a 29 percent chance he’ll be obese. He’ll be more likely to binge drink and, sadly, more likely to commit suicide.

Do you think smoking remains a big problem here?

In between big bites of bacon and eggs, with a side of pancakes no doubt, you might get a response that goes something like this: “It’s not nearly as bad as it used to be. I mean, I quit two years ago. Well, for a while, anyway. So, nah, not so big a problem anymore.”

And that typical Mainer would be half right. We have made progress on reducing tobacco use in Maine over the past decade and a half. The best known of Maine’s public health initiatives brought higher tobacco taxes, smoking bans in most workplaces and later such bans in all public settings. It also brought some very effective tobacco cessation efforts funded with money from a state settlement with the Big Tobacco companies. As a result, smoking rates in Maine have declined from about 25 percent of adults and 38 percent of youths in 1995 to about 19 percent of adults in 2014 and 10 percent of youths in 2015 (use of any tobacco products among youths was 16 percent). Over the past three years, about six in 10 adult Maine smokers quit for at least one day. That’s progress, but a close look at that typical Mainer tells us it’s not nearly good enough.

When we look at the investments we’ve made in recent years to prevent youth from using tobacco products and to help tobacco users become free of their dependence on nicotine, and then we compare those to the costs tobacco use still imposes in Maine’s communities, we get a picture of a modest investment yielding modest results. Unfortunately, this holds true for many of our efforts at improving public health. Yes, many good, smart and dedicated people are working very hard through innovative and effective programs to help us change our habits to be healthier, but those hard-won successes often represent humble progress against daunting challenges. We can and should do more.

I’m proud to be part of an organization that has as its vision, “Working together so our communities are the healthiest in America.” As part of that, MaineHealth provides the very best care it can as close to home as possible through our member hospitals, physician practices and outpatient facilities. However, we also help fund and manage programs and partner with others in efforts aimed at improving public health. For instance, the MaineHealth Center for Tobacco Independence runs the statewide tobacco treatment programing on behalf of the Partnership For a Tobacco-Free Maine – including providing free assistance with quitting through the Maine Tobacco Helpline. MaineHealth’s member organizations have helped lead the successful implementation and expansion of Let’s Go 5-2-1-0, which aims to increase physical activity and reduce obesity among youth in many of Maine’s communities. Our member hospitals are also doing a variety of outreach and programming aimed at making healthier communities.

But a healthier Maine cannot be achieved by our organization, or any organization, working alone. This takes real collaboration. All levels of government need to contribute with both funding and policies proven effective through scientific studies. Businesses, large and small, need to understand that investing in the health of their employees helps the bottom line. And schools, nonprofits, philanthropists, foundations and families and individuals all have a role. By working together and enhancing each other’s capacity, we will have the greatest impact.

This is a good time to be discussing the health of the people who live here. A unique statewide collaboration among Maine’s larger healthcare organizations and the state Center for Disease Control and Prevention has recently completed a report called the Community Health Needs Assessment. This document is a report card that grades our public health results in Maine.

The report provides data by county and for the state as a whole and can be viewed at www.mechna.com.

It paints that picture of the typical Mainer outlined above and also identifies challenges such as poverty, mental illness, substance abuse and addiction and access to healthcare coverage. These factors contribute to higher healthcare costs. They also make our lives shorter, less healthy and less happy. The data show, among other things, that smoking remains a big problem here. Lung cancer alone claims around 50 lives per 100,000 each year, and smoking-related deaths from all causes add up to about 100 out of every 100,000 people each year.

This doesn’t mean we shouldn’t be alarmed about obesity, mental health, drug and alcohol abuse and other factors that can erode our quality of life and contribute to premature death. We should be. But we should still be alarmed that tobacco use continues to kill so many, and we shouldn’t be satisfied with the progress we’ve made thus far.

The financial return on better health for Mainers is huge, but other than efforts targeted at specific employee groups, those returns tend to be diffuse and don’t collect as a single revenue stream. This makes funding health improvement tricky. Yet, higher worker productivity, lower utilization of expensive medical care and better quality of life have real value, making health improvement a smart financial investment.

Health improvement requires the attention of many stakeholders. It has been easy historically for any one of them to step back on the hope that others will pick up the slack. We’ve seen this in recent years as the Fund for a Healthy Maine, which was created by the state to fund health improvement activities with tobacco settlement monies, has been eroded to help balance the state budget.

Many large businesses, meanwhile, have stepped up with innovative and substantial employee wellness initiatives and have achieved impressive results, but many others have lagged. Meanwhile, small business owners – stretched for time and resources – struggle with strategies to motivate employees to pursue healthier habits.

And by no means have we in health care done all that we could or should, but we are focused on getting better. To that end, the consortium that undertook the health needs assessment – which calls itself the Shared Health Needs Assessment Planning Process – is coordinating with hospitals and other stakeholders to gather public input on our health status and the problems that need to be addressed.

In coming months there will be forums in every Maine county to get feedback that will be used by local hospitals to develop community health programing. For more information, contact your local hospital or go to www.meshnapp.com.

I look forward to someday stepping into that diner and sitting down next to a fit fellow enjoying some nonfat yogurt and fruit or maybe some oatmeal. He’ll have just come from a long walk along a new path built with the help of his local town and committed community volunteers. He will be proudly smoke free, a moderate drinker and happy to be living in such a beautiful place. When I ask him if tobacco use remains a concern, he won’t hesitate.

“We’ve got to keep at it,” he will say. “There are too many lives at stake.”

Original article published in the Portland Press Herald, December 27, 2015.

My research buddies at the NIH mHealth Institute (#mHealth14)

This year at the mHealth Summit, I opted to attend the 2014 NIH mHealth Institute pre-conference. This 2-day session, lead by Dr. Wendy Neilson (@WendyNilsen) from NIH’s Office of Behavioral and Social Sciences Research, gives a view of app thinking from the perspective of research, focusing on ways to use and study mHealth apps for change. This space is so important but not easy to do. Developers tend to focus on functionality, researchers on populations and study questions. mHealth research has to be practical as technology moves swiftly. No 3-year randomized control trials need apply. True transdisciplinary efforts must create agile approaches done in scientifically robust ways.

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Alain Koffi, MD, PhD, Johns Hopkins Bloomberg School of Public Health; Susan Woods, MD, MPH, Veterans Health Administration (@SueWoods), Linda Park, PhD, FNP-BC, U. California San Francisco; Dayo Ajayi-Obe, MD, SM, Imperial College Healthcare NHS Trust; Donna Spruijt-Metz, MFA, PhD, U. Southern California and NIH mHealth Institute Faculty (@metzlab); Amy Dunaway, MPH, MA, U. Missouri; Brad Tritle, CIPP, vitaphone e-health solutions (@BTritle); Zdenek Gutter, PhD, Czech National eHealth Centre, Stimcare; Sumal Nandasena, MD, MSc, MBBS, Sri Lanka Ministry of Health. Not in photograph: Robyn Stremler, RN, PhD, U. Toronto; EunSeok (Julie) Cha, PhD, MPH, RN, Emory University.

The best part of the experience was that it was shared. We worked in small groups at round tables coming up with problems to solve, and ideas and methods to study them. Our international group was collaborative, theorizing about serious stuff: pregnant women waiting for Medicaid eligibility assessment. What did we come up with? We decided to give women a smart phone, loaded with our ‘study app’ – connecting users to one another and to community information (Why not? It’s reasonable to think that handing out technology can improve health and cut costs, too). We were interested in studying effects of social networks and access to virtual resources — developed based on what was important in the women’s lives and designing to fit their needs. Lecturer “Billie” Nahum-Shani demonstrated her sharp methodology expertise, pushing us to ramp up our science-thinking.
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We probably won’t write a proposal together, but some are sure to pursue mHealth research funding in 2015. We had fun thinking about how to dig into a rapidly growing field and learned from all the speakers. Thanks to all the mHealth NIH Institute faculty (check here for future trainings). Our group gives special appreciation goes to Donna Spruijt-Metz, who kept us on our toes our 2nd day group facilitator – thanks, Donna!

Wouldn’t it be fun for this group to come back together — like Oprah — in 5 or 10 years and see what everyone’s up to? Let’s stay in touch, team!

We Must Have Patients and Caregivers Shaping Medical Curriculum

Many years ago, I sat through 2 years of lectures in medical school. Then, 2 years in the hospital. Then residency and clinics, hospital wards and more wards. How patients were viewed was always the same. They were there to answer questions, put up with exams, a lot of testing and feeling poorly. Writing of notes was endless, as were lists of possible diagnoses, test ordering and treatments.

At no time, and in no venue, did anyone consider patient as teacher. It was never conveyed that ‘patients were the experts of their issues’.

Such a lost opportunity. Maybe, just maybe, healthcare is waking up.

Pt Educ Counsel
A wonderful paper in
Patient Education and Counseling, What parents want from emails with their pediatrician: Implications for teaching communication skills is well worth a careful read. I believe it’s an important step and signal for the future. It’s a great example of Participatory Design, having patients and caregivers contribute to improvement of the health care system.
Schiller et al.

Researchers and educators in Ann Arbor, led by author Jocelyn Schiller, asked parents to read and review secure email messages between parents and medical students during their pediatrics clinical rotation.

Pediatrics faculty created ‘simulated messages’, or hypothetical messages from parents of pediatric patients. The medical students were asked to reply to the secure emails. Parents were then asked to read and comment on the messages. Finally, the parents comments were compared to the assessments done by the Pediatrics faculty.

The results were not surprising, but have significant implications for teaching medical students (or any health professional trainee) about communication. Parents were pleased when students provided information in a clear manner, with specifics on what to expect or ‘next steps’. Parents, however, gave lower scores than faculty for students’ ability to show empathy or show respect. The authors state,

…there may be subtleties in expressing empathy and respect that are acceptable to faculty and medical students, but that communicate negative connotations to patients and parents. These differences may be exacerbated in written communication.

The researchers remark that patients and caregivers are an important stakeholder in curricular reform, offering a different perspective from health professionals that enhances communication skills education.

The paper is a key contribution to Participatory Medicine. Patient advocates and participatory clinicians see this as necessary direction — getting patient voice into medical training. This needs to go even further than what this study accomplished; parents and patients directly involved in educational sessions, not just giving feedback on paper. After reading this work, the services of patient advocates just got better defined.