Tips from gaining health

The human body is well adapted to deal with short-term stress, but if it remains on orange alert for an extended period of time, you can grow vulnerable to some serious health problems. Heres how major systems respond to your worries.

NERVOUS

The "fight or flight" response begins here: When youre stressed, the brains sympathetic nerves signal the adrenal glands to release a chemical variety pack, including epinephrine (aka adrenaline) and cortisol. Persistently high levels of these chemicals may impair memory and learning, and up your odds for depression.

ENDOCRINE

Stress hormones trigger the liver to produce more blood sugar, to give you that kick of energy in the moment of perceived danger. But if the "danger" youre concerned with is a long-term dilemma and youre already at risk for type 2 diabetes, bad news: Elevated glucose levels may turn you into a card-carrying diabetic.

RESPIRATORY

At high-stress moments, you may find yourself breathing faster, feeling short of breath, or even hyperventilating. Over the long term, this strain on the system can make you more susceptible to upper-respiratory infections (so if youre considering a career in air-traffic control, you might want to stock up on Emergen-C).

CARDIOVASCULAR

Momentary, acute stress, like, say, when youre walking down the aisle to get married, will make your heart beat faster and blood pressure rise. Long-term stress, like unwelcome pressure from the folks to produce offspring, can cause narrowing of the arteries and elevate cholesterol levels, upping your chances of heart disease, heart attack, and stroke.

REPRODUCTIVE

Stress can lengthen or shorten your menstrual cycle, stop it altogether, or make your periods more painful. High levels of stress make bacterial vaginosis (BV) more likely and, during pregnancy, may increase the chance of your babys developing asthma or allergies later in life. Bring on the prenatal yoga.

IMMUNE

Short-term stress can actually boost the immune system, helping your body fight infection. Ongoing stress, however, turns things in the other direction, possibly slowing wound healing, leaving you more susceptible to infection, and worsening skin conditions such as eczema, hives, and yes — acne.

DIGESTIVE

Extreme stress isnt unlike the morning after a bender. It can cause dry mouth, indigestion, nausea, and gas, and it stimulates the muscles of the intestines, possibly causing diarrhea or constipation. Have these symptoms chronically, and you may increase your risk for irritable bowel syndrome, severe heartburn, and ulcers.

MUSCULOSKELETAL

Muscles tense to deal with what your body perceives as danger. No one whos pulled an all-nighter with only PowerPoint for company will be surprised that constantly tight muscles can cause headaches and neck, shoulder, and back pain. Chronic stress may also increase your likelihood of developing osteoporosis.

Is the pursuit of evidence-based medicine evidence based?  That was the head-cramping question the  Disease Management Care Blog grappled with when it read this just published Health Affairs article, Tool Used To Assess How Well Community Health Centers Function As Medical Homes May Be Flawed.

Readers will recall that the National Committee for Quality Assurance (NCQA) is a Washington DC-based not-for-profit that champions the use of performance measures to assess the quality of health care.  Provider organizations go through an assessment process based on the measures and, if they pass muster, are "recognized" by the NCQA.  The performance measures are based on peer-reviewed medical evidence, vetted by expert panels and then opened for public comment before they are finalized and used.

The DMCB knows this because it has served on two of the NCQA panels.

 While its most visible activity has been the ranking of health insurers, the NCQA has been offering a soup of recognition, accreditation and certification programs for other types of provider organizations including the disease management vendors (for example) and, more recently, medical homes.  More on that group of providers later.

Once you earn it, the NCQA quality badge is more than just a festively colored addition to your letterhead and collaterals. Given the past evidence that purchasers also pay some attention to it, the DMCB recalled being unsurprised when the number of disease management vendors sporting the newly established NCQA accreditation logo multiplied faster than the number of vixens at a Kennedy White House pool party.  They reasonably believed that it would help them gain credibility and give them a leg-up against their competition.

But even if the NCQA performance measures are based on the scientific quality as well as consensus and drive competition based on quality, the question remains: if an organization achieves NCQA recognition, does that really mean that patients are better off for it?

Enter Robin Clarke and colleagues who wanted to know if that was true for medical homes and their patients with diabetes. They adapted the 2008 version of the NCQAs medical home evaluation survey tool to 40 Los Angeles community primary care health centers. The medical director or executive team at each center had to complete the tool which was scored in the usual manner.  The score - and the corresponding level of recognition - was then compared to the centers clinical diabetes care measures based on the National Quality Foundations (NQF) quality measures. These measures were collected on samples of patients based on reviews of the medical records.

Only 30 of the centers completed the tool. They were made up of 88 LA clinics that were taking care of more than 600,000 mostly low income patients. The vast majority of the patient population was Medicaid.

The NCQA survey tool is based on a combination of "must pass" criteria combined with a 100 point scale.  The average score among the centers in this study was a respectable 67. Eight would have received the highest Level 3 Recognition (more than 75 points), three would have been Level 2 (between 50 and 75) and the remainder were Level 1. The percent of patients who had a measure of HbA1c, LDL, or blood pressure in the past twelve months was 84%, 70%, and 90%, respectively. Approximately 60% of patients had kidney disease screening and 35% had a diabetes eye examination.

However, when the authors used multiple methods to look for a statistical association between higher scores or Levels and higher quality percentages on the NQF measures, none was found.

To their credit, the authors point out that 1) theirs was a faux and unaudited NCQA process, 2) that a Level 1 accreditation, while no better than a 2 or a 3,  may be better than a "zero," 3) that persons with conditions other than diabetes may still benefit from this kind of process and 4) that they didnt use the 2011 edition of the tool.  The DMCB adds that this was in a community health setting involving mostly patients with Medicaid insurance. Its possible that patients in other settings, socioeconomic classes or with other types of insurance could benefit.

Despite the limitations, the DMCB thinks this is an important study that puts the NCQA into perspective and tells us what it may and what it may not be doing. Hopefully this kind of study will be done in other settings involving other provider types, including the disease management community.  In the meantime, the NCQA would be well served to continue to examine the links between its prsitine interpretations of the science and the real-world benefits for patients. 

In other words, its time for us to better understand the link between pursuing outcomes and actually achieving them.