Direct any of your patients struggling with growth disorders to the Hormone Foundation’s growth disorders resource page. Here they make available fact sheets covering acromegaly, idiopathic short stature, growth hormone deficiency in adults, precocious puberty, Turner syndrome, and growth hormone use and abuse. The Foundation also provide a more in-depth look through a 16-page book titled 

Growth Hormone Issues in Children and Adults

. The acromegaly, hormone use and abuse, precocious puberty, and Turner syndrome guides are also available in Spanish.

This medical reference from the University of Maryland Medical Center focuses on the treatment of hirsutism and introduces patients to causes of the disorder, signs and symptoms, risk factors, diagnosis, and treatment. The section on treatment covers both complementary and alternative medicine and hormone therapies such as birth spironolactone and eflorinithine.

http://www.umm.edu/altmed/articles/hirsutism-000081.htm

Merck Manual of Patient Symptoms: Hirsutism

This discussion of the nature of hirsutism is presented as a conversation between Robert Porter, MD, editor of the Merck Manual Online, and senior assistant editor Justin Kaplan, MD. Over the course of 14 minutes, the two discuss how one can identify hirsutism, the differences between hirsutism and hyertrichosis, an explanation of the biological mechanisms behind hair growth, and more. There is no link to the actual podcast, but all you have to do when you get to the doubleTwist Podcasts page is scroll down about halfway.

http://podcasts.doubletwist.com/The-Merck-Manual-of-Patient-Symptoms/y126oBPNYd#q=a&id=y126oBPNYd

Testosterone Deficiency and Men’s Health: A Crucial Connection

Authors André T. Guay, MD, Director, Center for Sexual Function/Endocrinology

Lahey Clinic Medical Center, and Martin Miner, MD, Co-director, The Men’s Health Center, The Miriam Hospital, wrote this activity in order to provide clinicians with the ability to better “identify symptoms of male hypogonadism” and “identify comorbid conditions associated with low levels of testosterone,” and do so by reviewing “recent literature,” a case study, and discussing “contemporary treatment and management options.”

http://www.primaryissues.org/testosterone/

To complete this activity, participants are required to read “Update on the Management of Hirsutism,” published in the June 2010 issue of the 

 (no subscription required). The article discusses, among other topics, the prevalence and impact of hirsutism, the effect of circulating androgens on hair follicles, idiopathic hirsutism, polycystic ovary syndrome, and the physical examination.

http://www.clevelandclinicmeded.com/online/journal/06_June-2010/0530808/

 Penn State researchers are recruiting 300 adolescent girls with 21-hydroxylase deficiency congenital adrenal hyperplasia (CAH) and the “parent, guardian, or significant caretaker of girls with CAH” to complete questions and submit to phone interviews. The girls will “answer questions about activities and interests, school, feelings about being a girl, stage of physical development, and family relationships during a home interview , provide saliva samples, and participate in phone interviews to answer questions about daily activities.” The adult cohort will “complete questionnaires about their daughter's activities, interests, and behaviors, educational goals, family demographics and relationships, grades, diagnosis and treatment of her CAH, their own activities, interests, and thoughts and feelings about being male or female. Parents answer questions during phone interviews about their daughters daily activities..”

http://www.clinicaltrials.gov/ct2/show/NCT01184651

In Vitro Maturation for Polycystic Ovary Syndrome

 Researchers will assess “the efficacy and safety of In-Vitro Maturation (IVM) for women with Polycystic Ovarian Syndrome (PCOS).” The primary outcome measure will be the “incidence of biochemical pregnancy (definded as a rising Beta-HCG level),” but researchers will also be looking at the “number of immature oocytes retrieved…rates of maturation and fertilization…incidence of Ovarian Hyperstimulation Syndrome…[and] live births.”

http://www.clinicaltrials.gov/ct2/show/NCT01237106

 Women and Infants Hospital of Rhode Island

 Researchers are looking to recruit 176 pregnant women to take part in this study which “aims to replace case-finding with a routine blood test that is highly effective at detecting hypothyroidism, thereby allowing treatment to correct the deficiency.” Specifically, researchers wish to identify the percentage of women who develop permanent hypothyroidism and post-partum thyroid dysfunction.

http://www.clinicaltrials.gov/ct2/show/NCT00818896

Progesterone Increase Counteracts Aldosterone Action in a Pregnant Woman with Primary Aldosteronism

Because “pregnancies in patients with primary aldosteronism (PA) are often characterized by maternal and fetal complications,” the authors felt the need to report on the case of a woman diagnosed with primary aldosteronism who “gave birth to a healthy baby boy” following an “uncomplicated” pregnancy.

 After withdrawing “treatment with mineralocorticoid receptor antagonist” the patient was transitioned to “calcium channel blocker and potassium supplementations, with good control of high blood pressure and maintenance of normokalemia…. Despite progressive increase of aldosterone levels, blood pressure decreased to normal values so that she gradually discontinued antihypertensive treatment and continued only potassium supplementations.” The woman’s blood pressure began to rise after delivery and therapy was begun again four days later. The authors posit that “the progesterone/aldosterone ratio could be proposed as a prognostic factor for pregnancy outcome in patients with primary aldosteronism.”

http://dx.doi.org/10.1111/j.1365-2265.2010.03901.x

Vitamin D Status, Physical Performance and Body Mass in Patients Surgically Cured for Primary Hyperparathyroidism Compared with Healthy Controls

 “Low plasma 25-hydroxyvitaminD (25OHD) levels, reduced muscle strength, and increased body mass index (BMI) are well-known characteristics of primary hyperparathyroidism (PHPT).” What is unknown, however, is whether muscle strength increase following surgical cure “corresponds to healthy controls’ performances.”

 The authors measured muscle strength via a number of maneuvers including “‘repeated chair stand’, ‘timed up and go’, muscle strength (hand grip, elbow flexion/extension and knee flexion/extension [60°/90°]), postural stability, biochemistry, and anthropometric indices.” They found that “former patients no longer differed from controls after adjustment for BM,” thus it would seem that “25OHD insufficiency is not a constitutional characteristics in patients with PHPT… Whether this is caused by decreased muscle strength or reduced muscular performance causes adiposity needs further investigations.”

http://dx.doi.org/10.1111/j.1365-2265.2010.03906.x

Hypoparathyroidism after Total Parathyroidectomy plus Subcutaneous Autotransplantation for Secondary Hyperparathyroidism - Any Side Effects?

 The authors undertook “this retrospective, case—control study… to find side effects of hypoparathyroidism after total parathyroidectomy plus autotransplantation.”

 The authors observed that “calcium, phosphate, and iPTH levels decreased significantly 1 week, 3 months, and 1 year after surgery, and Alk-ptase levels increased at 1 week and then decreased significantly 3 months and 1 year after surgery…Hypoparathyroid patients required significantly more calcium carbonate and vitamin D3 than nonhypoparathyroid patients did,” but “do not have any side effects.”

http://dx.doi.org/10.1007/s00268-010-0711-1

TSH — Understanding Thyroid Function Tests

Articles

Net Guide

Hormone Disorders

Woman with Acromegaly Presenting as Unilateral Vision Loss

This article describes the experience of researchers affiliated with the University of South Florida College of Medicine and their treatment of a 36-year-old-woman with acromegaly presenting as unilateral vision loss. She “underwent resection of a macroadenoma,” but because “only part of the tumor could be removed,” was prescribed maintenance corticosteroid dosage, radiation therapy, octreotide, and pegvisomant. The case presentation is followed by a discussion of “current concepts in diagnosis and management” of acromegaly.

This Hormone Foundation resource page provides patients with basic information on acromegaly, Cushing’s syndrome, hyperprolactinemia, and pituitary tumors (secretory and non-secretory tumors). The site also discusses lifestyle concerns, whether anything can be done to prevent tumor formation, and informs on the latest pituitary research.

Think of the Johns Hopkins Pituitary Center resource page as the Hormone Foundation resource page 2.0. Both sites cover the same topics, but Johns Hopkins does so in greater detail, while also featuring links to podcasts, and an introduction, complete with contact information, to every health care professional (23 in all) on their pituitary tumor care team.

This page serves as a very basic introduction to hyperprolactinemia, covering symptoms, causes, and treatment options. It is housed at FertilityJourney.com so might be used as part of a larger exploration of female infertility.

New York Hospital Queens does an excellent job of explaining how Cushing’s syndrome is diagnosed and treated. Whereas most information on any given disease simply lists the battery of tests and procedures used in disease management, New York Hospital Queens provides both definitions of each diagnostic test and an explanation for why they are used. Further, because “treatment for Cushing's syndrome depends on its cause,” the page explains everything (age, overall health, and medical history; extent of the disease; tolerance for specific medications, procedures, or therapies; expectations for the course of the disease; opinion or preference) that will will factor into a physician’s determination of he best course of treatment.

Unusual Changes in Physical Appearance in a Patient with AIDS

The third case in the University of Washington’s HIV Web Study attempts to uncover the different causes for body shape changes in HIV-infected patients. In the case of “a 44-year-old man on multiple medications who developed a multitude of body shape changes,” physicians will learn about “ritonavir-fluticasone interaction [which] can cause supraphysiologic concentrations of cortisol, leading to iatrogenic Cushing's syndrome.”

Exploratory Study of Farletuzumab to Treat Resectable, Non-functioning Pituitary Adenomas

 Researchers are looking into the safety, tolerability, and efficacy “of farletuzumab in subjects with resectable, non-functioning pituitary macroadenomas as measured by objective response in the tumor size” because “previous clinical work suggests there may be a role for a folate receptor in the treatment” of these tumors.

Efficacy and Complications of Neurosurgical Treatment of Acromegaly 

 Krzentowska-Korek A, Go%u0142kowski F, Ba%u0142dys-Waligórska, Hubalewska-Dydejczyk A

Researchers undertook this study in order “to evaluate the frequency of occurrence of pituitary failure following neurosurgery and the efficacy of transsphenoidal tumour resection in acromegalic patients.”

 The authors “retrospectively evaluated 85 patients (60 female and 25 male), of mean age 43.9 ± 13.2 years, treated by transsphenoidal neurosurgery,” and found that there was a “significant correlation between basal serum level of GH at diagnosis and size of pituitary tumour.” Efficacy was “affected by concentration of basal serum GH and IGF-1, GH at 120 min in OGTT, tumour size and invasiveness. Hypopituitarism after surgery is more frequent in patients with macroadenoma. Pituitary insufficiency, as a consequence of surgery, was found in 21% of patients with normal pituitary function prior to operation.”

Children with Cushing’s Syndrome: Primary Pigmented Nodular Adrenocortical Disease Should Always Be Suspected 

 Gonçalves da Silva R, Pinto E, GoldmanS

 Here the authors “discuss the clinical and molecular findings of two Brazilian patients with ACTH-independent Cushing’s syndrome (CS) due to Primary Pigmented Nodular Adrenocortical Disease (PPNAD) and…show the diagnostic challenge CS represents in childhood.”

 “After several clinical and laboratory drawbacks that misled the diagnostic investigation in both patients, the diagnosis of PPNAD was finally established and confirmed through pathology and molecular studies.” The authors stress that “the etiologic diagnosis of endogenous CS in children is a challenge that requires expertise and a multidisciplinary collaboration for its prompt and correct management” and that “although rare, PPNAD should always be considered among the possible etiologies of CS, due to the high prevalence of this disease in this age group.”

William H. Ludlam, MD, PhD, an endocrinologist with the Seattle Pituitary Center at the Swedish Neuroscience Institute explains the causes of acromegaly, symptoms, incidence, chances of successful tumor resection, post-surgical treatment options, and the long-lasting physical manifestations of the disease.

Over five and a half minutes, MauiMaryRN discusses excess adrenal, glucocorticoid, and mineralcorticoid production and exposure, the physical characteristics of Cushing’s disease, and the various treatment strategies depending on etiology. MauiMary also delves into “nursing considerations” that may be useful for your nursing colleagues to consider if they are part of a health care team under your direction.

Libido problems can be a serious adverse effect related to hypogonadism, hyperprolactinemia, depression, fear of sexual failure, certain medications, or systemic illness, impacting both men and women, and can lead to decreased quality of life or relationship dysfunction.

Calcium and Vitamin D to Optimize Bone Mass in Boys With Risperidone-Induced Hyperprolactinemia

 Over the course of a nine-month period, study participants will be given a placebo or calcium carbonate 625mg and vitamin D 200IU, orally, twice per day in order to assess the experimental combination’s affect on “trabecular bone mineral density in the ultradistal radius” and “total body bone mineral content.”

Pituitary Disorders

Speech recognition technology continues to improve, with many useful applications for use in our medical practices and in our daily lives.

Ever since Ali Baba commanded his cave to “Open Sesame,” speech recognition (SR) has been a dream of mankind. Now, here we are in the 21st century and instead of caves, we’re talking to computers, automated information operators, and our cars. The problem is, much of the time we’re not just talking to these machines, we’re yelling at them, because the technology still doesn’t work as well as The Jetsons or Arthur C. Clarke promised us it would. But the improvements are coming quickly, and it won’t be long before speech recognition is an integral part of all our lives, including those of us in the medical profession.

In fact, health care providers are already among the foremost users of speech recognition technology. So, let’s take a short step back and examine how SR for medical transcription works. For starters, the technology can be implemented in either the front-end or back-end of the documentation process. In front-end SR, the provider dictates into a speech-recognition engine, and the recognized words are displayed almost immediately after being spoken. This is also known as “natural language processing.” The dictator (or “speaker” if you’d rather not conjure up images of the Fuhrer railing into his microphone) is then responsible for editing and signing off on the document. It never goes through a medical transcriptionist/editor. For years, many of us have dictated our patient notes into a personal computer using software like Dragon Naturally Speaking rather than pay a transcription service.

Back-end SR, or deferred SR, occurs when the provider dictates into a digital dictation system, and the voice file is routed, along with the recognized draft document, to a transcriptionist, who then edits the draft and finalizes the report. At the moment, deferred SR is being more widely used in the industry.

Because searches, queries, and form filling are often faster to perform by voice than keyboard, many EHR systems can and will be more effective when deployed in conjunction with a speech-recognition engine. But there are different methods for getting the information from the SR engine into the EHR. Discrete reportable transcription (DRT) is the process of converting narrative dictation into text documents with discrete data elements than can be easily imported into the appropriate placeholders inside an EHR. Some back-end SR technologies support data structuring for EHRs, but they have a harder time moving structured information into EHRs like DRT can.

Beyond medicine, speech recognition technology is popping up all over the place. For example, my Motorola Droid smartphone lets me “dial by name” or look up information online by simply speaking my search query. This is awesome at the dinner table, when one of my sons asks me something I don’t know. Try entering: “What year did women get to vote?” into a smartphone and you’ll recognize how much time and energy SR technology can save when it works (It wasn’t until 1920). Most of these systems employ what’s known as direct voice input (DVI) technology, in which the user issues instructions to the machines via voice commands. DVI can be either “user-dependent,” which requires a personal voice template to be created before working properly, or “user-independent,” which will work with the voice of any user.

In addition to making simple conveniences even simpler, speech recognition technology can be used to provide people with certain disabilities access to computers, phones, and other electronic appliances they wouldn’t have otherwise. Blind people can use the technology to dial phone numbers they are unable to look up, while the hard of hearing can be served by the use of speech-to-text conversion.

There is no doubt that the health care industry has as much to gain as any by the recent advances being made in speech recognition, and it’s high time we started realizing that. Once again, though, it depends on us being willing to embrace the new technology rather than fear it. Because don’t we want to spend less time filling out forms and more time with our patients? After all, that’s why most of us got into this business in the first place, and what most of us in the end still do best.

Dr. Bertman is Physician Editor-in-Chief of 

. He is a Clinical Assistant Profes&shy;sor of Family Medicine at Brown University and president of AmazingCharts.com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a con&shy;sumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI.

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Tech Talk: The Age of the Speak Easy

Verizon Announces Free Access Offer to Medical Data Exchange Network — Open to All 2.3 Million American Medical Providers

Verizon Business recently made a big splash with plans to offer free access and usage of their Medical Data Exchange system to over two million US healthcare providers. Sounds like a pretty generous offer, right? On first pass, I’d certainly have to agree though I have a sneaking suspicion it may not turn out to be quite as altruistic as many of the headlines I saw make it sound. As one report (

The credentials will allow doctors and clinicians to access medical data via the Verizon Medical Data Exchange through a secure, private inbox. The inbox is part of Verizon’s Healthcare Provider Portal, which it has added to the exchange.

) is primarily designed to enable exchange of information between different electronic medical record platforms, with this personal inbox component added later. What this offer focuses on is individual healthcare providers and that’s precisely what makes it both interesting and disappointing.

The potential for benefit to the healthcare community here is in engaging individual and small private practices, not yet using an electronic health record or lacking in sufficient scale to be able to integrate into a healthcare information exchange, in some sort of electronic data exchange. Larger practices, hospitals, and health systems will already have dedicated staff or departments for medical records. The Verizon system, much like those proposed in recent reform legislation, is merely a conduit rather than a repository of information — no information will actually be stored centrally here. So what this offering really does is give many physicians the opportunity to transmit information in safe and legal ways.

The fundamental flaw in this system, however, is that it requires an extra step. When I admit a patient to the hospital, I go through all the records we have on them in our EHR. When I need records from elsewhere, it requires that the patient sign some forms, either I or other medical staff call the relevant office to request information, fax the forms, and then wait — a wait that can be critical when it comes to deciding on procedures, imaging, and so on. What we really need is central storage of information.

While this may seem like a bit of a let down, it’s worth remembering that the healthcare industry is currently in the midst of a continuing consolidation trend into large healthcare systems. According one report (

), in 2008 there were nearly 1,400 merger/acquisition deals in the industry in the prior two decades, with particular concentration in urban markets. The EHRs that these new systems have or will soon have will therefore cover a large portion of the American population, all potential sources of data for information exchanges.

So what I see in this offer is (1) a promotional offer that is really meant to attract (paying) hospitals/healthcare organizations to its core “conduit” business in the long term and (2) a temporary help in reducing barriers to information exchange when it comes to smaller healthcare practices especially. Verizon’s MDE is certainly bound to be an important and prominent feature of future healthcare IT systems and its user-to-user data exchange system will be helpful. But the real gains are with more centrally stored information and hopefully all of these systems are just a step in that direction.

ID Compendium: A Persiflager’s Guide — LITE

With content updates until June 2012, this hyperlinked, quick reference guide to infectious diseases provides more than 600 pages of information on antibiotics, organisms, and diseases. The app, written over 10 years by a practicing infectious disease physician, is intended for non-infectious disease practitioners. Check out the Pro version of the app for lifetime monthly content updates, full-text search, and custom user notes linked to topics.

Use this app to determine whether your patient is an appropriate candidate for cardiac radionuclide imaging based on the 2009 Appropriate Use Criteria, a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Enter information about the patient, based on questions like “Is the patient within 3 months of acute coronary syndrome?” and “Has the patient undergone prior revascularization?” to be provided with a 0-9 score—7-9 equals appropriate, 4-6 uncertain, and 1-3 inappropriate.

This program displays low-resolution drawings depicting the skull, some cranial and cervical nerves, and a two-part brain: the cerebellum and the cerebrum. Different layers or structures can be removed, but this does not actually result in revealing of more structures or detail. One part of the program allows you to take an individual coronal slice and rotate it 360 degrees in any direction. Unfortunately, there is insufficient detail represented in each slice to make this exercise revealing of any recognizable structure. No structures are labeled, so this program is not at all helpful for learning neuroanatomy. In fact, I don’t see any rationale for any medical person to purchase this program.

4.5 stars (14 ratings, current version/754 ratings, all versions)

This blood pressure-tracking and analysis tool uses color icons to indicate when a user’s blood pressure value is normal, high, or hypertensive, based on information entered after taking a reading (not done by the app). Interactive graphs allow patients to display values by week, month, year, and time of day. Users are encouraged to share the information documented by the app with their physician. We couldn’t find a negative review—“just what anyone who is tracking their BP needs,” and “This is an excellent tool for keeping track of my blood pressure. My doctor also likes it” were among them.

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App Wrap

Several studies (not to mention common sense) have shown that better communication and coordination of care should reduce preventable adverse outcomes in patients with chronic disease. This approach to disease management has been greatly facilitated by Web-based monitoring and reporting tools, smartphones, and other technologies. The question confronting physicians, patients, and payers as we move ahead is: does any of this work?

“Monitoring of live-feed data from the homes of the elderly or infirm will tell clinicians and family members about medication taking, ambulation, consumption, and other aspects of autonomous daily living. Implantable devices with wireless feeds will report patients’ physiological status to physicians and monitoring centers and will report functional anomalies to the manufacturer and relevant federal agencies. And that is not to mention inputs about weight and reaction times from automobiles, ambient environmental sampling data linked to one’s location by wearable global positioning system (GPS) devices, exercise data from implantable stress monitors, and sensors at one’s desk for other kinds of stress. In short, the future of interoperability is to bind together a wide network of real-time, life-critical data that not only transform health care but become health care.” 

— David J. Brailer, MD, PhD, Former National Health Information Technology Coordinator (

Just five years after Brailer’s Orwellian forecast, most of these predictions are already reality, spawned by our need to control an epidemic of chronic disease.

Chronic illness accounts for most of the disease burden in the United States. The cost, in lives and dollars, is staggering. Almost one out of every two adults has at least one chronic illness, and 70% of deaths are attributable to chronic disease (

). Chronic diseases consume 70% of healthcare expenditures, with a current estimated financial cost of $2 trillion per year and a projected cost of over $4 trillion by 2023 as the population continues to age (

). Most chronic diseases cannot be cured and, given our refractory lifestyle choices, are unlikely to be prevented. Can they at least be better managed?

Disease management (DM) evolved from the rational notion that better communication and coordination of care should reduce preventable adverse outcomes in patients with chronic disease. The concept was enthusiastically embraced, perhaps prematurely, by insurers and large employers eager to find ways to reign in health care costs and improve the health of their beneficiaries.

Early models of DM involved the development of call centers staffed with nurses who routinely contacted at-risk patients to provide follow-up and advice. Interventions were targeted toward those with the most common chronic diseases: asthma, congestive heart failure, depression, diabetes, and hypertension. Poorly controlled diabetics might, for example, be asked to communicate daily blood sugars and symptoms to nurses trained to adjust insulin dosages, with the hope that the need for hospital admissions might be preempted. Such programs were liked by patients and were generally accepted as being of value, although this latter conclusion may have been supported more on the basis of commonsense assumptions rather than rigorous financial analysis. Nonetheless, DM has grown into what is currently a $2.5 billion-per-year industry (

As interventions expanded beyond the call center, a wider concept of what constitutes DM evolved. DM is now broadly defined as “a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant” (

Not surprisingly, technology is extending the reach and scope of DM. Advances in monitoring devices allow for less obtrusive, real-time patient monitoring, while the Internet is replacing the telephone as a means of educating patients and allowing them to communicate with their providers. Adoption has been further accelerated by the availability of devices that work faster, cost less, and are easier to use, coupled with greater access to broadband and wireless pipelines by more segments of the population.

Web-enabled disease management: no longer science fiction

Effective DM depends on frequent, regular monitoring of patients. Devices now exist that can unobtrusively monitor a wide variety of physiologic data with little or no effort on the part of patients. For example, a band-aid like device is currently available that can monitor respirations, oximetry, patient movement, temperature, and electrocardiogram—and display that information on an individual’s cell phone or transmit it via the Internet (

). A sensor wire (the diameter of two human hairs) can be inserted under the skin by a diabetic patient to allow continuous wireless monitoring of blood sugars (

). A “smart-pill” system allows physicians to monitor medication adherence by attaching tiny microchips to patients’ pills; as each pill passes the stomach, the patient’s prescriber is notified by the patient’s smartphone via the Internet (

). For $3,500, one can even purchase an “Intelligence Toilet” system, capable of measuring sugar levels in urine, blood pressure, body fat, and weight (

). The toilet automatically transfers its data to a home network for analysis on a personal computer. Each of these devices is already commercially available. Other wearable innovations, such as a “smart tee shirt” used by the military to monitor vital signs and remotely detect gunshot wounds, will undoubtedly soon find their way into the DM armamentarium (

The biggest current obstacle to smarter DM is not sensor technology, however. According to Steven

Eisenberg, MD, senior vice president and chief science officer at LifeMasters Supported SelfCare Inc, “Physicians are never going to have the time to spend going through volumes and volumes of data, so it is going to be up to the computers themselves to integrate, correlate, and analyze” (

). Currently, device technology leads development of those systems, but the latter will undoubtedly catch up.

Ultimately, however, it is the non-technological factors that will likely determine the face of DM in the 21st century. Continuous transmission of intimate physiologic details over wireless networks and the Internet demands rigorous security and personal privacy protections. Indeed, such technologies may well challenge society to re-examine the definition of “personal space” (

). Furthermore, DM must prove itself cost-effective in an era of dwindling economic resources and competing societal priorities.

Critics and skeptics are quick to point out that DM has not yet convincingly been demonstrated to be an effective strategy. A 2009 Rand report concluded that DM could increase employer and government spending in Massachusetts by $6.7 billion over 10 years with little overall benefit (

). This followed a 2008 analysis of a Medicare pilot project of 200,000 patients, which concluded that DM did not reduce hospitalizations, emergency room visits, or deaths from chronic disease. Proponents of DM argue that the study included patients who were not representative of those most likely to benefit and that Medicare did not extend the study long enough to see benefits. They cite contrasting studies, such as one study of elderly veterans that found a combination of home telemonitoring, video visits, and coordinated care resulted in a 40% reduction in emergency room visits, a 63% reduction in hospital admissions, a 60% reduction in hospital bed days of care, and similar reductions in nursing home care (

Both sides of the debate note that studies of DM to date have been of variable quality, often involved small numbers of patients, and may have used flawed assumptions in their cost-effectiveness analyses. A study published last month in the 

) addressed these methodological concerns (also, see the accompanying editorial at 

). This randomized controlled trial followed 1,653 patients recruited from 33 cardiology practices across the US who were recently discharged following hospitalization for heart failure.

The study demonstrated that telemonitoring did not reduce readmission rates or death over the six month follow-up period. Not surprisingly, the researchers found that by the final week of the study period, only 55% of patients were still using the system at least three times per week; 14% of patients in the telemonitoring group never used the system. (These latter observations are probably not unexpected by physicians; technological solutions alone are unlikely to ever overcome the intrinsic difficulties of motivating and changing human behavior.)

The authors concluded that their results “underscore the need for rigorous, independent evaluation of disease-management systems before their adoption. In an environment in which vendors promote their products to health systems that are under increasing pressure to reduce readmission rates, the knowledge that telemonitoring is ineffective suggests the need to consider alternative approaches to improving care” (

). Studies of DM in other conditions should be forthcoming (http://hcp.lv/dBirb1).

In the meantime, action-oriented business leaders are already convinced; DM programs are currently offered by three-quarters of large companies and most Medicaid programs (

). Given this level of commitment by business and government, the future of DM would seem secure over the near term. The shape it will take, however, is less certain.

Currently, most formal DM is administered by disease management organizations contracted to insurers and employers. But this model has been criticized as being too remote from patients, both physically and personally. In an article in 

), General Electric’s Chief Medical Officer, Robert S. Galvin, MD, expressed skepticism that chronically ill employees would change unhealthy behavior at the direction of unfamiliar nurses calling from remote offices. This seems a salient point; behavior change is the ultimate determinate of effective self care, and most chronic diseases are, at least in part, the result of unhealthy habits. Galvin, a former primary care physician, stated it this way: “If you are going to influence someone, you need a social relationship with them.” He and others thus favor a different model of incentivizing patients’ own physicians to provide DM services from their offices.

Physician-directed DM is a central premise of the “patient-centered medical home,” a concept endorsed in a joint position statement by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association (

). In this model, it is the primary care physician who directs, provides, and coordinates DM within the context of an ongoing patient—physician relationship. Primary care physicians would, of course, expect reimbursement for providing these services, including the time spent reviewing and responding to remotely acquired patient data. There is uniform agreement that without major reimbursement reform, the patient-centered medical home and a shift toward physician-directed DM is unlikely to succeed.

Although the eventual form and ultimate impact of DM over the next decade remains speculative, the epidemic of chronic illness ensures that DM will play an increasing role in healthcare policy and delivery. Evolving technology will undoubtedly overcome remaining barriers, providing us with the capability to broadly scrutinize measures of health, disease, and behavior. These capabilities will continue to challenge our concepts of privacy and prompt us to re-examine fundamental assumptions, such as “What constitutes reasonable care?” “How should we prioritize healthcare funding?” and “What is the ideal patient—physician relationship?” In the end, however, we are still faced with the most daunting obstacle to chronic disease management: human behavior. Technology alone is unlikely to overcome this final fundamental barrier to better health.

editorial board member and program director, Internal Medicine Residency and associate professor of Clinical Medicine, Department of Medicine, University of Illinois College of Medicine, Peoria, IL. 

December 2010

Hormone Disorders

Pituitary Disorders

Tech Talk: The Age of the Speak Easy

App Wrap

Breaking Boundaries with Web-based Disease Management