Scaling Mindfulness to Population Health and Tobacco Addiction: The Science Behind the Art

Think about it....

Years ago, the young Population Health Blog was a part of a nurse-led tobacco cessation program.  Hundreds of patients later, we reported the one-year quit rate of over 30%. That seminal research catalyzed the creation of other nurse-based programs in asthma, diabetes and heart failure. The PHB and colleagues didn't know it at the time, but it was the start of an almost 20 year journey in population health that continues to pay dividends today.

The art and science of population health continues to evolve, however.  That's why the PHB is always happy to hear from the leadership of outfits like Craving to Quit.  And this is something different.

As readers may know, "apps" are becoming an important part of the population health landscape, but what the PHB didn't know is that an app could be combined with the science of "mindfulness."

Mindfulness?  Conscious intention was a part of the PHB's martial arts training, but it didn't know that there was a science to it and that could be applied to health care.

Mindfulness can be defined as being attentive to and aware of what is taking place in the present. By consciously stepping back and being aware of the status of your well being, the accompanying cognitive insight enables the "user" to better cope and manage the wide array of emotional states. That can include enhancing a state of wellness or, conversely, combating depression, anxiety, addictions and cravings  The PHB didn't know this, but it's been a subject of intense basic neuroscience as well as clinical real-world research (here and here) for years.  And if you're wondering if there is a Buddhist pedigree in all of this, you're right.

Enter Craving to Quit.

It's seeking to scale one-on-one mindfulness to populations using an app that can be used to combat tobacco addiction.  Users can prompt attentive mindfulness to manage nicotine-withdrawal related cravings.  Add in feedback, access to a community of like-minded users, live expert addiction coaching, plus a library of video-based instructional resources and - boom! - an academic backwater of "mindfulness" turns into a robust population-based intervention.

And credit to the leadership at CtoQ for committing the resources to precisely measure their outcomes for the scrutiny of peer review.  They're conducting an Institutional Review Board - approved randomized clinical trial to further document the impact of mindfulness. As the PHB has written here, without a disciplined approach to documenting outcomes, population health service providers are putting themselves and the industry at significant risk.

Being mindful of an attitude of plenty, this is good news for the art and science of population health.
No wonder it caught CNN's attention. It's worth paying attention to.
 
Their success is our success.

Do Employer-Based Wellness Programs Work?

Reuters tackles worksite wellness outcomes

Mrs. Smith (name changed) was overweight.  She knew it and her physician, the Disease Management Care Blog, knew that she knew it.  Since the DMCB was one of the two persons on the planet who knew her true weight, she could talk to it behind closed doors about diet, exercise, fads, over the counter meds, prescription appetite suppressants and even bariatric surgery. 

What the DMCB quickly discovered was that Mrs. Smith's weight-loss goals were not only unrealistic but, like many women struggling with weight, driven more by the prospect of how she'd look in a bathing suit than any real health benefit.

Mrs. Smith wasn't alone. This seminal study demonstrated just how unrealistic women's weight loss goals (in the range of 50 lbs.) can be.  Think of the popularity of The Biggest Loser and it's easy to see why persons think thinness is just a matter of a few months of dieting and exercise, and that being skinny leads to health and happiness, 

Easy, right?

DMCB readers know otherwise. That's why they're not going to be impressed by the tone of this May 24 Reuters article on worksite wellness.  RAND, in a not-quite released report to Congress, examined the impact of several employee based programs and found, in the words of the Reuters reporter, only a "modest effect."  Average weight loss was "only" three lbs., tobacco cessation rates were significant but "short term," average cholesterol levels were unchanged and reductions in health insurance claims expense failed to achieve statistical significance.

Researchers have known for years that conservative dietary and lifestyle therapy typically results in weight loss in the range described above. In addition, cholesterol reduction as a primary prevention intervention is low yield when it comes to health. On the other hand, even short term tobacco cessation is a good thing. When it comes to the ability of wellness to reduce health care costs, weight reduction is unlikely to drive claims expense for a health insurer within two to three years, the impact of obesity on overall mortality rates is not as large as you'd think and "prevention" rarely saves money.

What's more, these programs were able to achieve their "modest" outcomes without increasing claims expense.  Participants lost weight and stopped smoking at no additional cost to the system.  Now that is something.

Mrs. Smith and Reuters are very similar.  Both are struggling with nrealistic expectations thanks to dubious fashion trends, media misinformation and scientific ignorance.  Fortunately, Mrs. Smith had access to a resource that could help her better manage her weight.  The DMCB can only hope that Reuters has access to a resource that can help it manage its lack of background knowledge.

The Growing Power of Social Media In Scientific Scrutiny and Public Policy: Two Examples

Tomorrow's docs checking out
the medical literature

Regular readers of the Disease Management Care Blog are well aware of its enthusiasm for the emerging role of the internet and social media in advancing scientific knowledge and promoting public policy. 

Here are two great examples:

In this blog post, public health professor Michael Siegel takes the company Alere to task for allegedly making inflated claims on its web site about the success of its tobacco cessation program.  The sleuthful Dr. Siegel did a literature search to find out more about the science underlying its claim, and found that persons lost to follow-up were assumed to have quit.  The original Alere publication refers to a curious "responder analysis," but also documents a far more modest "intention to treat analysis" with a one-month quit rate of 21%.  That lower number - and the fact that quit rates are typically reported over 6 months, not one month - was excluded from Alere's marketing.

The Disease Management Care Blog has previously pointed out the hazards from Boards of Directors letting their company's management put dubious or vulnerable research into the public domain. Dr. Siegel is a perfect case in point of the power of an interested and skeptical scientist who can use the internet's public square to attack research "spin" and batter a company's reputation. This kind of reputational threat needs to be "top of mind" when population health and care management company Boards are thinking about their enterprise risk management challenges.

And as further testimony to the growing potency of bloggery, check out this posting on The Health Care Blog on "seven policy recommendations" that were jointly co-authored by heavyweights from the Urban Institute, Johns Hopkins and Yale.  Not only are the recommendations themselves worth consideration, they were "open-sourced" on a blog - not a journal - with a level of speed, timeliness and visibility that traditional print media can simply no longer match.