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The Complexity Matters blog features the Thursday Complexity Post as well as other complexity inspired news items.

 

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RX for Managing Diabetes: Trust and Communication

Posted By Prucia Buscell, Thursday, November 1, 2012

Diabetes cost the nation about $100 billion a year, and researchers say some of the most powerful preventive measures are behavior changes among care providers as well as life style changes among people who have the illness and are at risk to get it.

Monica Peek, MD, is a Robert Wood Johnson Foundation Harold Amos Medical Faculty Development Program scholar who studies how the social determinants of health impact African Americans. In an October 2012 presentation at the American Public Health Association, and a recent article described on the RWJF website, Dr. Peek reports: "We found that race, as a social construct, has the potential to influence two key domains of patient trust-interpersonal relationships and medical skills and technical competence. For example, African Americans in our study were concerned that physicians might be biased or using them in medical experiments without their consent. This influenced their perceptions about physicians’ overall competence, bedside manner, and ability to provide them with high-quality care.”

Research has shown that when diabetics engage in shared decision making with their care providers, their compliance with medication regimens, healthy life style choices, and management of blood pressure and blood glucose improve. In their paper "Patient Trust in Physicians and Shared Decision Making Among African Americans with Diabetes," Dr. Peek and colleagues say methods of building trust include enhanced patient education, physician training in interpersonal skills and cultural competence and efforts to engage patients in decision about their care. Although her research focused on African Americans, Dr. Peek believes the findings are applicable to other ethnic and cultural groups struggling with diabetes.

Dr. Peek is also an assistant professor of medicine at University of Chicago Medicine and co-principal investigator of an innovative project called Improving Diabetes Care and Outcomes on the South Side of Chicago, where high rates of diabetes impact a large African American population. The project involves collaboration among six clinics, academic institutions, and community organizations and businesses to provide education and increase access to care. In one program, a nutritionist toured grocery stores with diabetes patients, illustrating healthy food choices, and showing how label information can help manage carbohydrate and sugar intake. In a Food RX initiative, patients who visit one of the clinics can get a coupon for $5 off a $20 order of healthy food at participating Walgreen stores, and a $3 voucher for a weekly farmers market. Dr. Peek says the initiatives put the power of a doctor’s prescription behind nutritional advice. Because many shoppers were buying food at Save-A-Lot stores, initiative leaders established a relationship with the chain, which is now opening more stores in "underserved” neighborhoods that have been described as a "food deserts” and is offering educational information to customers. The store also sponsored a diabetes awareness cooking contest for healthy recipes.

The Improving Diabetes Care and Outcomes project is funded by the Merck Company Foundation through its Alliance to Reduce Disparities in Diabetes across five U.S. cities, and the National Institutes of Health, with the University of Chicago’s Institute for Translational Medicine.

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Organizations Can Take Cues from Natural Systems

Posted By Prucia Buscell, Thursday, October 25, 2012


"The Fruits of Success Contain the Seeds of Destruction"

To business theorist David K. Hurst, the 48-year emergence of Walmart into a mature large scale enterprise is similar to what happens in a forest ecosystem. Walmart began in the 1960s with two dozen small outlets in rural Arkansas. Today it is the biggest private employer in the U.S, with 1.4 million employees and more than 4,300 stores.

In an article in Strategy + Business, Hurst explains how forest succession, the processes of evolving change in an ecological community in the temperate zone, begins in an open patch of land where all plant life has unfettered access to sun and rain. He says weeds and wondering creatures that spread seeds, which he calls the entrepreneurs of the ecosystem, thrive because they have ready resources and no competition. As they flourish and compete, the plants and shrubs that have the best infrastructure-the deepest roots to get water first and leaves and branches that get the light-begin to dominate, and the growth of their competitors is stunted. Shrubs are then succeeded by soft wood trees, such as conifers that shed their needles on the forest floor, making fuel for fire, which allows their hard seeds to germinate. In the climax phase of forest succession, hardwood trees, such as oak, will overwhelm the pines. Their accumulated leaves create a layer of damp mold on the forest floor, which inhibits fire and lets acorns germinate.

The appearance of the hardwood trees used to be considered a sign of ecological equilibrium, Hurst observes, but now scientists know it isn't. It's the climax phase of the cycle. "Reduction in the variety of organisms in the ecosystem leads inexorably to a lack of resilience in the face of change," Hurst writes. "Too many trees of the same species and similar age are vulnerable to the same challenges, such as wind, disease and insect attack. The conditions are now right for a sudden catastrophe that will sweep away mature growth and open up the system for renewal."

So far, Hurst writes, Walmart's adaptability has helped the organization avoid the hazardous parts of maturity. Hurst concedes analysis cite many reasons for the company's success-ranging from entrepreneurial and logistical prowess to predatory pricing and the abuse of labor laws. But he thinks the ecological analogy is especially useful.

In the early years, traditional wholesalers didn't want to make small deliveries to remote rural spots, so Walmart developed its own distribution infrastructure and innovative logistics system. For example, Walmart adopted a cross docking system used by the military, in which goods received from suppliers are quickly shipped to branches, with minimum use of warehousing. Hurst notes founder Sam Walton often identified his store sites from the air. Architect Jesse LeCavalier, describing the network of modern sites in a Design Observer article, writes that 60 percent of the U.S. population lives within five miles of a Walmart, and 96 percent is within 20 miles. The predesigned buildings are adapted to local environments, and surrounded by acres of rural and suburban parking.

While Walmart's growth would put it in the hardwood phase, it has diversified as well as adapted to remain resilient, Hurst says. Its original discount stores are gradually being replaced by newer supercenters that sell food and multiple services along with conventional merchandise. Hurst says a new category of smaller neighborhood Walmart stores is similar to the ecological "shrubs" in that these stores produce only modest profits but inhibit growth of such rivals as dollar stores.

Hurst, the author of The New Ecology of Leadership: Business Mastery in a Chaotic World, offers an ecological perspective for business success:

  • Think of organizations as movements rather than structures
  • Realize change and disruption are inevitable. Prescribed burns and release of "pulses" of water from dams to renew rivers are examples of interventions to manage natural systems
  • Pursue change on the edges, in open places, where variety can thrive on a small scale, with little competition.
  • Remember the fruits of success always contain the seeds of destruction.
  • Creation requires destruction. Look for openings in turbulent markets, where information is scarce and navigation unclear.

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Crowd-Sourcing, Greed, Ingenuity: A Cancer Cure?

Posted By Prucia Buscell, Thursday, October 18, 2012

MIT Finance Professor Andrew Lo believes financial engineering can provide the money and motivation to cure cancer within two decades.

Lo, who is director of the Laboratory for Financial Engineering at the MIT Sloan School of Management, also runs the AlphaSimplex group, an investment firm with $3 billion in assets. Time magazine named him one of the year’s 100 most influential people in the world, and notes he has challenged traditional economics with his belief that markets have more in common with biological systems than they do with rule based physics. He applies evolutionary and neurobiological models to finance and risk. As Time describes his approach, "Market participants aren’t coldly rational creatures but squirmy evolving species interacting with one another in a primordial sludge of money.”

In one of his lectures, Lo observes cancer is not a single disease, but a complex collection of more than 200 diseases. He lost his mother to lung cancer, and notes nearly everyone has been touched in some way by the disease. Government and private sources already pour billions into cancer research, but Lo thinks new methods are needed to foster drug research and development, and he believes the recent financial crisis provide lessons on how that can be achieved. .

He proposes creation of a $30 billion megafund with money from a large number of individual and institutional investors that could support as many as 150 simultaneous research projects. Right now, he says, a typical clinical trial costs $200 million, takes 10 years, and has a five percent chance of success. While researchers have discovered as many as 200 compounds that might be useful in treating cancers, he says, only a small portion of that potential can be investigated under the present system. In his view, crowd-sourcing combined with an appeal to both greed and social conscience can promote a new way of financing large scale biomedical innovation.

A small scale example of how a megafund might work, he says, is the Defense Advanced Research Projects Agency (DARPA) balloon experiment in 2009. The agency placed 10 large red weather balloons throughout the country and offered a $40,000 reward to the team that could find them all first. The MIT Lab team, which won the challenge in less than nine hours, explained the secret to success was financially rewarding not only the individuals who reported the location of the balloons, but everyone who helped in any way.

Lo says the extraordinary growth of the housing market in the decade before 2006 shows what vast sums of money can be generated and analysis of the subsequent crashes suggests the stability of the financial system can be maintained by strict enforcement of rules on sales practices, disclosure, corporate governance, and suitability criteria for investors. The megafund would be a portfolio entity that could raise money by issuing debt and could use financial engineering techniques such as securitization to create a new kind of investment called a Research Backed Obligation. The new system, with its mix of equities, could potentially spread risk, maximize capital, expand research, and generate returns ranging from five to eight percent, depending on the investor’s chosen risk. Lo plans a conference next year, where cancer scientists, financial experts and large institutional investors will be invited to discuss details of how a megafund could be created and managed. Read "Commercializing biomedical research through securitization techniques," by Lo, Jose-Maria Fernandez and Roger Stein in Nature Biotechnology online and a Boston Globe story by Beth Healy. Lo thinks the same financial engineering techniques can address energy and climate change issues.

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Vital Signs: Taking the Measure of Clinical Teams

Posted By Jeff Cohn, Wednesday, October 17, 2012
Updated: Friday, September 19, 2014

Last month I attended the 11th International Conference on Complexity in Acute Illness in Ottawa along with former Plexus President Curt Lindberg. The conference was primarily focused on developing applications of the theories of Plexus Advisor Ary Goldberger, who has described the complexity of normal heart and lung physiology, and how a loss in that complexity could indicate emerging illness. Numerous speakers, representing disciplines of critical care medicine, surgery, informatics, mathematical modeling, and physics, described how these concepts could potentially lead to earlier recognition of potentially reversible illness. Patient populations described included critically ill infants, burn patients, major trauma patients, and adult patients on ventilators, just to name a few.

At the same conference we heard a presentation from Curt Lindberg about Billings Clinic and how focusing on changing and improving relationships is leading to healthcare delivery innovations. John Scott, MD, described his research on what patients and physicians have mutually agreed are "healing relationships” that involve factors such as mindfulness, valuing, appreciating power, and abiding. And Heather Mattila, PhD, from Wellesley, presented some of her research regarding the role of diversity in ensuring the health of honeybee colonies.

This caused me to think about the convergence of factors associated with restoring seriously ill patients to health. These patients are connected to numerous monitors that give important information to the group of clinicians providing care. Soon we may have additional monitoring capabilities to identify loss of complexity, which could enable caregivers to respond earlier and provide more effective rescue care. But then what? Once team members have the information, they need to go into action to provide the care the patient needs. And how do we know whether, at that moment, the team is "healthy” enough to provide that care? What is the status of the relational coordination (the subject of a recent Plexus call) of the team providing care? What is staffing like? Fatigue? How quickly are clinicians responding to their patients’ changes in condition? What if we had the ability to stream this kind of information together and have that displayed on monitors, reflecting the unit’s "health?” Maybe the unit’s vital signs are as important in determining the outcomes of care as the vital signs of the patients for whom they’re providing care. Please share any thoughts or ideas you have below, or email me at jeff@plexusinstitute.org.

Tags:  catching butterflies  cohn  complexity  health  healthcare  relationships 

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A Helping of Behavior Change With Lunch

Posted By Prucia Buscell, Thursday, October 11, 2012

New Law, Shape Up Somerville, and a French Lesson

Under the newly implemented Healthy, Hunger-Free Kids Act schools are required to serve nourishing lunches with fewer calories, less fat and mandatory fruits and vegetables. But legislation can’t make kids eat what’s good for them, and often they won’t.

Across the country youngsters who miss their habitual chocolate milk, cookies, french-fries and cheese nachos are rebelling by slipping away to buy junk food from school vending machines and off campus merchants, and brown bagging goodies from home. Some student have posted YouTube videos mocking the meals, singing protest songs, and feigning collapse from hunger.

A New York Times story by Vivian Yee describes a lunch strike in a Pittsburgh suburb and a boycott in town near Milwaukee. In New Jersey more than 1,200 people have joined a Facebook group urging Parsippany Hills High School students to boycott school lunches. The Times story is accompanied by a photo showing the mandatory vegetables and fruits in the lunch room trash.

While there formerly was no restriction on calories, new requirements limit high school lunches to 850 calories, and middle school lunches to 700 calories. Elementary school lunches are limited to 650 calories. Kids who throw away substantial portions will have even fewer calories. If schools still serve fries and pizza, the portions are smaller, have less fat, and the pizza is likely to have whole wheat crust and low fat cheese. Portions of meats and carbohydrates are smaller and fruits and vegetables aren’t always appreciated. Obesity is known to cause and exacerbate many chronic diseases, including diabetes, heart trouble and cancer, and obesity an chronic illnesses in the U.S. have been increasing for decades. The CDC reports that some 12.5 million children and adolescents between ages 2 and 19 are obese-that’s 17 percent of that age group, and poor kids are especially prone to obesity. Among low income preschool children, the CDC reports, one in seven is obese.

What can influence youngsters to like eating eat what’s good for them? The Times story quotes William McCarthy, a professor of public health and psychology at the university of California at Los Angeles. He says research shows kids need to be exposed to vegetables 10 to 12 times before they will start to eat them on their own, so one strategy is just waiting. Several school districts are providing lessons about healthy eating in class, offering free samples, creating gardens kids can tend, and educating students about locally grown food.

Even before the recent law, some efforts have been intense and long range. Shape Up Somerville, Eat Smart Play Hard, funded by the CDC, began in 2002 as a three-year environmental change initiative designed to prevent obesity in early elementary school children. Tufts University researchers found that nearly half of the school district’s first graders were overweight or at high risk of being overweight. The initiative, led by Tuft’s Christine Economos, PhD, involved the whole community-schools, restaurants, businesses, and families, and emphasized exercise and play as well as healthy food. The body mass index of participating children declined, and community support continues.

The French are proud of their cuisine, and public schools in France are serious about promoting appreciation for healthy food as well as practice in the social graces of eating. Even young children receive several courses with small portions, and they sample traditional face such as escargot, bouillabaisse, and ratatouille. A CBS news story illustrates a public philosophy and the dedication of chefs. Karen LeBillon is a teacher, author and mother who blogs about French school food, describing among other delicacies the beets, goat cheese, fish, fruit and freshly baked bread being served to youngsters in public schools in Paris. In some schools, parents have chosen to pay extra for organic meals. Obesity has increased in France, although the rate of obesity among children and adults is lower than it is in other European countries and the U.S.

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Canadian Study: 40% Would Pay Kidney Donors

Posted By Prucia Buscell, Thursday, October 4, 2012

Researchers at the University of Calgary have found a significant public support for financial incentives for kidney donors.

An online survey was conducted with more than 2,000 members of the Canadian public, 339 health professionals, and 268 people who have or are affected by kidney disease. Forty percent of the respondents thought it was acceptable to pay living donors for kidneys, and 70 percent favored some financial compensation such as payment of funeral expenses for donors whose kidneys were harvested after death. However, few respondents favored payments to a deceased donor’s estate.

Interestingly, only 14 percent of health professionals thought it would be a good idea to pay living donors. The study, "Attitudes Toward Strategies to Increase Organ Donation: : Views of the General Public and Health Professionals,” is published in the Clinical Journal of the American Society of Nephrology.

According to a story by Lindsay Abrams in TheAtlantic.com, people who oppose payment most often said they thought "a kidney should be donated from the goodness of the heart.” At the same time, the authors concluded people might be more willing to donate if they were paid. More than half of the respondents who said they would not be living donors to a stranger indicated they’d reconsider if they were paid $10,000.

A U.S. study by researchers at the University of Pennsylvania and the Philadelphia Veterans Affairs Medical Center asked 342 participants whether they would be more likely to donate a kidney if they were paid differing amounts, $10,000 and $100,000. Promise of cash nearly doubled the number who said they would donate their organ to a stranger. The study was published in the March 16, 2010 issue of the Annals of Internal Medicine.

It is illegal to buy and sell organs in the U.S. and most western countries. The issues involved are difficult, emotional, ethical and complex. The people who die awaiting transplants greatly outnumber the organs available and advocates for increasing the supply argue that a regulated market could avoid exploitation and save lives. There are periodic international and domestic scandals about a trade in human organs. And the 2002 movie "Dirty Pretty Things" directed by Stephen Frears is memorable for its dark plausibility: the story deftly depicts criminals who profit by selling the organs of poor immigrants in London. A writer in the McGill Journal of Medicine asks whether it’s time for western countries to follow the example of Iran, which has long had a government regulated and funded kidney transplant system with an independent third party association to make arrangements and pay the donors.

But a shortage of donated organs is not the only barrier to life-saving transplants. Kevin Sack in a New York Times story September 19, 2012, reports that while 4,720 people died in the U.S. last year awaiting transplants, more than 2,600 kidneys from deceased donors were discarded. Some of the kidneys were found to be unsuitable, but Sack quotes experts who believe as many as half of them could have been transplanted if the U.S. donated organ allocation system did a better job getting the right organ to the right recipient in the right amount of time. The system needs to be revised, according to these experts, to consider better matching in terms of projected life expectancies of recipients and the very tight time frame for testing, evaluation, decisions and transportation. Surgeons want to transplant kidneys within 24 to 36 hours after removal from the donor.

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The ‘Anternet’—Ancient and Cutting Edge

Posted By Susan Doherty, Thursday, September 27, 2012
Updated: Thursday, September 27, 2012

Harvester ants may increase knowledge about networked systems.

Deborah Gordon, a Stanford biology professor who has studied ants for 20 years, found something extraordinarily sophisticated about the way harvester ants forage for food. She discovered that the ant colonies regulate their foraging activities based on the amount of food available and the amount of time it takes for a round trip between the nest and the food.

Harvester ant foragers waiting inside the nest. – photo by Katherine Decktar, one of the researchers

Gordon recognized that this particular ant behavior approximates the way the Internet works, so she invited Stanford Computer Science Professor Balaji Prabhakar to have a look. Their collaboration is described in a Stanford News story about "the anternet” and their paper is published in Plos Computational Biology.

Individual ants leave the nest looking for the seeds, which they immediately bring back and drop deep into the nest. The more food they find, the faster they return. New foraging trips are initiated based on the rate of return from earlier trips. There’s no central control or boss ant, and no geographic information on where the food is located. Some ants leave pheromone trails in their travels, but these ants don’t. What happens is based on local interactions among the ants in the nest. New foraging trips are signaled by the rate of contact between the antennas of returning ants and the antennas of ants available to leave on the next trip.

Initially skeptical, Prabhakar quickly saw the validity of Gordon’s insight. "The algorithm the ants were using to discover how much food there is available is essentially the same as that used in the (Internet) Transmission Control Protocol,” he told the Stanford News.

The Transmission Control Protocol, or TCP, is the way information transmission among networked computers is regulated. As the Stanford story explains TCP, as a source A sends a file to a destination B, the file is broken up into numbered packets. Each time B gets a packet, it sends an acknowledgment, or ack, back to A. Speed of ack return indicates the amount of bandwidth available. If the ack comes back at a lower speed than it was sent, it means little bandwidth is available, and transmission traffic is slowed accordingly. If it returns quickly, transmission speed can increase. That’s pretty much the same thing the ants do.

The researchers found another similarity: When a data link is disrupted or broken, the source stops sending packets. If forager ants don’t get back to the nest in 20 minutes, no more ants leave to forage.

Each ant is limited, but colonies can achieve some impressively complex computations, and they’ve been evolving for millions of years, probably doing things humans haven’t thought up yet. Read Gordon’s wonderful essay "Colonial Studies."

"Ant algorithms have to be simple, distributed and scalable—the very qualities that we need in engineering distributed systems,” Gordon said. "I think as we start understanding more about how species of ants regulate their behavior, we will find many more useful applications for network algorithms.”

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Social Network Analysis Finds Truth in Myth

Posted By Prucia Buscell, Thursday, September 20, 2012
Beowulf wrestles 
with Grendel 
1933 Lynd Ward

 

An ancient tale tells us the monster Grendel, annoyed by the noise of warriors drinking and carousing in the great mead hall built by the Danish King Hrothgar, was moved to murder them all in their sleep. No one thinks the monster was real, but there may have been a real mead hall. While evidence is lost and blurred by passing centuries, the story of Beowulf, the mythical hero who slew the monster, may be rooted in actual events and places.

 

Historians, archeologists and literary scholars have long searched for evidence of reality hidden in ancient myths that have been altered and embellished with every retelling for centuries even before they were committed to writing. Now the science of social network analysis is offering new clues about what’s rooted in reality and what’s totally fictional.

 

Achilles tending the wounded 
Patroclus from The Iliad

A team of physicists mapped the social networks in three ancient narratives by creating a database of the characters and their interactions and categorizing their relationships as hostile of friendly. Beowulf contained 74 characters, The Iliad 716, and the Irish legend Tain Bo Cuailnge contained 404 characters. Padraig MacCarron and Ralph Kenna, physicists at the Applied Mathematical Research Centre at Coventry University in the United Kingdom, describe their work in "Universal Properties of Mythological Networks" from epljournal.org, a Letters Journal Exploring the Frontiers of Physics, and in the New York Times story "If Achilles Used Facebook...."

 

Scholars think Beowulf, the heroic epic set in sixth century Scandinavia, has historical inspiration. The Iliad’s Greek gods who intervened in a mythical Trojan War with their supernatural powers come from the realm of art and imagination. But the lives and times described may refer to happenings in the 8th century BCE, and archeologists think Homer, writing some 400 years later, is likely to have incorporated re-told and remembered tales of military conflict around Troy at the end of the Bronze Age.

 

Cuchulainn
Slays the Hound of Culain 
1904 Eleanor Hull
The Boys' Cuchulain

Many scholars have considered "Tain Bo Cuailnge" completely fictional. Often translated as the Cattle Raid of Cooley, the story tells how the rulers of Connaught make war on Ulster in order to steal a fabulously potent stud bull. Cu Chulain, a 17-year-old, is Ulster’s sole defender. John Bohannon writing in news.sciencemag.org says recent archeological evidence suggests it could be based on real conflict 3,200 years ago in Ireland. Written manuscripts dating from 12th and 14th centuries tell of a fight between Connaught and Ulster in the north and west of Ireland, and social network analysis lends credence to the historical root.

 

Kenna and MacCarron found the mythical networks have characteristics of real world networks. All three have structural balance, which the authors explain is related to the real-world idea that the enemy of my enemy is my friend. They are small world networks, meaning connectivity among nodes leads to pathways that link a large number of nodes, and there never are more than a few degrees of separation between two people. They are scale free because their structure and dynamics are independent of the number of nodes in the network, and they were also highly clustered, with groups of people who are well connected. In addition, the networks were assortative, meaning that as in the real world, people connect with people who are similar to them.

 

The authors examined social networks in several intentionally fictional narratives, such as Harry Potter, and found that none were scale free. In most modern fiction, Bohannon explains, minor characters generally link to the main character. Bohannon quotes Kenna as saying that in deliberate fiction, everyone tends to be linked to everyone else in order to make the story easier to follow. Unlike the real-world and studied mythical networks, the fictional networks were disassortative, indicating many connections between unlike nodes.

 

As the authors explain in their Times piece, their approach is not literary or historical, and tells nothing about the human condition. "Instead,” they write, " it promises a new way to analyze old material and find striking new perspective and evidence-in this case, that which we call ‘myths’ may not be as mythical as we thought.”

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IOM Calls for Continuous Learning in Healthcare

Posted By Prucia Buscell, Friday, September 14, 2012

Today’s clinical practice guidelines suggest a 79 year old woman with osteoporosis, osteoarthritis, diabetes, high blood pressure and chronic obstructive pulmonary disease could be taking 19 medications. Guidelines for osteoporosis suggest she should do weight bearing exercises, and guidelines for diabetes say she shouldn’t.

In 2000, some 125 million Americans suffered from chronic ill nesses. By 2020, that number is expected to be 157 million—32 million more people, in part because of an aging population. Right now, 75 million people in the U.S. suffer from multiple chronic diseases.

The new Institute of Medicine report Best Care at Lower Cost: The Path to Continuously Learning Health Care in America cites these figures to illustrate the many sets of circumstances that are increasing and exacerbating the challenges faced by clinicians and patients. It’s daunting enough that treatment guidelines may be contradictory when a patient has multiple conditions. The report also estimates that individual primary care physicians would have to spend 21 hours a day to provide all the care recommended for their patients’ acute, preventive, and chronic disease management needs. Further, the report quotes a study saying that during a single year, the average primary care physician coordinated with 229 other physicians in 117 different practices just for Medicare patients.

Complexity has increased exponentially. The U.S. healthcare system is characterized by more to know, do and manage than at any time in history, the IOM reports. There were, for instance, more than 200,000 research publications in 2000, and in 2010 new biomedical and clinical knowledge filled 750,000 such publications.

Patients may be beleaguered too. Healthcare costs have increased 76 percent during the last decade. For one of every 14 tests performed, patients weren’t told of abnormal results. The report cites a survey that found 25 percent of patients said tests had to be repeated because results hadn’t been shared among providers who cared for them.

Despite enormous increases in biomedical knowledge and therapeutic and procedural innovation, available knowledge is too rarely applied to patient care and information generated by patient care is too rarely gathered to improve existing knowledge, the report says. For instance, the report notes that in 1982 researchers found that the use of beta blockers after a heart attack reduced mortality by 25 percent. Researchers later found 40 percent reductions in mortality, and the practice was included in professional guidelines in the 1990s. But only in the last five years—a quarter century after the initial discovery—have most heart attack patients been receiving this treatment. The cost and quality of care vary enormously from one state to another, and high cost did not correlate with high quality. If the highest quality had been maintained in all states, 75,000 fewer people would have died in 2005.

While Americans spend $2.6 trillion a year in health care—18 percent of the gross domestic product—some $750 million is wasted. The IOM says that amount could pay salaries of all first responders, including police, fire fighters, and emergency medical technicians for 12 years.

Here is the IOM’s breakdown of estimated wasteful spending:

· Unnecessary services - $210 billion

· Inefficiently delivered services - $130 billion

· Excess administrative cost - $190 billion

· Prices that are too high - $105 billion

· Missed prevention opportunities - $55 billion

· Fraud - $75 billion

To address the complex issues of clinical care, individual and public health and overall cost, the IOM calls for a "continuously learning” health care system. Its characteristics would include:

· In science and informatics, real time access to best available knowledge, and the use of information technology to capture and analyze data from the patient experience

· Engaged, empowered patients and families to work with care providers to promote good health and treatment outcomes

· Incentives for continuous improvement and improved transparency

· Culture in which leaders foster and support continuous learning and supportive system competencies with feedback loops created for continuous analysis and improvement

The full report, a summary, and individual chapters, can be accessed here.

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World’s Worst Environments Intensify Innovation

Posted By Prucia Buscell, Thursday, September 6, 2012

A former astronaut who’s also a physician believes extreme and distant environments are "incredible test beds” for technologies that will advance medicine.

Scott Parazynski, MD, a veteran of five Space shuttle flights, is now chief medical officer for the Center for Polar Medical Operations, which supports the National Science Foundation’s U.S. Antarctic Program. Read about the doctor’s extraordinary adventures and observations in a FastCompany story by Neal Ungerleider.

Dr. Parazynski says he is drawn to remote and challenging environments, and Antarctica may have the worst the world has to offer. It’s almost completely dark for six months, the temperature hovers around minus 70 degrees F. and conditions make air traffic virtually impossible from February through October. Dr. Parazynski says it’s akin to being on Mars, or the back side of the moon, where every act requires forethought and errors can kill. He finds it a rewarding place to work and study.

"I think the drive toward Apollo and the things we got from the lunar program revolutionized medicine,” Dr. Parazynski told Fast Company. "The miniaturization of technologies, sensors, and microelectronics that are now ubiquitous in our intensive care units...the monitors you see... they’re all ‘space pedigree’.”

He says medicine practiced today in remote and harsh places will lead to advances in telemedicine and point of care diagnostic and therapeutic devices, as well as microelectronics, nanotechnology, genomics, and metabolomics. He thinks they will also advance "MacGyver medicine" named after the TV secret agent who had the skills and ingenuity to rescue almost anyone from almost anywhere, creating tools he needed from materials at hand. As one example, Dr. Parazynski describes how Dr. Jerri Nielsen Fitzgerald diagnosed her own breast cancer during the Austral Winter in 1999 when no plane could land anywhere near the Antarctic outpost. She was the only physician there. She performed her own biopsy, with the help of a resident welder who practiced by sticking needles in apples and yams. Chemotherapy drugs were delivered by a dangerous air drop. Her cancer went into remission, but returned in 2005 and she died in 2009.

Dr. Parazynski recommends breaking up any difficult task into manageable parts rather than trying to achieve the whole goal all at once. He says he applied that principle to mountain climbing, medicine, and his early ambition to become an astronaut. He has climbed mountains all over the world, and is the only person to have flown in space and reached the top of Mount Everest.

Alexander Kumar, a physician and researcher at Concordia, a jointly sponsored French-Italian research station in Antarctica, is conducting scientific experiments for the European Space Agency’s human spaceflight program. His studies include examinations of sleep patterns, dreams and nightmares and behavioral and cognitive changes induced by isolation and perpetual darkness. Read his New York Times blog.

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