EPtalk by Dr. Jayne 7/6/23

I mentioned recently that July marks the traditional start of the new training year for medical education in the US. Those interns are approaching the end of their first week on the job and are likely to be using a variety of coping strategies to figure out how they’re going to make it through the next three to 10 years of their lives. Figuring out when and what you’re going to eat when you have little time is usually a big part of that survival strategy. Jenn clued me in to this cooking contest for vegan hospital food. The District of Columbia Hospital Association recently held its third annual Healthy Hospitals Initiative Cooking competition with a “secret ingredient” this year of carrots. The event is also sponsored by the Physicians Committee for Responsible Medicine and winners included MedStar National Rehabilitation Hospital with its purple carrot ravioli and carrot halwa pistachio trifle.

I read with interest this piece about Cleveland Clinic opening a new telehealth hub at one of its hospitals. The facility’s 57 rooms are equipped with technology to allow patients to have consultations with physicians who are at other locations. Knowing that they plan to staff cases remotely, it will be interesting to see what kinds of providers and staff are actually in place at the facility. I’m guessing they’ll go with a minimum staffing approach, and as far as licensed providers, probably will leverage nurse practitioners and/or physician assistants more than you might at a facility with traditional staffing. I hope someone is doing outcomes research and looking at how these patients fare compared to those being cared for under usual care models. If research proves this approach is equivalent but less costly, or drives better outcomes with the same cost, it will truly be a game changer.

Speaking of telehealth, it’s often cited as being key to solving the access problem for patients in need of mental health services. Author Health, which has a platform for seniors on Medicare Advantage, just announced a $115 million funding round with Humana as a payer partner in south Florida. The platform also addresses substance use disorders. Author Health delivers care both virtually and in-person with a cross-functional team including physicians, therapists, nurses, and community health workers. All of the resources are virtual except the community health workers. They’re hoping to manage workforce issues by recruiting providers first and getting them licensed in target states, rather than trying to recruit those who already have specific licensure. That’s easy in some states but harder in others, so I’m sure it will drive their expansion plans.

In reading more about the Author Health arrangement with Humana, it appears to be based on a fee-for-service model with a goal of transformation to a value-based model in the future. They also hope to be able to demonstrate improved outcomes for patients’ comorbid medical conditions, such as diabetes. It will be interesting to see how the platform grows over time and whether or not the partnership with Humana helps it yield results faster than competitors. I enjoyed learning a little about their branding – the name Author Health is drawn from the idea that patients should be writing their own life story and defining how they want the next chapters to unfold. I’ve got the company on my tracking list, so we’ll see how it fares over the coming months to years.

Mental health apps are also a big topic of conversation as a way of solving the access issue. I ran across this article looking at the pros and cons of direct-to-consumer virtual mental health apps. Before reading the article, my major concern with these offerings was the protection of patient data. Most patients don’t realize that the majority of apps aren’t required to protect the privacy of patient data nor do they know that some app developers are actually selling their personal data. I’m sure the number of consumers that actually reads the full Terms and Conditions when downloading an app is very small. According to the article, there may be between 10,000 and 20,000 mental health apps out there. Although the sheer number might be a good thing, the article brings up additional pitfalls beyond privacy and security concerns. It notes that we don’t know for sure whether apps can deliver the same quality of care as existing treatments do, and that traditional healthcare providers and payers need to play a role in making sure that quality is assessed.

Given the fact that digital therapeutics companies who have the proof of their outcomes have struggled to make a go of it, I’m not optimistic about the ability of front-line care providers to participate in the process to prove whether an app meets the standard of care. The boom in app use in other disciplines has contributed to provider frustration, as many have to spend already scarce clinical time explaining why some apps might be a bad idea. Many of my colleagues in women’s health have spent a lot more time counseling patients on the risks of using period tracking apps because patient privacy cannot be guaranteed, especially for patients in states that have restricted abortion care. I used to occasionally have to counsel patients about the validity of various home blood pressure cuffs and the data they generated, and with current technology patients can send me hundreds of data points at the click of a button that I now have to figure out how to reconcile. There can be a lot of effort needed for physicians to figure out what to do with all this information, and given the conversation in the physician lounge, people may be less than enthusiastic about rising to this particular challenge.

Bad news for those of us who like our downtime: There may be a link between napping and esophageal cancer. Researchers at Washington University School of Medicine in St. Louis have identified prolonged sleep as a risk factor for esophageal adenocarcinoma, with those sleeping nine hours per night having double the risk of individuals sleeping seven hours per night. They also found increased risk in patients who slept less than six hours per night. In looking at patients who slept or napped during the day, they also identified increased risks. Researchers think that the link to increased cancer risk might be due to disruption of sleep/wake cycles that leads to reflux of stomach acid, or to immune dysfunction that might cause increased cancer risk. Thinking as an average person, it sounds like this isn’t terribly conclusive. There may be other factors involved such as obesity, although the researchers did adjust their data for sex, smoking status, body mass index, and whether or not patients engaged in shift work. I consulted my favorite otolaryngologist and we both agreed that a good afternoon nap is probably worth the risk.

When is the last time you had to do an all-night upgrade or IT work that made you want to nap the next day? If you’re a napper, are you willing to give it up to lower your cancer risk? Leave a comment or email me.

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