Guide Lean Diagnostics: Almost Everything You Think You Know About Lean is Probably Wrong

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Involves neutron radiation exposure, which poses potential danger during childhood and pregnancy. Portable, safe, reproducible, and low cost. Relies on population-specific regression equations; some of these equations are not released by the manufacturer. Some regression equations are not released by the manufacturer. The generation of a high- and low-energy emission by an x-ray source is used to differentiate between soft tissue and bone.

FM is then estimated from specific attenuation characteristics of soft tissues.

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Differentiates fat, lean, and bone tissue. Regional measures of body composition can be obtained. Safe for repeated measures; fast and noninvasive. There are differences within and between manufacturers and software versions. Inability to differentiate compartments within fat and lean tissues. Measurements are influenced by thickness of tissue and lean tissue hydration.

Low radiation exposure but is not safe for pregnant women. AT skeletal muscle, bone, visceral organs, and brain tissue can be identified by the different x-ray attenuation. Highly accurate quantitative and qualitative measure of body composition at the tissue-organ level, particularly total and regional AT and skeletal muscle tissue. High image resolution. Consistent image attenuation value within and between scans. Limited to highly specialized settings, costly, and requires specialized skills to operate.

Large radiation exposure. Cannot accommodate very large subjects cannot fit in the scanner. These protons are then activated by a radio frequency wave, absorbing energy. The signal generated is used to develop regional and whole-body cross-sectional images.

Quantifies adipose tissue, skeletal muscle, edema, and visceral organs. Excellent image resolutions. Most accurate method to determine body composition at the tissue-organ level, specifically whole-body and regional adipose tissue and skeletal muscle tissue quantity and quality. Safe across age range and groups. Limited to highly specialized settings, costly, and requires specialized skills. Procedure requires individuals to hold their breath.

Lean, fat, and free water tissues have different rates of relaxation rates that allow for differentiation. QMR differs from MRI in that the processed signal is obtained from the whole body at once without spatial encoding. High measurement precision. Rapid, noninvasive. Relatively new technique, limited to highly specialized settings; costly and requires specialized skills to operate. Tendency to overestimate FM compared with a 4-compartment model. High accuracy and reproducibility. Distinguish between trabecular and cortical bone components.

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Allows the measurement of density and 3-D geometric parameters of cortical bone. Trabecular volumes are largely independent of degenerative changes in the spine. High radiation exposure, high cost, and limited to highly specialized settings; costly and requires specialized skills to operate. Measurement of muscle and bone thickness is being studied. Safe, portable, fast, lower cost. Reliable, reproducible, and accurate measurement of AT. Lack of standardized measurement techniques; results affected by technical errors, protocol standardization, and anatomical irregularities.

Provides more qualitative than quantitative results. Results are highly dependent on the skills of trained operators. More commonly used in the 4-compartment models, including measurements of body volume hydrodensitometry or air displacement plethysmography , TBW dilution , and bone mass DXA. Gold standard and criterion method comprehensive analysis with minimal assumptions. Limited to highly specialized settings; costly and requires specialized skills to operate.

Computerized Tomography Imaging The use of CT imaging in the clinical setting has escalated in the past few years due to the accuracy, reliability, and availability of these images in certain clinical scenarios. Figure 2. Ultrasound Ultrasound is a commonly available technique used in clinical settings for diagnosis and follow-up purposes. Future Directions Methodologies to assess body composition have emerged as reliable predictors of physiological reserves, suggesting that superficial measures of body weight may potentially neglect risk and status. Supplementary Material Supplementary material: Click here to view.

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Assessment of nutritional status. Nutrition and the Cancer Patient. Baumgartner RN. Body composition in healthy aging. Ann N Y Acad Sci. Heymsfield SB. Development of imaging methods to assess adiposity and metabolism. Int J Obes Lond. The end of body composition methodology research? Sarcopenia: etiology, clinical consequences, intervention, and assessment. Osteoporos Int. Siervo M, Prado CM. Nutritional assessment of the critically ill patient.

In: Faber P, Siervo M, editors. Nutrition in Critical Care. Body composition indexes of a load-capacity model: gender and BMI-specific reference curves.

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Public Health Nutr. In press. Associations of body composition with physical performance and self-reported functional limitation in elderly men and women. Am J Epidemiol. Glossary Acoustic impedance: In ultrasound, acoustic impedance is the amount of sound pressure that is produced by the vibration of molecules at a given frequency.

Pixel: Single rectangular area of an image in a CT image. Sarcopenia: Low skeletal muscle mass associated with aging. Subcutaneous adipose tissue: Nonvisceral fat just below the skin. Visceral adipose tissue : Adipose tissue around internal organs. References 1. A population-based approach to define body-composition phenotypes. Am J Clin Nutr. Study of body composition: an overview.

Human Body Composition. Champaign, IL: Human Kinetics; ; The five-level model: a new approach to organizing body-composition research. Human body composition: advances in models and methods. Annu Rev Nutr. Lohman TG, Chen Z. Dual-energy x-ray absorptiometry. Assessing skeletal muscle mass: historical overview and state of the art. J Cachexia Sarcopenia Muscle. Appendicular skeletal muscle mass: measurement by dual-photon absorptiometry. Sarcopenic obesity: a critical appraisal of the current evidence. Clin Nutr. Age Ageing. Evaluation of dual energy x-ray absorptiometry as a method of measurement of body fat.

Eur J Clin Nutr. Dual-energy x-ray absorptiometry and body composition: differences between devices and comparison with reference methods. Influence of orthopaedic metal and high-density detection on body composition as assessed by dual-energy x-ray absorptiometry.

Clin Physiol. The official positions of the International Society for Clinical Densitometry: acquisition of dual-energy x-ray absorptiometry body composition and considerations regarding analysis and repeatability of measures. J Clin Densitom. Ross R, Janssen I. Computed tomography and magnetic resonance imaging. Champaign, IL: Human Kinetics; Composition of skeletal muscle evaluated with computed tomography. In Vivo Body Composition Studies. Mattsson S, Thomas BJ. Development of methods for body composition studies.

Phys Med Biol. Visceral adipose tissue: relations between single-slice areas and total volume. Total body skeletal muscle and adipose tissue volumes: estimation from a single abdominal cross-sectional image. J Appl Physiol. A practical and precise approach to quantification of body composition in cancer patients using computed tomography images acquired during routine care.

Appl Physiol Nutr Metab. Prado CM. Body composition in chemotherapy: the promising role of CT scans. Assessment of nutritional status in cancer—the relationship between body composition and pharmacokinetics. Anticancer Agents Med Chem. Cancer cachexia in the age of obesity: skeletal muscle depletion is a powerful prognostic factor, independent of body mass index.

J Clin Oncol. Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncol. The prevalence of sarcopenia in patients with respiratory failure classified as normally nourished using computed tomography and subjective global assessment. Crit Care. Karra S, Fearon K. Accessed May 28, Imaging body composition in obesity and weight loss: challenges and opportunities. Diabetes Metab Syndr Obes. Associations of visceral and abdominal subcutaneous adipose tissue with markers of cardiac and metabolic risk in obese adults.

Effect of dietary restriction and exercise on lower extremity tissue compartments in obese, older women: a pilot study. Myosteatosis and myofibrosis: relationship with aging, inflammation and insulin resistance. Arch Gerontol Geriatr. Muscle volume, MRI relaxation times T2 , and body composition after spaceflight. J Appl Physiol Measurements of total and regional body composition in preschool children: a comparison of MRI, DXA, and anthropometric data. Prealbumin is associated with visceral fat mass in patients receiving hemodialysis. J Ren Nutr. A new frailty syndrome: central obesity and frailty in older adults with the human immunodeficiency virus.

J Am Geriatr Soc. Cadaver validation of skeletal muscle measurement by magnetic resonance imaging and computerized tomography. Wagner DR. Ultrasound as a tool to assess body fat. J Obes. Bellisari A, Roche AF. Anthropometry and ultrasound. Keep in mind that this is just a starting point. There's a reason that dozens of books have been written about Lean. It's not easy to fully understand all in one night.

I have been learning about it for more than 15 years 20 years since Not that I'm holding myself up as the 1 expert on the topic. The goals of organizations that are practicing Lean are pretty consistent across industries. Their goals are to simultaneously improve:.

The goal is to provide long-term success for an organization and for everybody involved — customers, employees, owners, suppliers, and other stakeholders. In healthcare, it means providing the right care at the right place at the right time, which means reducing waiting times for appointments and reducing waits and delays when in a healthcare facility. Lean is respectful toward everybody who participates in a system, including customers, employees, suppliers, the community, etc. Lean has been applied in manufacturing factories, product design, and administrative functions as well as service industries including healthcare, banking, and government.

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The Toyota Production System , a. Together, Lean Six Sigma can lead a hospital to zero harm. Learn more about HROs at archive. Why is zero harm important? Of the 3 billion prescriptions filled each year, million are filled incorrectly. An estimated 7, patients will die as a result of a medication error. In addition, 2. A New England Journal of Medicine study estimated that this happens once in every 1, surgeries. One in five orthopedic surgeons will conduct a wrong-site surgery during his or her career. One of my wife's sister's father-in-laws died after having the wrong leg amputated.

One New England hospital had three wrong-side brain surgeries in one year. In , a doctor failed to diagnose my mother's colon cancer for four months. My wife's sister has had extended complications from a perforated colon caused by a colonoscopy. My wife's father died from a botched back surgery.

Most healthcare workers tell me that medical mistakes are underreported by a factor of 2 or 4. The IHI says that 50 patients out of every will suffer some form of preventable "harm" while hospitalized. That's over 17 million patients a year. And patients aren't the only people affected by healthcare problems. It is reported that 50 percent of hospitals have financial difficulties. Between and , financial distress forced acute-care hospitals to close, whereas 70 percent of rural hospitals and 50 percent of urban institutions were fighting to stay afloat.

With 70 to 80 hospitals expected to close each year through the s, the outlook was grim. The Journal of Healthcare Management reported that between and , 42 U. The Internet even has articles about how to file for bankruptcy as a hospital. How can an industry producing 20 percent of the gross domestic product GDP be so sick?

Moreover, the costs of healthcare don't only affect the industry; they threaten the livelihood of patients and their families. From a patient's perspective, medical bills were involved in 60 percent of personal bankruptcy cases in The high cost of healthcare is pushing patients into bankruptcy, and poor management of costs and receivables is pushing hospitals into bankruptcy.

Lean Six Sigma can lower costs for both hospitals and patients while delivering superior profits, performance, and patient outcomes. Having consulted with many hospitals and healthcare systems, I have seen that the problems of patient flow, clinical mistakes, and operational errors are the same across the industry.

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Fortunately, Lean Six Sigma can solve these problems. The hard part is getting the hospital culture to adopt the improvements of Lean Six Sigma and sustain them.

A American Society for Quality study of 77 hospitals found that:. Only 4 percent had fully implemented Lean.

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Only 8 percent had fully implemented Six Sigma. Most healthcare systems have gone through a number of implementations of process improvement PI or total quality management TQM. While most healthcare workers have been dipped in some method for quality improvement, few have applied it successfully. With healthcare reform all the buzz in Washington, most healthcare workers are hoping that they can just keep on going about their business and that the government will find a way to pay for universal healthcare for tens of millions of uninsured patients.

To make healthcare affordable for all, however, healthcare will have to contribute dramatic cost savings. Treasury Secretary. Healthcare costs as a percent of GDP. A staggering 50 percent of healthcare consumed seems to be driven by physician and hospital supply, not patient need or demand. Years ago, my friend Janet was diagnosed with breast cancer.

Clinical trials found that the treatment didn't work. Janet eventually opted for a mastectomy, although clinical trials have shown lumpectomies to work equally well. Formal science shows that the emperor is naked. Although radical mastectomy has been the standard for over 80 years, there's no systematic evidence that it actually works. Get into data. We have underestimated the depth of the taproots of the status quo. In a IHI speech, "My Right Knee," Don Berwick described his own experience with having an unnecessary knee surgery when he was a medical student that led to unnecessary pain and a potential joint replacement.

From his experience, he points out the IHI's results-oriented goals: no needless death don't kill me or pain don't hurt me , no helplessness share information and give me choices , no unwanted waiting don't waste my time , and no waste no unnecessary tests or treatment. An estimated , angioplasties each year are unnecessary according to Harvard Medical School's Dr. Roger J. Medicare found that aggressive treatment unnecessarily kills 30, patients a year.

Hospitals represent almost a third of healthcare costs Figure 2. One patient out of admitted to a hospital will die as a result of a medical mistake To Err Is Human , National Academy Press, With over 41 million admissions, this means that there could be , preventable deaths each year, making healthcare one of the top 10 causes of death in the United States. The National Healthcare Quality Report found "that patient safety has actually been getting worse instead of better…. One in seven Medicare patients experiences one or more adverse events, and thousands of patients develop central-line-associated bloodstream infections each year.

A Joint Commission Journal article stated that healthcare doesn't know if preventable deaths are actually any better because healthcare doesn't measure them. Another 6 out of patients will be permanently disabled as a result of a medical mistake. The IHI found that one patient out of every two 50 percent suffered some form of preventable harm in the hospital.

Fifteen out of every diagnoses are incorrect. Twenty to fifty out of diagnostic procedures e. Five to ten out of every admitted patients acquire an infection. Three patients out of every have an incorrect ID band.

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  • The average hospital spends one-quarter of its budget on billing and administration. Get the idea? Healthcare is rife with possibilities for improvement. Lean Six Sigma can help to minimize or eliminate all these problems. But healthcare clinicians and operational personnel have got to want to face the issues head-on and change the way healthcare is delivered to ensure better patient outcomes, faster service, and a better all-around experience. Patient safety. Error-free care. Patient-centered care rather than physician-centered care that optimizes the patient's experience , not the clinician's time.

    Reducing wait times and dangerous delays using Lean. Removing "waste" from the process using Lean. Fifty percent of a nurse's time is spent doing things that don't add value, like looking for medications that aren't where they're supposed to be or looking for equipment that isn't where it's supposed to be. While most visits to the emergency room ER; many hospitals call it the Emergency Department take two hours or more, Robert Wood Johnson Hospital in New Jersey Baldridge Award winner in does it in 38 minutes, on average. The hospital offers a minute door-to-doctor guarantee.

    The hospital did it by rethinking the emergency experience from the patient's point of view. For busy soccer moms with a sick kid, the choice between ERs is easy; they can save 80 minutes by going to the fastest ER. And the clinical side isn't the only issue. Healthcare operations—billing, ordering, etc. Insurance companies are quick to reject claims and slow to pay, which causes more problems.