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Opinion and Commentary from TMA

With a Grain of Salt

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Salt, sodium chloride, NaCl, is about 40% sodium and 60% chloride. It is ubiquitous and found in many different food items. It flavors food and is used as a binder and stabilizer. Salt has endured as an important part of our culture, and many different salt variants are available to meet our needs. 

The use of salt is now universal. Salt is thought to have entered the human diet about 5,000 years ago. Ancient Chinese texts described more than 40 types of salt about 4,700 years ago (Peng-Tzao-Kan-Mu, pharmacology). It is a food preservative – as bacteria can’t thrive in the presence of a high amount of salt – that helped humans migrate longer distances. 

NishantThe word “salary” was used to describe how Roman soldiers were paid for their duties with salt (Latin salarium). In 1930, Gandhi led thousands of Indians on a 240-kilometer salt march in defiance of the British Salt Act, which is considered a maiden event in India’s independence. 

Today salt is used as a way to preserve foods to prolong foods’ shelf life. 

The average American man and woman are estimated to consume 10.4 and 7.3 grams of salt per day respectively. The U.S. Department of Agriculture and Department of Health and Human Services recommend no more than 5.8 grams of salt (2.3 grams of sodium) per day, with a lower target of 3.7 grams for most adults (people over 40, blacks, patients with hypertension). One gram of sodium is equivalent to 2.5 grams of salt or sodium chloride. 

It is estimated that we need about 500 milligrams of sodium daily for our vital functions. But too much sodium in the diet can lead to high blood pressure and stroke. 

A study entitled “Salt Appetite” by University of North Carolina at Chapel Hill nephrologist Philip Klemmer, MD, showed that when he and a colleague went on an extremely low salt diet of 10 milliequivalents per day, they noticed a weight drop of 1.4 kilograms along with a drop in blood pressure. 

Multiple articles have shown weight and blood pressure drop with lower salt intake. A paper by Kirsten Bibbins-Domingo, MD, PhD, and others published in the New England Journal of Medicine showed that reducing salt consumption by 3 grams per day reduced coronary heart disease in the U.S. by 60,000 to 120,000 cases per year; the number of strokes decreased 32,000 to 66,000 cases a year. 

A study published in 1975 looked at the “salt-free culture” of South America’s Yanomami tribe, who had relied on food obtained by hunting and fruits. Of all the people studied in the tribe, the mean urine sodium excretion was 1.02 milliequivalents per day, whereas the mean systolic blood pressure was <110 mm Hg across all age groups. They also had high renin aldosterone levels given their high potassium, low sodium diet. 

Salt consumption is a cultural thing, where consumption is driven by taste and our appetite for processed food. 

Most salt we consume today comes as a preservative in foods that we buy. Table salt and salt added while cooking contribute to about 10% of salt consumption. (Figure below) 


According to the Centers for Disease Control and Prevention (CDC), the top 10 salt contributors (in mg) are:

  1. Bread and rolls (80-230),
  2. Cold cuts/cured meats (1 bacon 194/1 beef jerky 443),
  3. Pizza, 1 slice (500-700),
  4. Fresh and processed poultry (300-700 mg),
  5. Soups (300-500),
  6. Sandwiches like cheeseburgers (700-1700),
  7. Cheese, 1-oz. slice (330-440),
  8. Pasta dishes like spaghetti with meat sauce (400),
  9. Meat dishes like meatloaf with tomato sauce (600-1100), and
  10. Snacks like chips, pretzels etc. (140). 

This helps me talk salt to my patients, informing them that the real salt that one needs to cut is the salt that’s in packaged and processed foods. Feel free to sprinkle that salt on your watermelon! 

Nishant Jalandhara, MD, is a clinical nephrologist practicing in the Greater Fort Worth area. His areas of interest are hypertension and chronic kidney diseases prevention and management with a special emphasis on home dialysis. He graduated from the Texas Medical Association Leadership College in May 2019.  

Photo: Lexlex

Emergency Triage, Treatment, and Transport

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 Since the beginning of Emergency Medical Services (EMS) in the 1960s, ambulances have operated in a “you call, we haul” process. The 1965 Social Security Act included ambulance transportation as a covered benefit, therefore, Medicare pays ambulance providers for transportation to hospital emergency departments, skilled nursing facilities, and dialysis appointments. For years, much of EMS has operated in this model. 


EMS_Blog_VithalaniReports by the National Highway Traffic Safety Administration’s (NHTSA), Emergency Medical Services Agenda for the Future (1996) and EMS Agenda 2050 (2018), detail the necessity for EMS to move away from this practice and develop patient navigation pathways that include treatment in place, as well as transportation to alternative sites of care. Despite this, little has been done nationwide, other than the relatively recent development of Mobile Integrated Healthcare-Community Paramedicine. Much of this lack of movement, however, has been due to dearth of availability of funds for these types of programs.

In 2013, the U.S. Department of Health and Human Services and Department of Transportation released a whitepaper regarding alternative payment models for EMS systems. In it, they outlined various approaches that move away from the current standard not only of EMS payment, but also navigating patients away from emergency departments, estimating an annual savings of $560 million.

ET3 Model

On Feb. 14, 2019, the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare & Medicaid Innovation (CMMI) announced a new payment initiative for EMS – the Emergency Triage, Treat and Transport (ET3) Model. This voluntary alternative payment model will allow ambulance agencies and regional 911 centers to participate in new pathways to treatment for Medicare fee-for-service patients.

Enrolled EMS agencies will be able to develop processes for treating patients in place, after being evaluated by a Medicare-qualified health care professional on scene, or via video telehealth. They also may institute pathways for patients to be transported to locations for care other than a hospital emergency department, such as an urgent care clinic, physician’s office, sobering center, etc. In both instances, EMS would be paid for services they provide.

Local governments, or their designees, that run 911 communication centers will be able to apply to develop and manage processes for medical triage of low-acuity patients. These processes would allow patients the triage and navigation prior to the dispatch of an emergency medical resource, such as an ambulance. For example, patients could be sent to their primary care physician’s office or urgent care center via taxi or ride-sharing services, ordered by the medical triage line at the communication center.

Services will be encouraged to maintain high quality of care, with an additional 5% payment available based on pre-determined quality metrics.

Moving forward

Compared with other CMS/CMMI projects, the timeline for these initiatives is fairly aggressive. CMS will release their Request for Application for ambulance providers in summer 2019, and for local government communication centers in the fall.

Many EMS organizations already have begun developing their planned processes in anticipation of application releases. In one informal poll of social media-active EMS physicians, 16 of 25 (64%) of respondents stated their EMS agency would be applying and already have begun planning to do so. Further, three others (12%) stated they were not planning on applying, with the remaining six (24%) either unsure of their plans or unclear on the details of the ET3 model. In another survey of major metropolitan EMS medical directors (the “Eagles Coalition”) who were asked about planned participation in ET3, 19 (44%) of 43 respondents said their agency is planning on applying for the ET3 program. Another 11 (26%) were “ET3-curious,” and the remaining 13 (30%) were not interested in applying at this time.

There are many more considerations to be had prior to these programs going live. Clinically, agencies must develop processes to appropriately train and credential EMS providers for this new model of health care delivery. Both CMS and individual agencies must develop and begin to measure their outcome- and process-based performance measures to ensure appropriate quality assurance of these programs as they begin.

Operationally, the biggest consideration must be whether to attempt to implement these projects solely for Medicare fee-for-service patients or for all 911 callers. For the latter to be financially feasible, EMS agencies will need to work with other payers to sign agreements mirroring that of ET3; something CMMI states is a primary goal for the model. Further, many EMS agencies do not routinely employ, or have telehealth agreements with, qualified health care professionals other than their EMS medical director, nor is there a standard infrastructure for performing or documenting telehealth visits.


The ET3 Model already has proven to be a groundbreaking leap in the right direction toward aligning EMS as a true part of the health care field. As programs begin and outcomes are measured, hopefully it will be the first steps of many.

Veer Vithalani, MD, is the interim medical director for the Emergency Physicians Advisory Board in Fort Worth, which provides medical direction and oversight to the MedStar Mobile Healthcare System; as well as an attending emergency physician & the EMS director for the JPS Health Network. He is a fellow of the American College of Emergency Physicians and the National Association of EMS Physicians.

Digital Communication Tools Can Help Address Health Care Disparities

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According to the World Health Organization, “the social determinants of health are the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels.” Access to health systems also influence individuals and population.

Health care disparities are seen in chronic medical conditions like heart disease, diabetes, and arthritis in lower socioeconomic populations.

Dr_LincolnRectifying health care disparities is championed by physicians, especially primary care doctors, nurses, social service providers, and other medical professionals through individual and community education and community outreach.

In fact, you do not need to have a medical education to provide outreach – it just requires that you care. There are two primary goals of health equity endorsement: social obligation and benefit to the U.S. economy. As President Franklin Delano Roosevelt said, “The test of our progress is not whether we add more to the abundance of those who have much, it is whether we provide enough for those who have little.”

Addressing the social determinants of health requires thinking in a novel way, as well as a concerted effort of diverse people and stakeholders who have collectively different life experiences.

Some of you are probably wondering how a radiologist like me can play a role in furthering health equity. Information technology is at the heart of radiology’s daily practice, and employing technology through clinical-decision support tools like the Radiology Support, Communication, and Alignment Network (R-SCAN) is where radiology can play a significant role on the health care team.

In radiology, addressing health care disparities means putting special emphasis on reducing unnecessary tests, while generating financial savings. This aligns with one of the aims of the Transforming Clinical Practice Initiative, a Centers for Medicare & Medicaid Services (CMS)-funded program designed to empower clinicians to expand their quality improvement capacity.

R-SCAN is a free, online, informational instrument that cultivates increased communication between radiologists and referring health care providers in advanced imaging appropriateness of patients in both the outpatient and emergency settings.

This online software has an ever-expanding list of Choosing Wisely topics, with the goal of increasing quality of care by removing inappropriate imaging and by decreasing costs to health care systems.

At Baylor College of Medicine’s affiliate institution, Harris Health System, I along with several trainees collaborated with primary care physicians at a few Harris Health outpatient clinics on a low back pain and MRI lumbar spine project. We successfully reduced inappropriate MRI lumbar spine imaging in our patient population. Harris Health is a public health system that serves a population comprised of 59.4% Hispanics and 25.1% African Americans, and in which 60.1% are uninsured and 20.6% are covered by Medicaid.

The family medicine physicians at Harris Health-Baylor College of Medicine were receptive to our overture for constructive collaboration, and thus translated the project into a successful, collaborative, health equity venture. As I think back to my years of radiology training, I recall my mentor, Jacqueline A. Bello, MD, always stating that collaboration with our clinical colleagues is the key to the best outcomes for our patients, and that stays in my heart as I practice radiology today.

Christie M. Malayil Lincoln, MD, is a board certified radiologist with a certificate of added qualification in neuroradiology at the Baylor College of Medicine in Houston. She will graduate from the TMA Leadership College in May 2019.

Help Aging Texans Age Well

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Although Texas’ overall population is among the youngest in the nation, the state also is home to one of the largest older adult populations in the U.S.

Almost 3.5 million Texans are age 65 and older, a number projected to reach 9.4 million by 2050, according to the Texas Demographic Center.

That population, and the role they play in their communities, is celebrated in May during Older Americans Month.

The Texas Health and Human Services Commission’s (HHSC’s) Aging Texas Well initiative has been promoting opportunities for older adults for more than 20 years. The initiative offers a holistic view of issues affecting older adults. This helps the state and its communities prepare for all aspects of healthy aging.

Throughout Older Americans Month, Texas Medicine Today will share information from HHSC to help older Texans live and age well and live independently.

Are you concerned a patient’s social network is shrinking, they’re not getting enough exercise, or they’re at risk of falling? Keep reading these posts to see how you can help older Texans age well.

One common problem that can affect people as they age is social isolation. Loss of social networks can occur over time due to retirement, declining health, or the passing of loved ones.

A recent study found that Medicare spends more on socially isolated older adults than those with larger networks. The study found that spending was comparable to what the program spends on beneficiaries with certain chronic conditions. Isolated older adults were more likely to have multiple chronic illnesses, difficulty performing daily tasks, and a 50% higher mortality risk than non-isolated older adults.

If you’re concerned one of your older patients might be socially isolated, consider suggesting they attend a senior center or participate in Texercise, a group exercise initiative targeted to older adults. 

Many older adults who need care receive it from their family members. Likewise, some older adults become caregivers themselves, providing care to a spouse, a child with a disability, or even grandchildren. Organizations like the Area Agencies on Aging, Aging and Disability Resource Centers, and other community-based social services can provide valuable support services for older adults, their families, and caregivers.

The Age Well Live Well campaign provides people and communities with education on available resources, services, and supports. It also helps organizations begin aging initiatives and encourages communities to proactively plan for their aging population through policy and partnerships.

To learn more, or to educate your older patients about special issues and concerns through fact sheets or brochures, contact Age Well Live Well at (800) 889-8595 or via email.