Health Care Weekly Updates - Justmeans

Commonwealth Games vs. Common Health goals in India - Ano Lobb

Along with the expected fanfare accompanying the opening of the Commonwealth Games in New Delhi, India this weekend there was a generous serving of controversy. While there are many good reasons for skeptics to raise concerns, this post will briefly consider three: Public health, dengue fever, and malaria.

Bluntly stated, health equals wealth. More specifically, greater inequalities in national distribution of wealth are correlated with worse measures of population health. Rapid economic gains in India have not been shared by all; one telling statistics is that the personal wealth of the richest 49 Indians accounts for a whopping 31% of India's entire gross domestic product, according to the newspaper Financial Express.

Post continues: http://www.justmeans.com/Commonwealth-Games-vs-Common-Health-goals-in-India/33533.html

Race (still) Matters: Innovation needed to tackle health disparities - Ano Lobb

A recent posting looked at a new study of health technology being overused in breast cancer care.  Another study presented this month at the American Association for Cancer Research Conference sheds light on the importance that race plays in health outcomes, regardless of insurance status.

Assistant Professor Heather Hoffman and colleagues from George Washington University's School of Public Health performed a retrospective analysis of 983 women who underwent breast cancer examinations at six hospitals in Washington D.C. They measured diagnostic delay, the span of time between the detection of a breast abnormality and a definitive diagnosis, for women who were white, African American, or Hispanic, stratified by whether they were insured or not.

Post continues: http://www.justmeans.com/Race-still-Matters-Innovation-needed-tackle-health-disparities/33735.html

Is questionable medical information technology putting patients at risk? - Ano Lobb

There's been a lot of good news in cancer care lately: The American Cancer society recently reported a decrease in cancer deaths, medical information delivery harnesses technologies such as interactive patient-information kiosks, and nano-technology verges on a breakthrough for more targeted treatments. All of these, combined with more vigorous prevention and detection efforts and more effective standard treatments has helped to make cancer an increasingly survivable journey.

Technology, however, is not a panacea. A striking example is the increasing usage of computer-aided detection (CAD) for both screening and detection mammography. Rather than depending on the seasoned eyes of radiologists, CAD uses a computer program to analyze radiographic images.

Post continues: http://www.justmeans.com/Is-questionable-medical-information-technology-putting-patients-at-risk/33641.html

The Evolution of Primary Care: Part 4 - Sam Wertheimer

Delivery of primary health care services in the U.S. used to involve a physician and a patient. The physician would see the patient in a clinic, conduct an examination, enter notes in a paper record, prescribe a follow up appointment, and say goodbye until the next scheduled visit. Usually this process occurred within a 15-minute window arranged by the physician's front office staff. Although this type of health care visit still occurs, it is fast becoming an exception to the new rules of primary care. This column, the fourth in a series on the players changing primary care, focuses on non-physician health care providers.

One of the targets of change in the evolution of primary care is the 15-minute visit. This is because many find visits this short do not allow enough time to provide comprehensive health care.

Post continues: http://www.justmeans.com/-Evolution-of-Primary-Care-Part-4/33128.html

Volcanic ash cloud poses no health threat

The volcano that has critically injured the airline industry poses no real threat to human health.

We like to celebrate good health news here at Justmeans, so I’m pleased to say that despite the billion or so dollars that pesky Icelandic volcano has caused the airline industry, it apparently isn’t causing a whole lot of health problems for humans. A report from the World Health Organization (WHO) says that because the bulk of the ash is so high in the atmosphere, it isn’t expected to cause a lot of trouble on the ground - unless winds shift and cause localized, regional problems.

According to the WHO, it’s the size of the particulate matter of the ash cloud that counts. The most dangerous particulates are those that are smaller than 10 microns in size, because they can reach deep into the lungs and embed there. That can potentially cause far-reaching health problems. About one-fourth of all the particulate matter of the Icelandic ash cloud is that small, according to Dr Maria Neira, Director of Public Health and Environment Department at WHO.

Still, the WHO is encouraging people, especially those with chronic respiratory conditions like asthma, emphysema or bronchitis, to keep a close eye on the ash cloud and an ear tuned to their local health authorities. "Since the ash concentration may vary from country to country depending on the wind and air temperatures, our advice is to listen to local public health officials for the best guidance for individual situations," says Neira. "If people are outside and notice irritation in their throat and lungs, a runny nose or itchy eyes, they should return indoors and limit their outdoor activities."

The ash cloud was born last week, when a volcano belched a mass of smoke and ash into the air. That cloud drifted over much of Europe and grounded thousands of flights. Analysis has shown that the ash cloud particles consist mostly of quartz and glass. Health authorities have also found aluminium, silica and oxygen, as well as some fluoride.

Officials with the World Health Organization say the concentration of particles that may reach ground level is likely to be low and should not cause serious harm. Most of the ash that might reach the ground is likely to be too big to inhale into the lungs, but could irritate eyes, nose and throat. Remaining indoors will diminish the risk of these symptoms, since closed doors and windows will partly prevent penetration of the larger, irritating particles inside buildings. How has the ash cloud affected you?

Photo Credit: NASA Goddard

Doctors, hospitals slow to make “meaningful use” of electronic health records

Physicians have been slow to adopt the “meaningful use” of electronic health records required for incentives.

Despite billions of dollars in incentives for doctors and hospitals to adopt electronic heath records, researchers have found that actual, authentic and effective use of the records remains in its infancy. While a significant number of hospitals and doctors have made the upfront investment in electronic health records, they have been slower to use them in a way that translates into greater efficiency and improved health outcomes, the study’s authors found. For example, researchers found that the use of electronic health records to date have not led to improvements in patient mortality, surgical complications, nor length of stay and costs.

"We are still in the early days of electronic health record adoption, and there's little evidence for how best to implement the technology to make the greatest gains," study leader Catherine DesRoches, of the Mongan Institute, said in a statement. "Hospitals may not see the benefit of these systems until they are fully implemented, or it may take many years for benefits to become apparent." The study was published in the April issue of the journal Health Affairs.

The researchers analyzed data collected from 3,000 hospitals that responded to a 2008 survey of acute care hospitals belonging to the American Hospital Association. The health care institutions were asked whether they had put computerized systems in place for different functions, including medication orders, lab reports, specimen tracking and discharge summaries. What they found was that even among health care providers and facilities that invested in electronic health record software, not all were using their systems well.

Public health officials need to pay attention to this survey. The 2009 American Recovery and Reinvestment Act authorized approximately $30 billion in grants and incentives to support electronic health record adoption. Health care providers could receive bonuses through Medicare and Medicaid if they demonstrate "meaningful use" of electronic health records. Public health officials then had to define what "meaningful use" constituted, as they have begun to do.

But they’ll have to do more to get doctors and hospitals to really use the electronic health records. In addition to letting doctors know what meaningful use of the records is, public health officials may have to offer training. It does little good to offer incentives if those incentives aren’t translating into greater efficiencies and greater training. What suggestions do you have?

Photo Credit: npslibrarian

Protecting your health involves speaking up

Communicating effectively with your doctor could make all the difference.

Each day brings with it news about how people can protect their health - whether it's drinking more coffee (or less, depending on the survey), consuming less salt, getting more exercise, getting preventative screenings for certain diseases, etc. But a couple recent health-related articles reminded me that sometimes, the best tools for protecting one's health can be your own intuition and your own voice. Patients sometimes believe that so long as you tell a doctor what their major symptoms are, the rest will sort itself out. That's not necessarily true.

In the New York Times, one writer reports on a recent New England Journal of Medicine piece in which a doctor argues that "doctors, researchers, drug makers and regulators should pay more attention to patients’ firsthand reports of their symptoms while they take medicines, because their information could help to guide treatment and research, and uncover safety problems." The story goes on to detail how clinical phases of trials for new drugs - and sometimes even doctors and nurses themselves - don't give enough weight to patients' symptoms, concerns, complaints, etc. Sometimes this happens because patients don't speak up enough, or perhaps lie altogether out of shame or embarrassment over what's really going on with their bodies. But just as often it's likely because doctors get caught up and don't take the time to really listen, or delve into how a patient's symptoms are really affecting him or her.

The article nicely complemented another piece in the Los Angeles Times urging both doctors and patients to make an effort to communicate more effectively. It explained how certain circumstances likebeing upset at being made to wait, short appointments, or feeling like they're not getting enough attention on the patients' side; and having to deal with strong or unruly personalities, or patients who unnecessarily take up too much time by going off on tangents or focusing on details that don't matter on the doctors' sides, can hamper communication between the parties. Among the advice doled out to both sides, the author offered: "Physicians need to be willing to work collaboratively with patients, but patients need to carry out their end of the bargain. It's up to patients to follow through with the advice they're given. No one can take their medications for them or make the lifestyle changes necessary for good health in their stead."

It's just another good reminder that when it comes to your own health, you are responsible for voicing your pains, concerns and symptoms clearly, respectfully and reasonably.

Photo credit: U.S. Navy

Health decision making: New cancer treatment findings

Several interesting studies being presented at the European Breast Cancer conference in Spain are highlighting the difficulties that many women face when trying to decide on the appropriate course of treatment, prevention, or screening.

The decision can be especially challenging for women who have tested positive for mutations in the “breast cancer genes,” known as BRCA1 and BRCA2. Such women face a 55% to 85% chance of developing the cancer sometime in their life. These genetic mutations are inherited, and many women with a long list of female relatives who have suffered from the cancer choose radical preventive approaches, such as prophylactic mastectomy, or removal of one or both healthy breasts, either before a first incident of cancer, or to prevent a recurrence. This is based on the assumption that removing healthy tissue will reduce the risk of new or recurrent cancer.

Two new studies looked at prophylactic mastectomy of the healthy breast in women recovering from the cancer, who had BRCA1/2 mutations. After following 138 women who opted for risk reducing mastectomies, and comparing them to 210 similar women who opted for routine surveillance without the operation, researchers found no difference in overall survival. In other words, women who opted for risk-reduction surgery did not live longer or die of cancer less frequently than those who did not have surgery.

The second study looked at the chances of cancer recurrence in women who opted for total mastectomies compared to less radical “breast conserving treatment,” or BCT. After 15 years, 23.5% of women who chose BCT had a second bout of cancer, compared with only 5.5% of women who opted for total mastectomy. However, women receiving adjuvant chemotherapy along with BCT had no greater risk than the mastectomy group. The researchers concluded that BCT with chemotherapy is a sensible option for women who do not want to undergo total mastectomy.

A third study being presented underlines the importance of clear risk communication to those suffering from or at risk of developing cancer. In a small study of 27 women being treated for cancer in one breast, a British surgeon reports that women who chose prophylactic mastectomy of their healthy breast did so, at least in part, because they overestimated the risk of developing future cancer by up to ten times. A small study for sure, and with not entirely unexpected results, but an important reminder that risk communication is both difficult, and important in helping patients decide which course of treatment is best.

Photo credit: The author

Gay patients sometimes excluded from clinical health trials

A portion of the population could have health issues that are being ignored.

There are, unfortunately, many corners of our society that still exclude people who are gay. In most states, gay couples cannot marry; gay people cannot serve openly in the military, and some states even go as far as excluding gays from being able to adopt children. But scientists and doctors are now fearing that another type of exclusion is taking place - one that could have effects on those people’s health and wellness: clinical trials that examine diseases, drugs and medical treatments.

A letter published recently in the New England Journal of Medicine showed that 37 of 243 clinical trials studied that dealt with couples and sexual function barred people who were in same-sex relationships. Researchers at the Fox Chase Cancer Center in Pennsylvania who conducted the study worry that gay patients are routinely excluded from other studies as well, such as ones that study depression [http://www.justmeans.com/Is-Optimism-in-Young-Adults-Harmful-Mental-Health/7945.html] or cancer.

Doctors hoping to create a clinical trial to study a drug often develop a target demographic of people who are a certain age, have a certain disease, or participate in a certain kind of behavior associated with the drug in order to narrow down those who’d be most likely to use, and benefit from, the drug. It’s a vital element to creating a clinical trial. But if doctors, for whatever reason, universally exclude gay participants, then a whole segment of the population will inevitably have health issues that aren’t addressed or uncovered in such trials.

Brian Egleston, Michael J. Hall, and Roland Dunbrack wrote that not all clinical trials use exclusionary language, and that often, gay and lesbian patients might not even be aware that they’re missing out on certain trials:

“To ensure that we did not miss a general pattern of exclusionary language, we also examined eligibility criteria in 1019 studies that we identified by using the search term ‘asthma.’ Exploratory searches indicated that such studies did not have high rates of exclusionary language, and indeed, no asthma trials were found to exclude lesbians and gay men. However, we incidentally found a clinical trial of attention deficit–hyperactivity disorder that required that participants be ‘in a reciprocal relationship with a person of the opposite sex.’

Our results indicate that exclusion of lesbians and gay men from clinical trials in the United States is not uncommon, particularly in studies with sexual function as an end point. It is likely that most gay and lesbian patients are unaware that their sexual orientation is being used as a screening factor for participation in clinical trials. Researchers should be held to careful scientific reasoning when they develop exclusion criteria that are based on sexual orientation.”

Photo credit: Tom Varco

Health news: Media covers cancer stories poorly

Don’t get me wrong, I prefer good health news. Its much more inspiring to hear of innovation, burgeoning cures, survival, getting better, being healthy. But in addition to shades of grey, health news is black and white: With the good news comes bad, the possibility of dying or being plain miserable.

The news media isn’t so good about covering that bad news when it comes to cancer. That’s the conclusion of a new paper in the Archives of Internal Medicine that analyzed 2228 cancer stories from 436 randomly selected American newspapers and magazines. Most articles focused on breast (35%) or prostate (15%) cancers, the most common gender-specific cancers in women and men, 20% addressed cancer more broadly. While interest in cancer is likely motivated by our fear of dying from it, only 7.6% of stories focused on death, while 32% were about survival and being cured, and only 2.3% dealt with survival and death. .

"It is surprising that few articles discuss death and dying considering that half of all patients diagnosed as having cancer will not survive," the authors write. "The findings are also surprising given that scientists, media critics and the lay public repeatedly criticize the news for focusing on death."

Stories of treatment and survival are certainly more uplifting, but even there most failed to provide the whole story: 57% focused on aggressive treatments, but only 13% mentioned that they’re not always successful or that some cancer is incurable. Adverse events of treatments, such as pain, nausea, and hair loss, where mentioned in 30% of stories. End of life (palliative) care was seldom covered: 0.5% of stories focused on it exclusively, and 2.5% mentioned it along side discussions of aggressive treatments.

It’s tempting to over-simplify health stories, assuming that a condition is treatable in all people who undergo a certain treatment for a certain amount of time. But it’s almost always more complicated than that. With cancer in particular, death is often a very real possibility, and while we try desperately to avoid death, it’s not a “bad” thing. Its part of the story of those things we call cancer.

Telling the whole story about health and disease is not just a hallmark of good journalism, it’s part of the larger picture of ethical, patient-centered health care. Over the years we’ve grown accustomed to waging “war” against cancer, where death equals defeat. And in war its considered poor form to plan for defeat. But cancer isn’t an enemy, and treatment isn’t war. We do our best to cure people, but must also be aware that some cancers aren’t curable, and sometimes the best treatment is to stop combating the cancer and focus on controlling symptoms, managing pain, coming to terms with mortality, and letting the natural progression of disease take its course. That’s not failure, that’s not defeat, it is part of being human. It’s also what palliative care provides, and it all begins, I believe, with telling the full story about cancer, health, life, and death.

Photo credit: The author

Erectile dysfunction predictor of health, and death

Erectile dysfunction is more than an issue of sexual health. It is a strong predictor of death and cardiovascular health.

We’ve been lulled by the commercials into believing that erectile dysfunction is a mere annoyance, a minor blip on the sexual health screen that can be easily remedied by a pill in various convenient dosing options. But researchers warn that those sultry, idyllic, twin-bathtub-in-the-middle-of-nowhere images mask more sinister health threats associated with erectile dysfunction (ED). In fact, ED is a strong predictor of death from all causes and of heart attack, stroke and heart failure in men with cardiovascular disease, German researchers reported this month in Circulation: Journal of the American Heart Association.

Researchers found that men with cardiovascular disease and erectile dysfunction (compared to those without ED) were twice as likely to suffer death from all causes and 1.6 times more likely to suffer the composite of cardiovascular death, heart attack, stroke and heart failure hospitalization. More specifically, they were:

• 1.9 times more likely to die from cardiovascular disease;
• twice as likely to have a heart attack;
• 1.2 times more likely to be hospitalized for heart failure;
• 1.1 times more likely to have a stroke.

As if that weren’t bad enough, researchers said, too many men with ED don’t realize how poor their heart health is and how great their risk of death is because they don’t know they also have cardiovascular disease. They don’t learn of the other condition because they are successfully treated for erectile dysfunction by their primary health care provider or urologist. They aren’t referred to a cardiologist for an evaluation until their cardiovascular disease is advanced.

“Men with ED going to a general practitioner or a urologist need to be referred for a cardiology workup to determine existing cardiovascular disease and proper treatment,” study author Michael Böhm, M.D., lead author of the study and chairman of internal medicine in the Department of Cardiology and Intensive Care at the University of Saarland, Germany, said. “ED is an early predictor of cardiovascular disease.” Usually, though, that doesn’t happen, especially if the ED treatment was successful. “The medication works and the patient doesn’t show up anymore,” Böhm said. “These men are being treated for the ED, but not the underlying cardiovascular disease. A whole segment of men is being placed at risk.”

The study is an important reminder of how inter-related health conditions can be. Neglect one aspect of your health, and you may unwittingly make another worse. More importantly, too many people diagnosed with Condition A don’t realize their diagnosis puts them at significant risk for developing Condition B. While the link between ED and heart disease seems logical – both involve blood vessels, for instance – that’s not true for all linked conditions. Asthma and depression, for example. Some linkages may seem downright counter-intuitive, so it’s important to be an informed health care consumer.

Gentlemen, that goes for you: If you have ED, ask your doctor if a cardio workup is right for you.

Photo Credit: taberandrew

Depressed parents can pass on mental health problems to kids

Kids with depressed parents often have anxiety issues; but studies show therapy helps.

Anyone who has ever flipped on a TV can tell you that depression is everywhere - commercials touting various anti-depressants emphasize the need to treat depression right away, lest it take an increasing toll on one’s life. Some drugs also play up the physical harm depression can create, manifesting itself in various aches and pains.

Indeed, researchers are now delving into the effects depression has on children who grow up with a depressed parent. It’s been a bourgeoning area of research for the last couple decades, and the Los Angeles Times reports that “evidence is mounting that growing up with a depressed parent increases a child's risk for mental health problems, cognitive difficulties and troubled social relationships.” One study found that depression in mothers can affect infants – they were found to cry more often. The effects can linger in kids as they grow up, too: Other studies have found that kids with depressed parents often have greater anxiety levels.

While postpartum depression can obviously play a big role in mother-child interactions, recent studies have found that depression in either parent can cause behavioral or mental health problems in children. One study, led by Vanderbilt University researcher Judy Garber, found that kids who have a depressed parent are at greater risk for having trouble in school, and for substance abuse and suicide. Of the 316 students who were the focus of Garber’s study, all of them said they had either experienced symptoms of depression in the past, or at the time the study began. Half of the teens were sent to group therapy sessions; and those teens reported fewer signs of depression after eight weeks.

A similar study by Johns Hopkins Children’s Center placed kids of depressed parents ages 7 to 12 in an eight-week course of behavioral therapy, and those children showed no signs of emerging anxiety problems a year later. But of the kids in a comparison group who did not receive therapy, 30 percent did get diagnosed with anxiety disorders. Though therapy has been shown in multiple studies to ward off or lessen depression and anxiety in children and teens, not many health insurance companies cover such treatments. But perhaps as health care reform inches closer to reality, and as continuing studies reveal the effectiveness of such programs, behavioral health therapy treatments will eventually become more readily available.

Photo credit: Hendrike

Childhood vaccines protect even the unvaccinated

Giving children the flu vaccine can protect the wider community, study finds.

It’s obvious that giving a child the flu vaccine will protect him or her from the influenza. But a new study suggests the benefit of vaccinating children can extend well beyond the youngsters themselves. Results of a clinical trial conducted in a largely self-contained religious community during the 2008-09 flu season show that vaccinating children against the seasonal flu can significantly protect unvaccinated community members as well. The study was conducted to determine if children who received the vaccine could act as a barrier to limit the spread of the flu to the wider, unvaccinated community, a concept known as “herd immunity.”

According to the National Institutes of Health, researchers recruited volunteers from 46 Canadian Hutterite religious colonies that have limited contact with surrounding, non-Hutterite populations. (Hutterite communities have a lifestyle similar to the Amish and Mennonites). Of the close to 1,000 children participating in the study, roughly half were given the flu vaccine, while the other half were give the hepatitis A vaccine, which served as the control. The researchers found that the flu vaccine was 61 percent effective at indirectly preventing illness in unvaccinated people if they lived in a colony where approximately 80 percent of the children had received the flu vaccine.

The researchers further suggested that giving school-aged children the flu vaccine could be an effective way to stop the spread of the flu. In a statement provided by the National Institutes of Health, the researchers wrote “it may be advantageous to selectively immunize children in order to reduce community transmission of influenza.”

It’s not clear if the study gives license to assert the converse: Not giving your child the flu vaccine can actually harm others. But it’s certainly something to think about. I’m not ready to require that parents go out and get the flu vaccine for their kids as a requirement to attend public school. I do wonder if that might someday be the case for the swine flu, which cut a respectable swath of school closings across New York City last year. (In an open letter earlier this year to health care providers across the country, federal Commissioner of Food and Drugs Margaret A. Hamburg warned doctors of a “significant” chance that the swine flu will return later this flu season after showing recent signs of waning). We certainly do require other vaccines in order to attend school, despite some lingering fears among parents of their safety. In any case, I will take the opportunity here to suggest that taking care of yourself, which can include getting yourself vaccinated against the flu, is an act you owe not only yourself, but others in our society as well. I don’t want to legislate healthful habits, but I also think there’s something to be said for keeping healthy as a means of reducing health care costs and increasing productivity.

What do you think?

Photo Credit: UNICEF Sverige

Health care imaging that’s costly, risky, and overused

The FDA has recently gone on the offensive against the overuse of health care imaging scanners such as CTs and MRIs, which can lead to unnecessarily high doses of radiation. While emphasis was placed on the responsibilities of device manufacturers to ensure safe usage of their products, and calling on the patients not to insist on imaging over their doctor’s protests, little emphasis was placed on perhaps the most important performer in the medical choreography that results in an imaging test: the physician. Doctors are, after all, the ones who order such procedures.

Now a new publication is calling for more rational use of imaging technology, and using the compelling example of pelvic and lower abdominal pain in women to make the case. Even though the standard means of visually evaluating female pelvic conditions is the ultrasound, CT scanners are increasingly being used. In addition to providing a massive dose of potentially cancer-causing radiation, CTs are vastly more expensive than ultrasound, which carries no cancer risk since it uses sound waves to create images. A further irony is that CTs frequently need to be followed up with ultrasound to confirm a potential diagnosis.

Harvard doctor Beryl Benacerraf, who wrote the commentary, calls on his fellow clinicians for a more rational use of imaging. Why, after all, choose the most expensive, less accurate option that carries health risks, when a cheaper, more reliable, and risk free alternative is available?

On a policy level, this is the type of physician behavior contributing to the paradigm that has emerged over 3 decades of health services research showing that regions of the United States that treat patients with more imaging, more procedures, and longer hospital stays, actually have worse outcomes, even when you control for the health of their populations. And they also spend significantly more. On an individual level, it’s compelling evidence for patients not to insist on imaging or testing when your doctor recommends against it.

Photo credit: The author