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

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?

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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.

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New Health Care Technology can “Sniff Out” Asthma

A new machine can “sniff out” asthma, leading to more accurate diagnosis and better health care outcomes.

Those with asthma, and their health care providers, know how drawn out the diagnostic process can be. First come the multiple colds and upper-respiratory infections, then the doctors’ visits and specialist referrals, then a bunch of lung function tests that involved exhaling to the point of passing out. It can take weeks for health care providers to puzzle out a diagnosis, months if you include all those colds and infections the adult-onset patient endures before realizing something more serious is in play.

The days of waiting might be coming to an end. Italian health care researchers have announced the development of an electronic breath-sensor device that may be more accurate in diagnosing new asthma cases than traditional diagnostic tools. The device, which health care researchers have called the “electronic nose,” detected nearly 90 percent of people with asthma compared to about 70 percent who were accurately diagnosed using the more common lung function tests. The “electronic nose” works by identifying certain compounds in a person’s exhaled breath. These compounds produce specific patterns in people with asthma. The Italian health care researchers studied 27 people with mild, allergy-based asthma and 24 healthy people. The research was published in the April issue of the journal Chest.

The “electronic nose” sounds intriguing. Asthma used to be a fairly unusual health care condition that many sufferers eventually outgrew. Not so anymore. The respiratory condition has been building in frequency and durability in recent decades, and ranks as a common ailment. Much of the increase may be environmental; the Rand Corporation has estimated in a different study that air pollution caused nearly 30,000 emergency hospital visits and admissions from 2005 to 2007 in California. Almost eight percent of Americans have asthma, according to the American Academy of Allergy, Asthma & Immunology, so finding a quick and accurate tool to diagnose the condition appears to be a good thing. But the electronic nose is likely a good ways away from appearing in a health care provider’s office near you. The practical costs are not yet known, and it’s not yet clear how well the device could work with people whose asthma isn’t allergy-related.

Don’t even think about trying to diagnose yourself. But if spring-time pollen is delivering some of the typical asthma symptoms below, the good folks at the National Institutes of Health suggest it might be time to talk to your doctor.

• Coughing. Coughing from asthma is often worse at night or early in the morning, making it hard to sleep.
• Wheezing. Wheezing is a whistling or squeaky sound that occurs when you breathe.
• Chest tightness. This may feel like something is squeezing or sitting on your chest.
• Shortness of breath. Some people who have asthma say they can’t catch their breath or they feel out of breath.

Photo Credit: Mark Watson

Unsure about how health reform affects you? Start here

Some great resources exist that make dissecting the health care bill much less intimidating.

If you've been paying attention the last week, you've probably quickly realized that just because health care reform became the law of the land, the myths and misunderstandings about the bill, and how it will affect people's lives, still remain. As the New York Times pointed out, “While some of the more outlandish rumors may dissipate, it is likely that misperceptions will linger for years, hindering substantive debate over the merits of the country’s new health care system. The reasons are rooted in human psychology.” People are inclined to believe things that confirm their already existing views, which is why if someone believes something about the health care bill – true or not – it's difficult to convince him otherwise.

But for people who really want to know what the bill entails, when certain provisions will go into effect and how it will play a role in their personal care, there are good resources out there that are worth seeking out.

Of course, the most official resource is the government itself, and the Department of Health and Human Services will play a key role in informing the public about the bill, and about how to obtain coverage for those who need it. At http://www.healthreform.gov, new updates and news should be available as it happens.

The Kaiser Family Foundation's health reform subsidy calculator is also a great tool. It “illustrates premiums and government assistance provided under the health reform bills originally passed by the House and Senate and the final legislation for people under age 65 who purchase coverage on their own in an Exchange and are not covered through their employer, Medicare or Medicaid.” If you're not receiving health insurance through an employer, it's a good way to get an understanding of how much you're likely to pay through the exchange.

This New York Times graphic is also worth checking out – it is easy to follow and allows for multitude scenarios. Virtually everyone should be able to get a better understanding of how they'll be affected by checking it out.

As with any complex issue, (shameless plug for the journalism profession ahead!) it is a good idea simply to read about the developments every day (or close to it) in a publication you trust. You might not understand each provision, or each story every day, but ultimately you'll be creating for yourself a foundation of knowledge that will build over time.

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Federal health reform has passed. Now, states respond

Some states are suing the federal government over health reform. Others are gutting health care programs for the poor. Seems like everyone’s in on the act.

You know times are strange when state lawmakers eliminate a wildly popular health care program for low-income kids in an election year. But these are extraordinary times, thanks to the political maelstrom of health reform and the financial strain of the recession tail. In Arizona, where former Republican presidential nominee Sen. John McCain is facing a tough primary challenge for re-election, state lawmakers have proposed eliminating the Children’s Health Insurance Program, a safety net for low-income families who can’t afford their own insurance yet earn too much to qualify for standard Medicaid.

Arizona Gov. Jan Brewer (R) has signed a budget that guts the program, which will leave nearly 47,000 low-income children without health care coverage. The state also will roll back Medicaid coverage for childless adults, which is expected to eventually drop 310,000 people from the rolls. Is this a partisan move, a retaliatory response to health reform and a precursor to the stated Republican strategy of “Repeal and Replace?” Brewer has said Arizona’s dire financial straits left no choice but to cut, and she hopes voters will approve a penny increase in the state’s sales tax that could soften those cuts. Indeed, if Brewer’s playing games, she’s likely betting against the house: Arizona could face further loss of federal dollars for failing to maintain a certain level of health care programs for the poor. And that could lead to more, not fewer, uninsured in Arizona despite the health reform law.

Not that (mostly) Republican attorneys general are content to let governors have all the action. More than a dozen GOP AGs and one Dem have signed on to a group effort to challenge the constitutionality of the health reform plan. Many legal scholars don’t give the challenge much of a chance, other than a chance to make a public point. The effort is being led by Bill McCollum, attorney general of my former home state of Florida. The top lawyers for those states claim Congress overstepped its powers to regulate commerce when it declared that every American must have health insurance or else risk federal tax penalties. Insuring the health of one’s one body, they say, is not commerce.

Meanwhile, Indiana Gov. Mitch Daniels (R) has said that his state will eliminate the Healthy Indiana Plan in light of the passage of the health reform bill. Healthy Indiana is a Medicaid waiver plan, the first of its kind to use Medicaid funds to provide a benefit package modeled after a high-deductible plan and health savings account to previously uninsured adults. The state plans to transition the 45,000 low-income residents currently enrolled in the program onto Medicaid, and Governor Daniels has announced he is capping enrollment for the program while the state phases it out. Daniels has been highly critical of the President Obama’s health reform plan, saying it left little room for innovative programs like Healthy Indiana. He has said the health reform bill forced him to dismantle the program.

It will be interesting to see what everything looks like after all the dust is settled. I understand why states are trimming their own programs in light of the passage of health reform. States have long complained about “unfunded mandates” from the feds when it comes to covering low-income Americans, and they will eventually have to chip in for some of the extended Medicaid under the health reform plan. I just hope health reform isn’t ending one “doughnut” hole – the one involving Medicare drug coverage – only to create another: tens of thousands (or more) of people who go uncovered in the time between the elimination of state health care programs and the expansion of federal ones.

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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.

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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.

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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.

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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.

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Some “male enhancement” products can harm your health

Some “all natural” male enhancement products contain undeclared ingredients that can harm your health.

You’ve seen the campy commercials: One member of a golf foursome scores a hole in one. Women at an office party scuffle for a chance to be near that certain man. But public health officials say beware: Many of the so-called all natural male enhancement products contain undeclared ingredients that can harm your health or even kill you. The federal Food and Drug Administration issued yet another warning this week about the products, many of which are sold online. The FDA says that despite its repeated warnings, consumption of these products is increasing – as are the reports of harmful health effects.

Public health officials say many of the products that are supposed to be all natural, dietary supplements actually contain various amounts of the ingredients found in prescription drugs such as Viagra, Cialis and Levitra. Public health officials warn that taking products that contain these kinds of ingredients can be particularly dangerous for people who are also taking prescription drugs that contain nitrates, such as nitroglycerin. That's because they can interact to cause dangerously low blood pressure. Furthermore, people with diabetes, high blood pressure, high cholesterol, or heart disease often take nitrates. And since erectile dysfunction is common in men with these conditions, public health officials say they may seek out these sorts of products.

Rather than classifying these products as a drug – which of course would put them under much closer scrutiny – these products are marketed as “dietary supplements,” which are barely regulated. Plus, as public health officials point out, these so-called supplements are not likely to be made under the same quality controls as prescription drugs, so the identity or the amount of the Viagra-like ingredients could vary greatly. The FDA has actually found the prescription materials in much higher quantities in the so-called all natural products than what a doctor would prescribe in a regulated medication. Many of the male enhancement products that are catching the eye of public health officials are imported from other countries. Numerous shipment have been seized and tested, which is how officials know how much of the prescription medication has been found in the so-called natural products.

While steps have already begun to be taken, these warnings serve as a reminder why we need to beef up regulation of dietary supplements. And while I’m at it, let’s talk about setting real standards for organic foods so that people who are chemically sensitive don’t accidentally ingest harmful contaminants in foods that are supposed to be clean and organic. So many people take different supplements of different varieties in hopes of becoming better, faster, more energetic or simply to destroy free radicals. Yet it’s nearly impossible to know if you are getting the potency the supplement makers claim their product has – or even if it’s advisable to take that level of the vitamin. Please correct me if you disagree, but I have a hard time believing that taking 2,667 times the recommended daily dose of any vitamin or mineral is a good idea. What do you think?

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