My Return to Health Blogging

This is my first post here in a year and a half. The reason is that in the interim, I’ve moved from Kansas to Portland, Oregon, to take a position as director of the Master of Science in Human Nutrition and Functional Medicine program at the University of Western States. This has been a very satisfying and exceptionally busy period for me.

I look forward to commenting on health news here on a regular basis once again.

Thanks to everyone who has urged me to return to writing on a regular basis. Since we’ve just hired an excellent Associate Director for my program, it looks like I’ll be able to do that.

Atul Gawande: Health Reform Update

Atul Gawande is a medical physician in Massachusetts whose work on implementing checklists before surgery has saved countless lives worldwide and will save countless more. He is among the most perceptive writers on the American healthcare system.

This is the best short summary I’ve seen of what to expect in the next several months in the politics of health reform.

The law’s actual manifestation, however, is rather anodyne: as of October 1st, healthcare.gov is scheduled to open for business. A Web site where people who don’t have health coverage through an employer or the government can find a range of health plans available to them, it resembles nothing more sinister than an eBay for insurance. Because it’s a marketplace, prices keep falling lower than the Congressional Budget Office predicted, by more than sixteen per cent on average. Federal subsidies trim costs even further, and more people living near the poverty level will qualify for free Medicaid coverage.

How this will unfold, though, depends on where you live. Governors and legislatures in about half the states—from California to New York, Minnesota to Maryland—are working faithfully to implement the law with as few glitches as possible. In the other half—Indiana to Texas, Utah to South Carolina—they are working equally faithfully to obstruct its implementation. Still fundamentally in dispute is whether we as a society have a duty to protect people like Paul Sullivan. Not only do conservatives not think so; they seem to see providing that protection as a threat to America itself.

Obstructionism has taken three forms. The first is a refusal by some states to accept federal funds to expand their Medicaid programs. Under the law, the funds cover a hundred per cent of state costs for three years and no less than ninety per cent thereafter. Every calculation shows substantial savings for state budgets and millions more people covered. Nonetheless, twenty-five states are turning down the assistance. The second is a refusal to operate a state health exchange that would provide individuals with insurance options. In effect, conservatives are choosing to make Washington set up the insurance market, and then complaining about a government takeover. The third form of obstructionism is outright sabotage. Conservative groups are campaigning to persuade young people, in particular, that going without insurance is “better for you”—advice that no responsible parent would ever give to a child. Congress has also tied up funding for the Web site, making delays and snags that much more inevitable.

Some states are going further, passing measures to make it difficult for people to enroll. The health-care-reform act enables local health centers and other organizations to provide “navigators” to help those who have difficulties enrolling, because they are ill, or disabled, or simply overwhelmed by the choices. Medicare has a virtually identical program to help senior citizens sort through their coverage options. No one has had a problem with Medicare navigators. But more than a dozen states have passed measures subjecting health-exchange navigators to strict requirements: licensing exams, heavy licensing fees, insurance bonds. Florida has attempted to ban them from county health departments, where large numbers of uninsured people go for care. Tennessee recently adopted an emergency rule declaring that anyone who could be described as an “enrollment assister” must undergo a criminal background check, fingerprinting, and twelve hours of course work. The hurdles would hamper hospital financial counsellors in the state—and, by some interpretations, ordinary good Samaritans—from simply helping someone get insurance.

This kind of obstructionism has been seen before. After the Supreme Court’s ruling in Brown v. Board of Education, in 1954, Virginia shut down schools in Charlottesville, Norfolk, and Warren County rather than accept black children in white schools. When the courts forced the schools to open, the governor followed a number of other Southern states in instituting hurdles such as “pupil placement” reviews, “freedom of choice” plans that provided nothing of the sort, and incessant legal delays. While in some states meaningful progress occurred rapidly, in others it took many years. We face a similar situation with health-care reform. In some states, Paul Sullivan’s fate will become rare. In others, it will remain a reality for an unconscionable number of people. Of some three thousand counties in the nation, a hundred and fourteen account for half of the uninsured. Sixty-two of those counties are in states that have accepted the key elements of Obamacare, including funding to expand Medicaid. Fifty-two are not.

 

Prescription Opioid Overdose Deaths in Women Increase Five-Fold in Ten Years

This is a most alarming story

The number of women dying from overdoses of opioid painkillers increased 5-fold between 1999 and 2010, according to new data released today by the US Centers for Disease Control and Prevention (CDC).

The problem of prescription opioid drug overdoses in women is “getting worse and getting worse quickly,” CDC director Tom Frieden, MD, MPH, said during a media briefing.

Deaths due to opioid drugs have “skyrocketed in women; mothers, wives, sisters, and daughters are dying from overdoses at rates we have never seen before,” he noted.

“The increase in opioid overdoses and opioid overdose deaths is directly proportional to the increase in prescribing of painkillers.” Opioid prescriptions are “increasing to an extent that we would not have anticipated and that could not possibly be clinically indicated,” Dr. Frieden added.

Diet Sodas Linked to Type 2 Diabetes Risk

The American Diabetes Association, without endorsing artifically sweetened sodas as a health food, has long recommended them in preference to the sugar- or high fructose corn syrup-sweetened variety.

This study may tip the balance away from diet sodas. The best answer, of course, is to avoid both.

Here’s the abstract, posted January 30, 2013 on the American Journal of Clinical Nutrition.

BACKGROUND: It has been extensively shown, mainly in US populations, that sugar-sweetened beverages (SSBs) are associated with increased risk of type 2 diabetes (T2D), but less is known about the effects of artificially sweetened beverages (ASBs). OBJECTIVE: We evaluated the association between self-reported SSB, ASB, and 100% fruit juice consumption and T2D risk over 14 y of follow-up in the French prospective Etude Epidemiologique aupres des femmes de la Mutuelle Generale de l’Education Nationale-European Prospective Investigation into Cancer and Nutrition cohort. DESIGN: A total of 66,118 women were followed from 1993, and 1369 incident cases of T2D were diagnosed during the follow-up. Cox regression models were used to estimate HRs and 95% CIs for T2D risk. RESULTS: The average consumption of sweetened beverages in consumers was 328 and 568 mL/wk for SSBs and ASBs, respectively. Compared with nonconsumers, women in the highest quartiles of SSB and ASB consumers were at increased risk of T2D with HRs (95% CIs) of 1.34 (1.05, 1.71) and 2.21 (1.56, 3.14) for women who consumed >359 and >603 mL/wk of SSBs and ASBs, respectively. Strong positive trends in T2D risk were also observed across quartiles of consumption for both types of beverage (P = 0.0088 and P < 0.0001, respectively). In sensitivity analyses, associations were partly mediated by BMI, although there was still a strong significant independent effect. No association was observed for 100% fruit juice consumption. CONCLUSIONS: Both SSB consumption and ASB consumption were associated with increased T2D risk. We cannot rule out that factors other than ASB consumption that we did not control for are responsible for the association with diabetes, and randomized trials are required to prove a causal link between ASB consumption and T2D.

Fagherazzi G, Vilier A, Saes Sartorelli D, Lajous M, Balkau B, Clavel-Chapelon F. Consumption of artificially and sugar-sweetened beverages and incident type 2 diabetes in the Etude Epidemiologique aupres des femmes de la Mutuelle Generale de l’Education Nationale-European Prospective Investigation into Cancer and Nutrition cohort. Am J Clin Nutr. Jan 30 2013.

Meat Industry Now Consumes 4/5 of Antibiotics

Option A is to limit use of antibiotics to animals who are actually sick. Option B is for people to stop eating meat. The U.S. has chosen Option C, at least thus far, which is to look the other way and let the antibiotic-resistant organisms proliferate.

This will not end well unless the policy changes in substantial ways soon.

From a Mother Jones article by Tom Philpott:

Last year, the Food and Drug Administration proposed a set of voluntary “guidelines” designed to nudge the meat industry to curb its antibiotics habit. Ever since, the agency has been mulling whether and how to implement the new program. Meanwhile, the meat industry has been merrily gorging away on antibiotics—and churning out meat rife with antibiotic-resistant pathogens—if the latest data from the FDA itself is any indication.

The Pew Charitable Trusts crunched the agency’s numbers on antibiotic use on livestock farms and compared them to data on human use of antibiotics to treat illness, and mashed it all into an infographic, which I’ve excerpted below. Note that that while human antibiotic use has leveled off at below 8 billion pounds annually, livestock farms have been sucking in more and more of the drugs each year—and consumption reached a record nearly 29.9 billion pounds in 2011. To put it another way, the livestock industry is now consuming nearly four-fifths of the antibiotics used in the US, and its appetite for them is growing.

Pew Charitable Trusts.
h/t Diane V Gandee Sorbi

 

CFO Magazine Urges Fortune 500 Firms to Explore Cost Savings Via Alternative and Integrative Medicine

A fine article by John Weeks at Huffington Post, well worth reading in its entirety.

CFO Magazine would seem an unlikely source of cheerleading for more inclusion of complementary and integrative medicine practices and providers into U.S. health care delivery. Yet the magazine that targets chief financial officers (CFOs) of Fortune 500 firms has been shaking those pom poms in recent months.

There is a smart economic alignment that connects these stakeholders at the economic hip. They may even be a perfect marriage, as one writer recently put it.

An October CFO Playbook on Health Care Cost Management webinar featured the medical doctor who chairs the most significant lobbying group for integrative health care, the Integrative Healthcare Policy Consortium. The presentation from Leonard Wisneski, M.D., was assertively titled “Integrative Medicine: The Future of Health Care Delivery.” Wisneski, a former medical officer for a large employer, urged extensive piloting of integrative approaches for their cost-saving possibilities.

Early efforts to integrate complementary and alternative medicine therapies and practitioners with conventional delivery — later called integrative medicine — taught us a hard lesson. Hospitals weren’t going to make money with “CAM” the way they do with high-priced services like interventional cardiology.

Rather, the big money in complementary and integrative medicine fields and their preventive and health promoting focus that CFO Magazine’s McCann notes is not in churning services. It is in saving money by limiting services. Use of lucrative interventional cardiology services may be reduced. Hospital business models typically don’t like this. Employer business models do.

Pediatricians Say to Minimize Pesticide Exposure

Good for the American Academy of Pediatrics. I am not aware of previous instances where a group representing the medical establishment has advocated for this.

Children should have as little exposure to pesticides as possible, the American Academy of Pediatrics urged.

A policy statement and technical report from the organization outlined steps for pediatricians to identify pesticide poisoning, evaluate for pesticide-related illness, provide appropriate treatment, and help prevent unnecessary exposure and poisoning.

“Children encounter pesticides daily and have unique susceptibilities to their potential toxicity,” James Roberts, MD, MPH, and colleagues wrote in the December issue of Pediatrics.

Household insecticides, pet flea and tick chemicals, and agricultural pesticide residues are all hazards but may not constitute the biggest impact.

“For many children, diet may be the most influential source,” the statement noted.

It pointed to an organic food intervention study that cut pesticides out of the diet, which showed “drastic and immediate decrease in urinary excretion of pesticide metabolites.”

Flaxseeds Help Hypertension

Great news from a study in Cuba presented at the meeting of the American Heart Association:

Adding flaxseed to the diets of patients with peripheral arterial disease (PAD) resulted in large drops in blood pressure (BP) of around 10 mm Hg systolic and 7 mm Hg diastolic after six months, according to the results of a double-blind, placebo-controlled study.

“This reduction of SBP and DBP after administration of dietary flaxseed is the largest decrease in BP ever shown by any dietary intervention,” said Dr Delfin Rodriguez (University Hospital Holguin, Cuba) speaking here today at the American Heart Association 2012 Scientific Sessions. Such reductions would be expected to result in around a 50% fall in the incidence of stroke and a 30% reduction in MI, he added.

 

Where the Affordable Care Act Goes from Here

Since the Supreme Court’s decision earlier this year declared the law to be constitutional, the next big hurdle was the November election. If Republicans had taken the White House, it would have been repealed. That’s not happening.

But what is happening? Here’s a helpful commentary from Christene Vessel in Health Affairs:

President Obama’s re-election puts the Affordable Care Act on firm ground for the first time since it was enacted. Now it is up to states to decide whether and how they want to participate.

At issue are two major decisions: whether states are willing and able to run their own health insurance exchanges, and whether they will consent to expanding their Medicaid programs to everyone with an income up to 133 percent of the federal poverty line, as envisioned in the law.

Most Democratic-led states are expected to fully participate in both, although some may seek flexibility. But among the 30 states that will be run by GOP governors starting next year, it is unclear how many will opt in. Many predict that the federal government’s offer of covering the full cost of the Medicaid expansion for the first three years, and 90 percent after that, will be too rich for states to refuse.

The first order of business is committing to running an exchange, entering a partnership with the federal government or opting out altogether. That decision is due next Friday, November 16. For some Republican-led states that have put off the uncomfortable decision to implement a law they oppose, a state-run exchange may no longer be an option.

So far, no deadline has been set for a decision on expanding Medicaid, but states can be expected to address the issue sooner rather than later. When state legislatures open next year, Medicaid expansion will be at the top of most agendas. Meanwhile, states will be carefully watching to see how much the federal government decides to reduce its share of Medicaid funding when a final deficit reduction law is enacted in January.

“Antibiotic Stewardship” Program Helps Pediatricians Cut Off-Guideline Antibiotic Use

This needs to spread across the medical profession and across the nation.

A program of education and feedback for pediatricians cut inappropriate antibiotic use by about half, a researcher reported here.

In a cluster-randomized trial, the off-guideline use of broad-spectrum antibiotics for acute respiratory infections fell 48% in nine practices that got the intervention, according to Jeffrey Gerber, MD, of the Children’s Hospital of Philadelphia.

In contrast, the use of broad-spectrum drugs in nine control practices fell by 18%, Gerber told reporters at the IDWeek meeting here.

While so-called antibiotic stewardship programs have been successful in hospitals, Gerber said, most antibiotics are prescribed in an outpatient setting, especially for children.

“It made sense to see if we could extend some of these principles to the outpatient setting,” Gerber said.

The Children’s Hospital of Philadelphia, he noted, is associated with 29 pediatric practices that share a common electronic health records system. He and colleagues recruited 18 of them, including 174 clinicians, to take part in the trial.

Practices in the intervention arm got an education session with Gerber or a colleague to discuss guidelines for three diseases – sinusitis, group A streptococcal pharyngitis, and pneumonia – that are best treated, according to guidelines, with narrow-spectrum drugs.