Posts Tagged ‘New England Journal of Medicine’

Drinking Coffee Can Make You Live Longer

Wednesday, May 30th, 2012

A recent study of the link between drinking coffee and mortality suggests that latte lovers have a lower risk of death. “I would say it offers some reassurance to coffee drinkers,” said Neal Freedman, a nutritional epidemiology researcher at the National Cancer Institute (NCI).  “Other studies have suggested a higher risk of mortality with coffee drinking and we didn’t see that in our study.”

Men whose coffee intake was at least six cups a day had a 10 percent lower chance of dying during the 14-year study period than those who drank none.  For women, the risk was reduced by 15 percent, according to Freedman’s work, published in the New England Journal of Medicine.  Approximately 64 percent of American adults drink coffee every day, according to Joe DeRupo, spokesman for the National Coffee Association.  At an average of 3.2 cups each, that amounts to 479 million cups a day.  Coffee lovers can take the new results seriously.  The mortality reduction is modest but solid, Freedman said.

Freedman and his team in NCI’s Division of Cancer Epidemiology and Genetics examined the coffee habits of more than 402,000 people between 1995 and 2008, including more than 52,000 who died.  They included approximately 229,000 men and 173,000 women ages 50 to 71 who participated in the NIH-AARP Diet and Health Study, which tracked comprehensive lifestyle questionnaires.  Freedman’s analysis centered on healthy people; anyone with cancer, heart disease or who had suffered a stroke was excluded from the review.  “We didn’t know what to expect,” said Freedman.  “There have been a lot of studies and the results have been mixed.”

There’s been concerns for a long time that coffee might be a risky behavior,”  said Freedman, who drinks coffee ‘here and there.’ “The results offer some reassurance that it’s not a risk factor for future disease.”

Writing in Time, Marilynn Marchione said that “No one knows why.  Coffee contains a thousand things that can affect health, from helpful antioxidants to tiny amounts of substances linked to cancer.  The most widely studied ingredient — caffeine — didn’t play a role in the new study’s results.  It’s not that earlier studies were wrong.  There is evidence that coffee can raise LDL, or bad cholesterol, and blood pressure at least short-term, and those in turn can raise the risk of heart disease.  Even in the new study, it first seemed that coffee drinkers were more likely to die at any given time.  But they also tended to smoke, drink more alcohol, eat more red meat and exercise less than non-coffee-drinkers.  Once researchers took those things into account, a clear pattern emerged: Each cup of coffee per day nudged up the chances of living longer.  Careful, though — this doesn’t prove that coffee makes people live longer, only that the two seem related.  Like most studies on diet and health, this one was based strictly on observing people’s habits and resulting health.  So it can’t prove cause and effect.  But with so many people, more than a decade of follow-up and enough deaths to compare, ‘this is probably the best evidence we have’ and are likely to get, said Dr. Frank Hu of the Harvard School of Public Health.  He had no role in this study but helped lead a previous one that also found coffee beneficial.”

The study’s findings should be viewed with caution.  “For those who do drink coffee, there’s no reason to stop.  Periodically someone will say it’s bad, but I think this strengthens the view that it’s not harmful,” said Dr. Lawrence Krakoff, a cardiologist from the Mount Sinai School of Medicine in New York, who wasn’t involved in the new research.  “Whether it’s beneficial — without knowing the cause, it’s hard to say,” he said.  “I wouldn’t encourage people to suddenly drink a lot of coffee with the expectation of benefit.”

Not so fast, according to cardiologist Steve Nissen of the Cleveland Clinic, who wasn’t involved in the study.  Asking people about their coffee consumption just one time in a 13-year timeframe can be misleading, since drinking habits change.  Nissen pointed out that the study didn’t include vital medical information that affects longevity, such as cholesterol or blood pressure levels.  “This study is not scientifically sound,” Nissen said.  “The public should ignore these findings.”

The study determined that men who drank two to three cups a day had a 14 percent lower risk of dying from heart disease, 17 percent lower risk of dying from respiratory disease, 16 percent decreased chance of dying from stroke and a 25 percent lower risk of dying from diabetes than those who drank no coffee.  Women who consumed two to three cups a day had a 15 percent lower chance of dying from heart disease, 21 percent lower risk of dying from respiratory disease, seven percent decreased chance of dying from stroke and a 23 percent lower risk of dying from diabetes.

Hospitals, CMS Butt Heads Over Too Many Readmissions

Tuesday, February 14th, 2012

Medicare has plans to penalize hospitals that frequently readmit patients who really don’t need hospitalization. According to one estimate, this practice costs the federal government $12 billion every year.  Medicare’s goal is to persuade hospitals to be certain that patients get the care they need following their discharge.  This new policy is likely to excessively impact hospitals, particularly those that treat low-income patients, according to a Kaiser Health News analysis of data provided by the Centers for Medicare & Medicaid Services.  Hospitals that admitted the most underprivileged Medicare patients were approximately 60 percent as likely to have significantly higher readmission rates for heart failure.  At these hospitals, lower-income people comprise a larger share of the patients than they do at 80 percent of hospitals.

“When some of our patients get home, their lights and gas are shut off,” said Roland Abellera, vice president of quality and corporate compliance at St. Bernard Hospital in Chicago’s blighted Englewood neighborhood.  “So what ends up happening is that the ambulance brings them back to us and we have to house them until our staff can help them get the utilities turned on.  We have a community in need.”

Within 30 days of discharge, 25 percent of Medicare patients with heart failure are readmitted to the hospital.  The Patient Protection and Affordable Care Act (ACA) has ruled that beginning next October, Medicare will fine hospitals whose patients who have had heart attacks, heart failure or pneumonia return to the hospital too soon.  By 2014, hospitals with high readmission rates can potentially lose up to three percent of their Medicare reimbursements.

Medicare has set aside funds so hospitals can more effectively plan patients’ post-discharge care.  According to Patrick Conway, Medicare’s chief medical officer, some funds will be targeted to hospitals that serve significant numbers of poorer people.  “We especially are concerned about safety-net hospitals that take care of a high portion of patients in poverty and racial and ethnic minorities,” he said.  At the same time, his agency is committed to the readmission penalties, in part because it is the law and because it believes the penalties will persuade hospitals to be certain that patients get the follow-up care they need.

Some hospital administrators are concerned that the new policy is too harsh.  “In essence, they are penalizing those hospitals and areas that need the most help and the most money to address these issues because we have the sickest, most noncompliant and vulnerable patient population,” said Guy Alton, chief financial officer at St. Bernard.  According to Abellera, St. Bernard’s heart failure patients usually have more than one serious conditions, such as kidney failure, hypertension and diabetes.  “A patient does not come here for heart failure alone,” he said.  “They have no less than six or seven diagnoses — we’ve had many with more than that.”

Dr. Ashish Jha, in the latest New England Journal of Medicine, makes the case that readmissions aren’t the best gauge of unnecessary care — even though they’re a natural target for budget-cutters.  The Harvard University professor points out that many hospitals with the highest readmission rates serve the poorest areas with the biggest health problems.  “Readmissions are caused by what hospitals do, who the patients are, and what’s happening in the community,” he says. “You want hospitals to fix the things they can, but you don’t want to punish them for taking care of poor people, and you don’t want to punish them for being located in a poor area.”

Two of the most frequent reasons for hospital readmissions are medication errors and failure to see a physician – both of which could be reduced if patients were supervised through home care visits following discharge.

Healthcare Jobs Still the Fastest-Growing Sector

Tuesday, February 7th, 2012

Job growth in the healthcare profession seems to be virtually recession-proof. In Florida, a state with a sizeable percentage of senior citizens, there are about 960,000 healthcare and social assistance jobs, approximately 13 percent of all nonfarm payroll positions in the state.

Some experts are not as optimistic about job growth in the healthcare sector.  “Reform may accelerate the trend toward healthcare’s being the dominant employment sector in the economy,” according to a recent New England Journal of Medicine (now known as NEJM) article.  A significant amount of the growth in healthcare that result from reform might be in support positions, rather than physicians and nurses, several economists said.  “As for jobs for health professionals, I doubt that this will or can increase the number of doctors or nurses.  While there will be greater demand for their services, there will also be offsetting effects as medically unnecessarily procedures are paid less,” said Amitabh Chandra, an economist and public-policy professor at Harvard University.

As the insured population grows under the federal Patient Protection and Affordable Care Act (ACA), healthcare workers will be in high demand.  These gains come on the heels of growth already required to serve an aging population.  In Florida, the aging population’s impact on healthcare employment is more dramatic than in the rest of the country: about 17 percent of the state’s population is older than 65, compared with a 13 percent average in the other states., according to the Census Bureau.

Other experts are far more sanguine about healthcare’s ability to create jobs.  “The big places we waste money is patients who are discharged and there’s not a lot of follow up and they end up in the hospital a month later,” said Leemore Dafny, an economist at Northwestern University whose expertise is competition in healthcare markets.  According to Dafny, reform will create new primary-care physicians and physician “extenders,” such as nurse practitioners; at the same time, it could decelerate growth in spending on medical specialists.  “If the ACA is repealed, it will be business as usual — except that more of the population is now uninsured — so the demand for primary-care professionals will increase much more slowly,” said Dafny.

In fact, according to the Bureau of Labor Statistics (BLS), the healthcare sector for some time has provided about the only bright spot in an otherwise drab report on job growth.  Healthcare employment created 205,100 new jobs in the first eight months of 2011.  Approximately 14.1 million people are employed in the healthcare sector with more than 4.7 million jobs at hospitals; more than 6.1 million jobs in ambulatory services; and more than 2.3 million jobs in physicians’ offices, according to BLS statistics.

According to Risa Lavizzo-Mourey, M.D., CEO of the Robert Wood Johnson Foundation, and Mark Pinsky, president and CEO of the Opportunity Finance Network, “The current economic recovery effort presents an opportunity to build stronger, healthier communities.  That’s a central goal, for example, of the Create Jobs for USA Fund that the OFN and Starbucks launched late last year to support job creation and retention.  Economic growth and job creation provide more than income and the ability to afford health insurance and medical care.  They also enable us to live in safer homes and neighborhoods, buy healthier food, have more leisure time for physical activity, and experience less health-harming stress.  The research clearly shows that health starts in our homes and communities and not in the doctor’s office.  In that way, economic policy is, in fact, health policy.  The end goal?  Create and sustain job growth across the country.  Improve communities.  Improve health.  Give people the opportunities to make smart, healthy decisions so that they can act in the best interests of their communities, themselves, and future generations.”

Healthcare added 17,200 jobs in November of 2011, an increase over the 11,600 jobs reported in October, according to BLS data.  Healthcare accounted for 14.3 percent of 120,000 new jobs created across all sectors in November.  On the whole, healthcare represented 24 percent of the 1.2 million non-farm jobs created this year and is expected to create 321,000 new jobs by year’s end.  That represents a 22 percent increase over the 263,400 healthcare jobs created in 2011.

MLK & Healthcare Reform

Monday, January 30th, 2012

A recent byline article in Forbes magazine by Carolyn McClanahan, M.D., CFP, raises many issues about healthcare in the year 2012.  According to McClanahan “The New England Journal of Medicine’s (NEJM) article on the fate of healthcare reform in 2012 greatly saddens the optimist in me. It discusses four important events, and I’ll share my “simplistic view” of these events:

“State legislatures getting in gear to fill their role assigned by the ACA.  As I’ve discussed previously, we have a complicated healthcare system which is expensive and inefficient.  Instead of simplifying, each state will implement or delay implementing the law based solely on their political interest.  This is not productive.”

“The second event is the Supreme Court’s ruling on the legality of the ACA in May. It is possible that the entire law could be struck down, (albeit unlikely).  If this scenario plays out, we will have wasted billions implementing parts of the law to date.  Another more likely scenario is the law will be upheld but the mandate that everyone purchase health insurance be thrown out.  This would severely weaken the law because people will only buy insurance when they are sick.  There will still be a requirement that insurance companies have to sell insurance to everyone regardless of health status.  This is not financially feasible.  Most likely, the law will stand, but who really knows?”

“The third key event is the deadline for states to apply for federal grants to operate their health insurance exchange.  State who don’t apply will either have to cede control of the exchanges to the federal government or pay for the cost of implementation themselves.  State governors and legislatures against the ACA, like my home state of Florida, risk turning away resources and having more of the federal government running the show.  Talk about the law of unintended consequences.”

“The fourth key date is the election in November.  If President Obama wins re-election, implementation will continue.  If he loses, the winner will have a difficult time repealing the law unless the Republicans can win 60 seats in the Senate.  So what is their plan?  Have everyone drag their feet on implementation or do a half-baked job.  Wouldn’t it be nice if instead they came up with a good plan to fix the parts that are not working?  Simplify and clean up the mess of the insurance part of the law and implement with speed and clarity the good parts like preventive care initiatives, rebuilding our primary care workforce, and improving our ability to handle large disasters.”

A similar viewpoint was expressed by Department of Health and Human Services (HHS) Secretary Kathleen Sebelius, who said that access to healthcare is the next civil rights frontier.  According to Sebelius, “On Martin Luther King Day, it is easy to congratulate ourselves on our progress in moving beyond segregated schools, lunch counters and drinking fountains. The hard question is this: what injustices do we still accept that should, in fact, be intolerable?  Surely Dr. King would find the next civil rights frontier in healthcare, with nearly 50 million uninsured, almost 45,000 deaths annually due to lack of insurance, and more than half of all personal bankruptcies linked to illness and medical bills.”

“While the Affordable Care Act will bring improvements, such as decreasing the ranks of the uninsured, supporting community health centers, and investing in prevention, it leaves many gaps. At least 23 million people will still be uninsured in 2019. Tens of millions will be underinsured, one serious illness away from financial ruin. Most people who suffer medical bankruptcy had private insurance before getting sick. And medical bankruptcy is a cruel double whammy. Already beset with pain, anxiety and fear – due to serious illness – families find themselves financially devastated.  This doesn’t happen in other industrialized countries, which have high-quality health systems that cover everyone.”

As a department, we are committed to ensuring that all Americans achieve health equity by eliminating disparities and doing what we can to improve the health of all groups, including the poor and underserved,” Sebelius said. “One of the most important ways we are doing this is through our new health care law, the Affordable Care Act.”

Is Getting People on Medicaid Doing More Harm Than Good?

Tuesday, July 19th, 2011

To control soaring Medicaid costs,  several states have started the new fiscal year by cutting payments to doctors, hospitals and other healthcare providers that treat the poor.  Some experts say the cuts could add to a shortage of physicians and other providers participating in Medicaid.  “Further depressing payment rates can only worsen the situation,” said Sara Rosenbaum, chair of the health policy department at George Washington University.  She says some states cutting rates — South Carolina, for example — already have acute Medicaid physician shortages.

Insurers and employers believe that cutting the rates will prompt providers to raise their prices for patients who have private insurance.  “It’s always a concern that when providers get less from Medicaid, that they will shift the costs to private insurance so families and employers pay more,” said Robert Zirkelbach, a spokesman for America’s Health Insurance Plans (AHIP), the healthcare industry’s lobbyist group.

States reducing Medicaid payments to physicians are Colorado, Nebraska, Oregon and South Dakota.  Arizona, which cut rates in April, will impose another cut in October.  States reducing payments to hospitals include Colorado, Connecticut, Florida, Nebraska, New Hampshire, North Carolina, Oregon, Pennsylvania, South Carolina, Texas, Virginia and Washington.  New York cut hospital payment rates in April.  In March, California okayed a 10 percent Medicaid cut to doctors and hospitals; those reductions are pending because of a lawsuit that has not yet been resolved.

The payment cuts, which require federal approval, are part of an effort by states to cut Medicaid costs, typically the largest- or second-largest expense after education.  A joint state-federal program, Medicaid serves more than 50 million low-income and disabled Americans.  Under the provisions of the Patient Protection and Affordable Care Act (ACA), more than 16 million more people will become eligible 2014, with the federal government picking up the majority of the cost.  To lure more physicians to accept Medicaid patients, the law raises rates for primary-care physicians in 2013 and 2014 to match those paid by Medicare.  On average, states currently pay Medicaid providers approximately 72 percent of what Medicare pays.

Federal-state Medicaid costs totaled $366 billion in fiscal 2009.  The federal stimulus package gave states $100 billion to help pay their share, but that funding ended June 30, and “states are struggling,” said Laura Tobler, a policy analyst at the National Conference of State Legislatures.  The ACA does not allow states to restrict eligibility for the program.

Because of cuts in reimbursement, the Government Accounting Office (GAO) has found that fewer physicians are accepting children on Medicaid as patients.  More than 75 percent of 932 doctors surveyed by the GAO reported difficulty when referring children with public insurance for specialty care, citing an overall shortage of specialists, and different waiting lists for children receiving Medicaid or Children’s Health Insurance Program (CHIP) benefits than children covered by private insurance.  In 2010, more than 40 million children in the country received healthcare through one of the two programs which cost $79 billion in federal and state funds.  Physicians serving rural areas are more likely to accept new patients with Medicaid and CHIP than doctors in urban areas.  Rural primary-care doctors reported greater difficulty referring their Medicaid and CHIP patients to specialists than urban physicians.

Writing in Forbes, Avik Roy says that “The real problem, however, is that many physicians don’t accept Medicaid patients, primarily because Medicaid underpays them for their time and costs.  The Health Tracking Study Physician Survey found that internists are 8.5 times as likely to reject all Medicaid patients versus those with private insurance.  The New England Journal of Medicine recently published a study showing that 66 percent of Medicaid children were denied an appointment with a specialist for an urgent medical condition — such as uncontrolled asthma or seizures — compared to only 11 percent for the privately insured.  What makes this even more appalling is that we’re spending billions of dollars to take millions of children away from high-quality private insurance, and shoving them in Medicaid instead.  As Peter Suderman notes, the Congressional Budget Office has estimated that of the children who have been added to Medicaid’s sibling, the State Children’s’ Health Insurance Program (CHIP), one-quarter to one-half were adequately covered by private insurance beforehand.”

Watson Supercomputer Could Revolutionize Medicine

Monday, February 21st, 2011

There has been significant buzz about the IBM supercomputer Watson’s recent appearances on the television quiz show “Jeopardy” and whether the machine will beat Ken Jennings and Brad Rutter, the program’s two superstars. While Watson’s celebrity may be cemented by its television appearances, the supercomputer also has the possibility to transform medicine.  Writing in USA Today, Yong Suh, a medical student at the Johns Hopkins University School of Medicine, says that “The company that revolutionized the personal computer industry in the 20th century has the potential to do the same for healthcare in the 21st century.”  Watson was the victor, winning with a commanding lead of $77,147.

According to Suh, “Performing well on ‘Jeopardy’ and diagnosing sick patients have similar prerequisites: a broad fund of knowledge, ability to process subtlety and ambiguity in natural language, efficient time management, and probabilistic assessment of different possibilities.  Like ‘Jeopardy’ clues, a patient’s symptoms, medical history, physical exam findings and laboratory results present clues that must be synthesized into a differential diagnosis.  While computer systems to assist clinical decision-making have existed for decades, adoption of legacy systems has been hindered by rigid algorithms that require translation of natural language into machine language and heavy reliance on user input.”

Watson has the ability to address two serious problems in healthcare today: deaths due to medical errors and shortage of physicians.  The Institute of Medicine (IOM) has reported that as many as 98,000 deaths a year are due to medical errors – making them the fifth leading cause of death.  Misdiagnosis is frequently the result of cognitive errors physicians make.  Watson’s advanced memory and ability to process information means it can analyze all medical evidence, and minimize bias when making diagnoses.  In terms of the physician shortage, Watson could become a significant technology that forces the medical community to rethink how patients interact with healthcare providers and how the delivery system is organized.

A somewhat contrary view of Watson’s potential for enhancing healthcare is presented by Fahmida Y. Rashid on the website “Medical Center.”  According to Rashid, “Of course, the enormity of the hardware and the algorithmic advances required to make a truly ‘revolutionary’ tool such as this are obviously staggering. Considering that it takes 10 racks of multiprocessor IBM servers with 15 terabytes of memory and a team of varied domain experts writing algorithms for several years to accomplish the NLP advances and lookups to answer ‘Jeopardy’ style trivia questions, one can only imagine what a truly useful cybernetic medical assistance system would look like.  It should also be remembered that Watson does not think.  Humans do.  I believe a machine even close to passing a ‘New England Journal of Medicine Turing test’ (a measure of a machine’s ability to demonstrate intelligence will be a long time in coming.  Until then, we should be encouraging better support for human physicians struggling to use their medical expertise in a sea of bureaucracy, stress and overwork (part of which will increasingly be a struggle with mission-hostile health IT).”

More and more frequently, physicians are using hand-held devices – such as smart phones – to access information on their patients.  This way, they do not have to rely on memory to determine exactly what medications a particular patient is taking.

Johns Hopkins’ Suh also notes that “The prospect of using Watson in medicine also raises some difficult questions.  What will be the new roles for physicians, nurses, technicians and other healthcare professionals when the current hierarchy, delineated by varying levels of medical knowledge, is flattened by an intelligent machine?  What will be the impact on the practice of humanistic medicine?  How will patient outcomes be affected by patient-machine interactions? Who will be held accountable for medical errors that arise from decisions made by a machine?”  Only time will tell.