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A NEW WINDOW INTO THE DISCUSSION ON HEALTH CARE POLICY
by Dan Weintraub

After more than 25 years covering public policy and politics for California newspapers, Dan Weintraub begins a new online journalism initiative that promises to report on California's government and its communities in new ways.

HealthyCal.org, a nonprofit web site I'm creating with initial funding from the California Endowment, will cover public health policy from inside the Capitol and from communities across California. The goal is to connect the two in a conversation that will inform both.

Nearly two dozen medical schools that have recently opened or might open across the country, the most at any time since the 1960s and '70s.

These new medical schools are seeking to address an imbalance in American medicine that has been growing for a quarter century.

Many bright students were fleeing to offshore medical schools, or giving up hope entirely, when they could not get into domestic schools. 

In a weird aberration of "outsourcing", the medical field was outsourcing medical education to foreign countries, and then hiring foreign nationals to work in our American healthcare system, presumably at lower rates and longer hours.

During the 1980s and '90s only one new medical school was established.

"Huge numbers of qualified American kids were not getting into American medical schools or going abroad to study," Dr. Lawrence G. Smith, dean of the proposed Hofstra University School of Medicine, in Hempstead, N.Y., which is not yet recruiting students, said last week. "I think it was a kind of wake-up call."

The proliferation of new schools is also a market response to a rare convergence of forces:

• a growing population;
  
• the aging of the health-conscious baby-boom generation;
  
• the impending retirement of, by some counts, as many as a third of current doctors;
  
• the expectation that, the present political climate notwithstanding, changes in health care policy will eventually bring a tide of newly insured patients into the American health care system.

Colleges serve a "Gatekeeping Function" as well as education of new practitioners.  By carefully limiting the number of trained professionals, those with established careers have less competition -- and that can be important to personal care services that must maintain a full staff even when they have a light load of patients.  Under-staffing also causes long delays in getting an appointment, and has healthcare consequences when care is delayed.

If all the schools being proposed actually opened, they would amount to an 18 percent increase in the 131 medical schools across the country.

Read more at the REFERENCE SOURCE:  New York Times

Despite a general belief among physicians that extreme obesity is too difficult to treat, except with bariatric surgery, researchers at the Pennington Biomedical Research Center have learned a substantial proportion of individuals with extreme obesity can lose 10-percent or more of their body weight through medical treatment that does not include surgery.

10% Loss Improves Risk Factors and Health

Furthermore, even though those individuals are still obese, they have improvements in risk factors and other health markers.

Weight Loss Surgery Not Often Affordable or Reimbursed by Insurance

"This is important, because surgery is not often affordable or reimbursed by insurance," said leading scientist Dr. Donna Ryan. "In fact, many medical treatments are frequently not reimbursed by insurance if they are for obesity. So this research is needed to show that primary care doctors are capable of helping obese patients lose weight to improve health, even those with extreme obesity. "

Ryan said losing only five-percent of body weight can reap healthy benefits for the extremely obese, and nearly 61-percent of those in her clinical trial achieved that. More than 40-percent lost 10-percent body weight or more.

Physicians Trained in Intensive Medical Intervention

Ryan and her team spread out across Louisiana to recruit and train practicing physicians and their office staffs in eight cities in what she called "intensive medical intervention," in which physicians used a combination of medication, low-calorie diets and behavior changes. All of the techniques were endorsed by national guidelines for obesity management. Training of physicians and their staffs took about a day and a half.

Funded by the Louisiana Office of Group Benefits, which provides health coverage for state employees, the research team contacted state employees, seeking participants to screen for and enroll in the trial. Nearly 400 participants enrolled in the two-year trial, called LOSS, using the nearest trained physicians.

About half of the participants received the intensive medical intervention, the other half received what Ryan called "usual care." 

Program Starts with Low-calorie Liquid Diet

Those in the intense intervention group were immediately placed on a low-calorie liquid diet. They gradually moved to a low calorie, highly controlled diet using meal replacements, and received weight loss medication and group behavioral therapy that included lessons in exercise, activity, self-monitoring and recommendations for walking, water exercise and weight training. The group sessions were supervised by office staff.

Recommended Activities

• exercise
• activity
• self-monitoring
  
• recommendations for walking
• water exercise
  
• weight training

Success in Daily Routine of Doctor's Practice

"We conducted this trial as close to the reality of a typical clinic setting as we could," Ryan said, "We didn't want to learn just if these strategies worked, but if they would work in the daily routine of a doctor's practice."

Challenge of Keeping Weight Off

Ryan noted that the continual challenge in weight loss is keeping weight off, and that means sticking with a routine.

More than 50% of the LOSS participants stuck with it for two years or more, keeping much of the weight off, but Ryan said that does leave room for improving weight loss maintenance.

The LOSS trial results were published in the current issue of the Archives of Internal Medicine.

The Pennington Biomedical Research Center is a campus of the Louisiana State University System and conducts basic, clinical and population research.

Chronic kidney disease affects 26 million people in the United States.

Challenging prevailing wisdom that only children with end-stage kidney disease suffer physical, social, emotional and educational setbacks from their disease, research led by Johns Hopkins Children's Center shows that even mild to moderate kidney disease may seriously diminish a child's quality of life.

The findings, reported in the February issue of Pediatrics, suggest that earlier attention to quality-of-life issues in children with chronic kidney disease is needed.

"Even mild and moderate declines in kidney function may lead to serious physical, emotional, intellectual and social challenges," says lead investigator Arlene Gerson, Ph.D., a pediatric psychologist at Hopkins Children's.

Kidney Disease Screening is Needed

"What this means is we should be thinking about screening children for these challenges and intervening earlier than we once thought."

Recently diagnosed children who report learning problems may benefit from help before grades drop, researchers say, noting that children with chronic diseases currently do not qualify for special education until their scores decline dramatically.

Links Between Kidney Function and Quality of Life

In their study of 402 children, ages 2 to 16, with mild-to-moderate kidney disease, researchers analyzed the link between kidney function, disease severity, age of onset and disease duration, on the one hand, and physical, emotional, psychological and school functioning on the other.

The researchers also compared quality-of-life outcomes between healthy children and children with early-stage kidney disease. Children with mild-to-moderate kidney disease and their parents reported worse overall outcomes on standard quality-of-life questionnaires and worse outcomes on all quality-of-life factors.

Specifically, children with early-stage kidney disease scored on average 75 out of 100 on quality-of-life measures, compared to 83 out of 100 for healthy children. The difference was especially pronounced in school functioning, where children with early-stage kidney disease scored 64 out 100, compared to 80 out of 100 for healthy children.

How Children Cope with Kidney Disease

The study also found that the younger the child at the time of the diagnosis and the longer the child lived with kidney disease, the better the overall quality of life, a surprising finding, suggesting that as time passes children learn to cope better with their condition, the researchers say.

The researchers found that children with impaired growth and shorter stature, a common effect of their disease, had worse overall quality of life and poorer physical functioning, an indicator of the importance of early treatment.

Treatments for Children's Kidney Disease

"Timely and individually tailored treatment, be it with nutrition, salt supplements or growth hormones, if needed, can make a big difference. We cannot overemphasize the importance of early intervention in children with early stages of chronic kidney disease," says senior investigator Susan Furth, M.D. Ph.D., a pediatric nephrologist at Hopkins Children's.

The research is part of an ongoing 57-center study funded by the National Institutes of Health to study chronic kidney disease in children.

Heavy backpacks place a measurable strain on the spines of children, with heavier loads causing greater spinal strain and increased back pain, reports a study in Spine, January 2010 

My husband and I started getting concerned about heavy backpacks when our son was required to carry a very heavy backpack weighted down with a year's worth of books when he was in gradeschool.  It just didn't make sense.  It's taken a long time to get the research to prove the problems.  But it's here now, and solutions need to be found -- such as eBook readers.

The next step in convincing schools to "lighten the load" is to show how expensive back pain and back care is to our society.  Maybe business and government can prevent that long term impact on healthcare costs by providing children is an alternative to heavy books.

Test Results for Children's Back Health 

Magnetic resonance imaging (MRI) scans show compression of the spinal discs and spinal curvature caused by typical school backpack loads in children, according to Dr. Timothy Neuschwander of University of California, San Diego, and colleagues.

Backpacks' Effects on Disc Height and Spinal Curve Linked to Back Pain

The study included eight children, mean age 11 years. A special upright MRI scanner was used to image the children's spines in standing position--first with an empty backpack, then with increasing weights of 9, 18, and 26 lb. These weights represented about 10, 20, and 30 percent of the children's body weight.

Two key spinal measurements changed as the backpack load increased.

• Heavier weights caused compression of the intervertebral discs, which act as a cushion between the vertebrae (bones of the spine).
  
• Especially in the lower spine, the disc height became smaller (reflecting greater disc compression) at heavier backpack weights.
• Heavier loads were also associated with increased curvature of the lower spine, either to the right or the left.
  

Half of the children had a significant spinal curve even with the 18 lb weight. Most of the children had to adjust their posture to bear the 26 lb backpack load.

As backpack weight increased, so did the amount of pain reported by the children. At the heaviest load, the average pain score was nearly five (on a ten-point scale).

Parents are increasingly concerned about the heavy backpacks their children have to carry. The new study is the first to use imaging techniques to see how backpacks affect children's spines.

More than 90 percent of U.S. children carry backpacks, typically with weights equal to 10 to 22 percent of their body weight.

Carry Backpacks on One Shoulder or Two?

The results suggest that heavy backpacks cause compression of the spinal disks and increased spinal curvature, both of which are related to back pain reported by the children. Although the children were wearing the backpack straps over both shoulders when the MRI scans were performed, the researchers note that spinal curvature could be even greater if the backpack was carried over one shoulder--as many children do.

Lower Back Pain for Children -- Through Adulthood

"Low back pain in children may be worsened by discogenic [disc-related] or postural changes," Dr. Neuschwander and colleagues write. This could have long-term implications, as children with back pain are at increased risk of having back pain as adults. The researchers call for similar studies to examine the effects of heavy backpacks in children with existing back pain.

About Spine
Recognized internationally as the leading journal in its field, Spine is an international, peer-reviewed, bi-weekly periodical that considers for publication original articles in the field of spine. It is the leading subspecialty journal for the treatment of spinal disorders. Only original papers are considered for publication with the understanding that they are contributed solely to Spine. According to the latest ISI Science Citation Impact Factor, Spine ranks highest among subspecialty orthopedic titles. Visit the journal website at www.spinejournal.com

Surgeons are less likely than family physicians or patients to view surgery as the preferred treatment option for low back pain, according to a study in the January 1 issue of Spine.

Quality of Life Issues

For patients with back pain, quality-of-life issues are the main factor affecting treatment preferences--which has important implications for shared decision-making between patients and their doctors, according to the new study led by Dr. S. Samuel Bederman at University of Toronto.

Family Doctors Have Highest Preferences for Surgery

The researchers presented hypothetical back pain scenarios to surgeons (orthopedic surgeons and neurosurgeons), family physicians, and patients with back and/or leg pain. The scenarios reflected key factors related to back pain:

• walking ability
• pain duration
• pain severity
• neurological symptoms
• factors inducing pain
• pain location
  

Each group rated their preference for surgery in each scenario, and the factors affecting preferences were analyzed.

Perhaps unexpectedly, surgeons had the lowest overall preferences for surgery, while family physicians had the highest preference for surgery.

• For orthopedic surgeons, the preference for surgery was somewhat lower than for neurosurgeons.
  
• Both the family doctors and patients had a higher preference for surgery than either group of surgeons.

The factors affecting preferences for surgery varied as well. 

Location of Back and Leg Pain

For surgeons, the most important factor was the location of pain. In particular, they preferred surgery for patients with pain predominantly in the leg, rather than the back. Surgery provides better results in patients with problems affecting the spinal nerve roots, which tend to cause leg pain.

Family Physician Preferences for Surgery

In contrast, for family physicians, the most important factor affecting preferences for surgery was neurological symptoms, followed closely by walking ability and pain severity.

Family doctors may be unaware of which factors affect the chances of good outcomes from back surgery, the researchers suggest.

Top Back Pain Patient Concerns

For patients, the most important factors were pain severity, walking ability, and pain duration. "All of these symptoms are highly related to quality of life and have little direct bearing on outcomes following surgery," Dr. Bederman and co-authors write.

Successful Pack Surgery

When other treatments have failed, surgery can help patients with moderate to severe lower back pain. Family physicians play an important role in sending back pain patients for surgical evaluation. However, few studies looked at the factors considered by primary care doctors consider in referring patients for possible spinal surgery. The final decision is generally made through a shared process between the patient, family physician, and surgeon.

Key Metric for Surgery Solutions for Back Pain

The new results suggest that, in various scenarios, surgeons have a lower preference for surgery than family physicians. In addition, the factors that surgeons feel are most important--especially the location of pain--don't match those considered most important by family doctors.

Importance of Quality of Life Factors

The study also highlights the importance of quality-of-life factors--especially pain severity and duration and walking ability--in affecting patients' treatment preferences.

Dr. Bederman and colleagues hope their findings will help in "aligning" the opinions of patients and doctors, thus improving the shared decision-making process and promoting more accurate patient expectations of the results of surgery. "This can directly result in a significant improvement in patient satisfaction with the healthcare process and even overall health status following treatment," the researchers write.

About Spine
Spine is an international, peer-reviewed, bi-weekly periodical that considers for publication original articles in the field of spine. It is the leading subspecialty journal for the treatment of spinal disorders. According to the latest ISI Science Citation Impact Factor, Spine ranks highest among subspecialty orthopedic titles. Visit the journal website at www.spinejournal.com

Office of Resource Conservation and Recovery provides the following guidance:

"Consumers can check with their local recycling facility to see if they collect these kinds of contaminated jewelry and trinkets. To find a local recycling facility, they can go to www.earth911.com .

If a local recycling facility doesn't take these articles, consumers can go ahead and throw them in the trash. Our modern landfills are made to be able to hold such contamination without leaking it into the environment."

So, we can dispose of these safely.

For more information on the disposal of waste, please visit our Website. For information on product recalls and keeping people safe in and around the home, visit the US Consumer Product Safety Commission's Neighborhood Safety Network.

Start at the Beginning...

While it is important to know what to do with current products that are, or could likely be contaminated with lead and other elements detrimental to health, it is important to THINK EARLY and not buy them in the first place.

Establishing your own "Purchasing Policies" for gifts, housewares, hobby supplies, etc. make a lasting difference in the level of toxins in your home or workspace.  For example, you can adopt "best practices" that fit your needs such as:

• Buy from certified suppliers (Know which certifications are best in your field)
• Buy just what you need for the anticipated life of your project (Stuff gets old :-)
• Think long term -- limit purchases of fads and temporary fixes
• Buy less, but buy BETTER
• Buy multi-use items vs. single application tools, supplies and furnishings

Reduce Heart Disease, Stroke and Heart Attacks

Scientists writing in The New England Journal of Medicine conclude that lowering the amount of salt people eat by even a small amount could reduce cases of heart disease, stroke and heart attacks as much as reductions in smoking, obesity and cholesterol levels.

If Americans consumed half a teaspoon less salt per day, there would be between 54,000 - 99,000 fewer heart attacks each year and between 44,000 - 92,000 fewer deaths, according to the study, which was conducted by scientists at University of California San Francisco, Stanford University Medical Center and Columbia University Medical Center.

Processed Foods are the Key Source of Salt

Health authorities at federal, state and municipal levels are considering policies to mandate that food companies reduce salt in processed foods, which are considered to be the source of much of the salt Americans eat.

For 40 years in this country we've been trying to get individuals to reduce the amount of sodium we consume and it hasn't worked.

New York City announced an initiative to urge food manufacturers and restaurant chains to reduce salt in their products nationwide by 25 percent over the next five years.

California, according to an author of the study, Kirsten Bibbins-Domingo, an associate professor of medicine and epidemiology at University of California, San Francisco, is considering setting salt limits on food the state purchase for schools, prisons and other public institutions.

The Institute of Medicine, the independent research arm of the National Academies of Science, will be issuing a report soon that will make recommendations about reducing salt intake, including actions government and manufacturers can take.

The Food and Drug Administration was considering whether to change the designation of salt from a food additive that is generally considered safe to a category that would require companies to give consumers more information alerting them to high levels of salt in food.

Greatest Benefit:  Blacks, Hypertension and Seniors

The researchers found that everyone would benefit from less salt, but people at higher risk for heart problems -- blacks, people with hypertension and people over 65 -- would benefit most.

While research isn't showing that individuals will be greatly affected by small changes in salt intake, "Small incremental changes in salt, such as lowering salt in tomato sauce or breads and cereals by a small amount, would achieve small changes in blood pressure that would have a measurable effect across the whole population," researchers said.

Huh?  Does YOUR salt intake affect MY health?   I understand public health concepts, but this seems a bit strained.  However, if what they mean is that people who eat way too much salt will take action and reduce their personal health... I can see that rationale. 

In the meantime, ask your medical adviser if you are overdoing the salt for your own good health!

Read More at NY Times

Newswise -- Buying medicine by mail may encourage patients to stick to their doctor-prescribed medication regimen, new research suggests.

Patients with diabetes, high blood pressure and high cholesterol

Researchers from UCLA and Kaiser Permanente's Division of Research in Oakland, Calif., found that patients with diabetes, high blood pressure and high cholesterol who ordered their medications by mail were more likely to take them as prescribed by their physicians than patients who obtained medications from a local pharmacy.

"The field of medication adherence research typically focuses on patient factors for poor adherence, leading to a 'blame the patient' approach for non-adherence," said Dr. O. Kenrik Duru, the study's lead researcher and an assistant professor in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA.

Streamline the medication-acquisition process

"Our work helps to place this issue in a larger perspective," Duru said. "Our findings indicate that mail-order pharmacies streamline the medication-acquisition process, which is associated with better medication adherence."

The researchers found that 84.7 percent of patients who received their medications by mail at least two-thirds of the time stuck to their physician-prescribed regimen, compared with 76.9 percent of those who picked up their medications at traditional "brick-and-mortar" Kaiser Permanente pharmacies.

"The results were consistent for all three classes of medication, including medications to control diabetes, high blood pressure and high cholesterol," said co-investigator Julie A. Schmittdiel, Ph.D., a research scientist with the Kaiser Permanente research division.

Other findings include:

• Before adjusting for other variables, white patients were more likely than Hispanics to obtain medications by mail (61.0 percent vs. 37.1 percent) and to be in the highest socioeconomic status quartile (27.5 percent vs. 17.8 percent).

• Mail-order pharmacy users were more likely than local pharmacy users to have a financial incentive to fill their prescriptions (49.6 percent vs. 23.0 percent) and to live a greater distance from a local pharmacy (8.0 miles vs. 6.7 miles). An example of a financial incentive is receiving a three-month supply of medication for the cost of a two-month supply.

• After adjusting for other variables, whites were more likely to use mail-order pharmacies (24.1 percent) than were Asian/Pacific Islanders (8.4 percent), Hispanics (5.2 percent), African Americans (4.0 percent) and individuals of mixed race (8.0 percent).

While other research has examined the association between medication costs and mail-order and local pharmacies, this is the first study to look at the relationship between pharmacy type and medication adherence. Furthermore, it controls for differences in out-of-pocket costs and medication supply (by number of days) between mail-order and local pharmacy users, something other datasets have not included.

"In other words, our study is able to isolate the use of mail-order pharmacies specifically, without the results being affected by differences in cost or in the number of pills provided with each dispensing," Duru said.

The study does have some limitations. For example, the findings need to be confirmed by a randomized controlled trial.

Still, the research suggests that increased mail-order use to obtain medications could improve patients' adherence.

In addition to Duru and Schmittdiel, researchers included Wendy Dyer, Melissa Parker, Connie Uratsu, James Chan and Andrew J. Karter of the research division at Kaiser Permanente Northern California.

Grants from the U.S. Centers for Disease Control and Prevention and the National Institute of Diabetes and Digestive and Kidney Diseases funded this study.

The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large.

The General Internal Medicine and Health Services Research Division in the department of medicine at the David Geffen School of Medicine at UCLA provides a unique interactive environment for collaborative efforts between health services researchers and clinical experts with experience in evidence-based work.  

December 14, 2009

Non-surgical Method for Diagnosing Breast Cancer Safe, Nearly as Effective as Surgical Biopsy, New Report Finds

Some methods of minimally invasive biopsy for breast cancer are nearly as accurate as surgical biopsy but have much less risk of harms, according to a new report funded by theUS HHS' Agency for Healthcare Research and Quality (AHRQ).

The report found that certain core needle biopsies could distinguish between malignant and benign lesions approximately as accurately as open surgical biopsy, which is commonly considered the "gold standard" method of evaluating suspicious lesions.

Core needle biopsies have a much lower risk of severe complications than open surgical procedures, researchers found in a report published this month in Annals of Internal Medicine.

The report also found that women who are initially diagnosed with breast cancer by surgical biopsy are more likely to undergo multiple surgical procedures during treatment than women who are initially diagnosed with breast cancer by core needle biopsy.

"One challenge of providing appropriate care for patients is finding balance between the accuracy of a test or procedure and causing the least harm and burden to patients," said AHRQ Director Carolyn M. Clancy, M.D. "This report indicates that core needle biopsy may strike that balance in many instances. Patients should continue to speak to their doctor when making important decisions about testing, and use all available information to make the decision that is right for them."

Open surgical biopsies, which involve removing a sample of tissue from the suspicious area through a surgical incision, are highly accurate. The procedure may be performed under general anesthesia, sedation plus local anesthesia, or local anesthesia only. But, while generally considered safe, open surgical biopsies are surgical procedures that, like all surgeries, carry a small amount of risk. Given that only a fraction of women who undergo breast biopsy procedures are diagnosed with cancer, use of traditional biopsy leads to large numbers of women who do not have cancer undergoing an invasive surgical biopsy.

By contrast, a core needle biopsy is a procedure that removes breast tissue through a hollow core needle inserted through the skin. The procedure is usually performed under local anesthesia. Multiple core-needle samples may be taken from the suspicious area.

Because it is less invasive, core-needle biopsy costs less than open surgical biopsy, consumes fewer resources, and generally is preferred by patients, according to the report.

The report found that recent technological improvements to core needle biopsy, including stereotactic guidance, ultrasound guidance and vacuum assistance, have improved the method's accuracy.

AHRQ's new report, Comparative Effectiveness of Core Needle and Open Surgical Biopsy for the Diagnosis of Breast Lesions, is the newest analysis from the Agency's Effective Health Care program. That program, authorized by the Medicare Prescription Drug, Improvement and Modernization Act, represents an important Federal effort to compare alternative treatments for health conditions and make the findings public. The program is intended provide information in order to help patients, doctors, nurses, and others choose the most effective treatments. Information, including the new report and summary guides for clinicians and patients, can be found at http://www.effectivehealthcare.ahrq.gov.