For Nursing Home Patients, Breast Cancer Surgery May Do More Harm Than Good

Surgery is a mainstay of breast cancer treatment, offering most women a good chance of cure.

For frail nursing home residents, however, breast cancer surgery can harm their health and even hasten death, according to a study published Wednesday in JAMA Surgery.

The results have led some experts to question why patients who are fragile and advanced in years are screened for breast cancer, let alone given aggressive treatment.

The study examined the records of nearly 6,000 nursing home residents who had inpatient breast cancer surgery the past decade. It found that 31 to 42 percent died within a year of the procedure. That’s significantly higher than the 25 percent of nursing home residents who die in a typical year, said Dr. Victoria Tang, lead author and an assistant professor of geriatrics and hospital medicine at the University of California-San Francisco.

Although her study doesn’t include information about the cause of death, Tang said she suspects that many of the women died of underlying health problems or complications related to surgery, which can further weaken older patients. Patients who were the least able to take care of themselves before surgery, for example, were the most likely to die within the following year. Dementia also increased the risk of death.

It’s unlikely that many of the deaths were due to breast cancer, which often grows slowly in the elderly, Tang said. Breast cancers often take a decade to turn fatal.

“When someone gets breast cancer in a nursing home, it’s very unlikely to kill them,” said study co-author Dr. Laura Esserman, director of the UCSF

breast cancer center. “They are more likely to die from their underlying condition.”

Yet most patients in the study got sicker and less independent in the year following breast surgery.

Among patients who survived at least one year, 58 percent suffered a serious downturn in their ability to perform “activities of daily living,” such as dressing, bathing, eating, using the bathroom or walking across the room.

Women in the study, who were on average 82 years old, suffered from a variety of life-threatening health problems even before being diagnosed with breast cancer. About 57 percent suffered from cognitive decline, 36 percent had diabetes, 22 percent had heart failure, 17 percent had chronic lung disease, and 12 percent had survived a heart attack.

The high mortality rate in the study is striking because breast surgery is typically considered a low-risk procedure, said Dr. Deborah Korenstein, chief of general internal medicine at New York’s Memorial Sloan Kettering Cancer Center.

The paper provided an example of how sick, elderly people can suffer from surgery. An 89-year-old woman with dementia who underwent a mastectomy became confused after surgery and pulled off all her bandages. Health care workers had to restrain her in bed to prevent her from pulling off the bandages again. The woman died 15 months later of a heart attack.

Surgery late in life is more common than many realize. One-third of Medicare patients undergo surgery in the year before they die, according to a 2011 study in The Lancet. Eighteen percent of Medicare patients have surgery in their final month of life and 8 percent in their final week.

Nearly 1 in 5 women with severe cognitive impairment, such as Alzheimer’s disease, get regular mammograms, according to a study in the American Journal of Public Health.

The new study leaves some important questions unanswered.

The paper didn’t include healthier nursing home residents who are strong enough to undergo outpatient surgery, said Dr. Heather Neuman, a surgeon and associate professor at the University of Wisconsin School of Medicine and Public Health. These women may fare better than those who are very ill.

Esserman and Tang said their findings suggest doctors need to treat breast cancer differently in very frail patients.

“People think, ‘Oh, a lumpectomy is nothing,’” Esserman said. “But it’s not nothing in someone who is old and frail.”

In recent years, doctors have tried to scale back breast cancer therapy to help women avoid serious side effects. In June, for example, researchers announced that sophisticated genetic tests can help predict which breast cancers are less aggressive, a finding that could allow 70 percent of patients to avoid chemotherapy.

The Medicare database used in this study didn’t mention whether any of the patients had chemotherapy, radiation or other outpatient care. So the UCSF researchers acknowledged that they can’t rule out the possibility that some of the women suffered complications due to these other therapies. In general, however, authors noted that only 6 percent of nursing home residents with cancer are treated with chemotherapy or radiation.

The authors said doctors should give very frail patients the option of undergoing less aggressive therapy, such as hormonal treatments. In other cases, doctors could offer to simply treat symptoms as they appear.

The new study raises questions about the value of screening nursing home residents for breast cancer, Korenstein said. Although the American Cancer Society hasn’t set an upper age limit for breast cancer screening, it advises women to be screened as long as they’re in good health and expected to live at least another decade.

Residents of nursing homes generally can’t expect to live long enough to benefit from breast screening, Korenstein said.

“It makes no sense to screen people in nursing homes,” Korenstein said. “The harms of doing anything about what you find are far going to outweigh the benefits.”

KHN’s coverage of these topics is supported by
John A. Hartford Foundation and
Gordon and Betty Moore Foundation

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Hurricane Maria’s Official Death Toll In Puerto Rico Now Stands At Nearly 3,000

Nearly 3,000 Puerto Ricans died as a result of the devastation caused by Hurricane Maria last year, a number that dwarfs the government’s initial tally of 64, according to a report commissioned by Puerto Rican officials and released Tuesday.

Gov. Ricardo Rosselló, who asked for the research following criticism of the American territory’s low death count, said his government accepts the new numbers and wants to learn from the crisis.

“The magnitude of the catastrophe was without precedent in Puerto Rico and there was certainly disagreement with the total number,” Rosselló said at a press conference. The report was completed by researchers at the George Washington University’s Milken Institute School of Public Health who examined death records for six months after the storm and attributed 2,975 deaths to the disaster.

In comparison, Hurricane Katrina, which is one of the deadliest storms in U.S. history, killed more than 1,800 people.

Hurricane Maria barreled into Puerto Rico Sept. 20 as a Category 4 storm. Destruction was widespread, severely crippling the island. Both the electrical and water systems were knocked out in some areas for months. Hospitals and other public health services were damaged, doctors’ offices lost power and often remained closed and medical supplies were difficult to find.

Health advocates scoffed at the government’s initial death toll and said many people died after the storm because they lacked medicine, couldn’t get adequate medical treatment or had chronic diseases that were aggravated by the post-storm conditions.

The official government estimate of 64 deaths was low because it counted only those directly attributable to the storm, such as drowning deaths or injuries caused when buildings collapsed, according to the report. The George Washington researchers instead inspected death certificates and other records, and they calculated the excess deaths by comparing historical death rates to the actual number of people who perished.

In addition, the GW researchers analyzed death statistics for age groups, gender and geography.

“I would say this is a study that can provide everybody a sense of security that, yes, this is a number that you can use as a reference for the future,” said Carlos Santos-Burgoa, principal investigator and professor of global health at GW’s  school of public health.

According to the study, the number of excess deaths is 22 percent higher than what would be expected had the hurricane not hit the island. The risk of dying for men over the age of 65 was 35 percent higher than the baseline, and it remained elevated through the end of the study. And people living in poorer areas were 45 percent more likely to die.

Santos-Burgoa said the risk people in poorer municipalities faced is a “major concern” because it shows the level of inequity on the island before the hurricane hit and was exacerbated in the aftermath.

“It’s a very strong message in Puerto Rico and people addressing natural disasters all over the world: Don’t treat people as homogenous groups,” Santos-Burgoa said.

At a briefing for reporters in San Juan, Rosselló discussed several initiatives to bolster the island’s disaster preparedness, including counting vulnerable populations like the chronically ill and creating a commission to handle recommendations to improve the island’s emergency response systems.

“This is a time for Puerto Ricans to bind together, to mourn, to reflect on the things that were done properly and things that were mistakes,” he said. “And have the firm commitment to identify those mistakes and make sure that moving forward toward the future, those mistakes aren’t committed.”

The report is the latest in a series of analyses done by universities and one newspaper to answer the question of how many perished in the storm.

A survey published in May in the New England Journal of Medicine estimated more than 4,600 excess deaths occurred from the day the hurricane made landfall to the end of the year. A separate investigation by The New York Times found 1,052 lives lost. A research letter published in JAMA in August estimated more than 1,100 deaths.

Earlier this summer, Puerto Rican officials quietly released data that dramatically upgraded its official death toll to 1,427.

The researchers also examined Puerto Rico’s crisis communications and death certification process in place during Hurricane Maria. Interviews at the governor’s central communications office revealed there was no written plan in case of a disaster. Government officials said they had no knowledge of a coordinated plan between the health department and public safety department to report deaths.

Instructional materials about death certification did not tell providers how to handle deaths in the event of a disaster. And so many deaths that were related to the damage from the hurricane were not recorded as storm-related, complicating efforts by officials to identify Maria’s death total.

John Mutter, a professor at Columbia University who researches disaster management, said death certificates are “critical” to determining what is attributable to the hurricane. Mutter, who was not involved in the GW study, said specific death information can help researchers identify who died as a result of the disaster and who were the most vulnerable populations.

“It is the way we scale tragedy,” he said, noting that he believes the GW study is a good estimate.

The report offered recommendations on how Puerto Rico can improve its response systems, including updating communications plans and enhancing training for public health professionals. Those investments could prove tricky for the island, however, because its finances are controlled by a federally appointed fiscal control board.

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Scientists unpick how cannabis component may fight psychosis

LONDON (Reuters) – British scientists have unraveled how a non-intoxicating component of cannabis acts in key brain areas to reduce abnormal activity in patients at risk of psychosis, suggesting the ingredient could become a novel anti-psychotic medicine.

Green shoots of cannabis are seen in a field overlooking a lake in Yammouneh in West of Baalbek, Lebanon August 13, 2018. Picture taken August 13, 2018. REUTERS/Mohamed Azakir

While regular use of potent forms of cannabis can increase the chances of developing psychosis, the chemical cannabidiol or CBD appears to have the opposite effect.

CBD is the same cannabis compound that has also shown benefits in epilepsy, leading in June to the first U.S. approval of a cannabis-based drug, a purified form of CBD from GW Pharmaceuticals.

Previous research at King’s College London had shown that CBD seemed to counter the effects of tetrahydrocannabinol or THC, the substance in cannabis that makes people high. But how this happened was a mystery.

Now, by scanning the brains of 33 young people who were experiencing distressing psychotic symptoms but had not been diagnosed with full-blown psychosis, Sagnik Bhattacharyya and colleagues showed that giving CBD capsules reduced abnormal activity in the striatum, medial temporal cortex and midbrain.

Abnormalities in all three of these brain regions have been linked to the onset of psychotic disorders such as schizophrenia.

Most current anti-psychotic drugs target the dopamine chemical signaling system in the brain, while CBD works in a different way.

Significantly, the compound is very well tolerated, avoiding the adverse side effects such as weight gain and other metabolic problems associated with existing medicines.

“One of the reasons CBD is exciting is because it is very well tolerated compared to the other anti-psychotics we have available,” Bhattacharyya of King’s College said.

“There is an urgent need for a safe treatment for young people at risk of psychosis.”

The Institute of Psychiatry, Psychology and Neuroscience at King’s College now plans a large 300-patient clinical trial to test the true potential of CBD as a treatment. Recruitment into the trial is expected to start in early 2019.

The latest findings underscore the complexity of the cocktail of chemicals found within the marijuana plant, at a time when cannabis laws are becoming more liberalized in many countries.

Reporting by Ben Hirschler; Editing by Kirsten Donovan

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Doctors may not follow peanut guidelines for allergy-prone babies

(Reuters Health) – Primary care physicians and pediatricians may not be following current guidelines that recommend introducing puréed peanuts to allergy-prone babies before the age of 6 months, a Canadian study suggests.

In a survey of pediatricians, family doctors and allergy specialists, the majority of pediatricians and family doctors recommended introducing allergenic foods between 6 months and 1 year of age. Most allergists correctly said milk, egg and puréed peanuts or peanut powder should be introduced between the ages of 4 and 6 months.

Emerging evidence that early peanut ingestion can help prevent peanut allergy in high-risk children has resulted in changing guidelines, said lead study author Dr. Elissa Abrams, a pediatric allergist at the University of Manitoba in Winnipeg.

“We felt it was important to identify what knowledge gaps existed, if any, among both primary care physicians and allergists with respect to guidelines about allergy prevention in infancy,” Abrams said in an email.

The researchers sent a survey to members of the Canadian Pediatric Society, the Canadian Society of Allergy and Clinical Immunology and a wide sample of Canadian family physicians. The survey asked about the doctor’s approach to managing infants at high risk for food allergies.

Eighty allergists, 170 pediatricians and 206 family practice physicians responded.

“Some primary care physicians are still recommending delaying introduction of allergenic solids, which was an interesting finding as the guidelines support earlier introduction of these foods to prevent food allergy, especially in children with a family history of allergies,” Abrams said.

Infants with known egg allergy or severe eczema are also considered to be at high risk of other food allergies, the study team writes in The Journal of Allergy and Clinical Immunology: In Practice. After being evaluated by a physician, these kids should be introduced to peanut between 4 and 6 months of age.

In the survey, allergists were almost 10 times more likely than pediatricians and family practitioners to recommend allergy testing before introducing peanuts to infants with severe eczema. Only 17 percent of allergists, 8 percent of pediatricians and 10 percent of family practitioners routinely recommended peanut allergy testing in infants with egg allergies, however.

Almost all allergists considered infants with severe eczema or egg allergy as being high risk. Most family practitioners and pediatricians defined high risk as having siblings or parents with peanut allergy.

“American Academy of Pediatrics and the Canadian Pediatric Society guidelines have defined an infant at risk of food allergy as having one or more immediate family members with an allergic condition such as food allergy, allergic rhinitis (hayfever), asthma, or eczema,” Abrams said.

The National Institute of Allergy and Infectious Diseases addendum guideline on peanut allergy prevention more recently defined an infant at risk of peanut allergy specifically as having either severe eczema and/or egg allergy. It’s likely that risk is a gradient, and perhaps some infants – such as those with severe eczema – are at higher risk than others, Abrams noted.

The researchers also found that allergists tended to recommend at least three feedings of peanuts each week, while the other practitioners didn’t offer any advice on how often peanuts should be fed after they’re introduced.

“I think this was a much-needed study to give an idea of how the guidelines are being implemented clinically,” said Dr. Rita Kachru, an allergist at the David Geffen School of Medicine at the University of California, Los Angeles who wasn’t involved in the study.

The results underline the need for better dissemination of data to all groups, she said.

“The recommendations in the U.S. are that infants at the highest risk for development of food allergy (severe eczema and/or egg allergy) be introduced to peanut as early as 4-6 months after allergy testing either by serology (specific IgE) or skin testing,” Kachru said in an email.

“If the testing is negative, introduction of food is implemented; if the testing is done by pediatrician/FP and is positive, the recommendation is a referral to an allergist for possible further testing/oral challenge.”

SOURCE: The Journal of Allergy and Clinical Immunology: In Practice, online August 13, 2018.

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Parent Alert! Your Kid May Be Vaping More Than Tobacco

By now, many parents know kids are vaping sweet-smelling tobacco — often using devices that look deceptively like pens or flash drives. And most parents are hip to the prevalence of underage marijuana use.

Now comes a combo of the two: vaping pot. Experts and educators say young people are — once again — one step ahead of the adults in their lives, experimenting with this new and more heady way to consume weed.

“It’s only a matter of time” before adolescents are vaping nicotine and pot in equal measure, said Mila Vascones-Gatski, a substance abuse counselor at Arlington Public Schools in Virginia. “Anything in liquid form can go into a vape, and that’s scary.”

Surveys provide a snapshot of the problem.

Among California high school students who have used an electronic smoking device, 27 percent said they used it with some form of cannabis, according to a report by the state Department of Public Health, based on 2016 data, the latest available.

Nationally, among high school seniors who reported using a vaping device in the past year, 11 percent said they had vaped cannabis, according to a 2017 survey by the National Institute on Drug Abuse and the University of Michigan. More than half said they vaped “just flavoring” and about 33 percent said nicotine.

The California Department of Public Health says researchers do not fully understand how using cannabis oils and waxes with vapes affects health. What they do know is that vaporized cannabis can contain a lot more THC, the cannabis ingredient responsible for psychoactive effects such as anxiety and paranoia.

“When you make it into an oil or wax, the [THC] concentration can be very high,” Vascones-Gatski said. “This is when psychotic symptoms are intensified.”

Recreational marijuana use is illegal among children in all states. In California, such use was legalized for adults 21 and older beginning this year. Critics argue the change could make pot more accessible to young people, although researchers say it is too early to tell.

Meanwhile, as vaping becomes more popular and socially acceptable, more young people are bound to try pot in this form, said Stanton Glantz, professor of medicine and director of the Center for Tobacco Control Research and Education at University of California-San Francisco.

“You are starting to see the much more aggressive push for flavors” in the cannabis liquids, he said.

Some popular cannabis oil flavors include mint, jasmine, banana smoothie, pumpkin spice and gummy fish, according to industry sites.

Even if the cannabis industry says its target is not youth, there is no denying that fruity smells attract kids, Glantz said.

Zoei, a 14-year-old student at Lodi High School, about 40 minutes south of Sacramento, has seen — and smelled — that firsthand. Students who vape pot in school follow up by spraying perfume or cologne to conceal the smell because — while fruity — “it still smells like weed,” said Zoei, who spoke on condition that her last name not be used.

Some of her schoolmates vape both marijuana and nicotine in restrooms, the cafeteria, even in classrooms, despite signs around campus warning kids not to vape, she said.

She tried vaping nicotine juice once after being attracted by a sweet strawberry smell. She hasn’t vaped pot yet, but confessed she’s curious. If it were offered to her, she’d probably try it, but not at school where most kids get caught, she said.

“I just want to see what happens,” she said.

Some experts say the dangers of pot vaping among kids are receiving less attention than they should, and that the vaping industry needs more regulation.

“Schools tell us that tobacco prevention is important, but we really need something on marijuana,” said Ryan Crowdis, with the Tobacco-Use Prevention Education program at the Orange County Department of Education. “The problem is our hands are tied because our funding comes from the tobacco tax revenue, so that’s what we have to focus on.”

The state Department of Education said it expects to receive funding from Proposition 64, the ballot measure that legalized recreational pot, in the 2019-20 budget to help fund education and awareness around youth use of marijuana.

Industry representatives deny trying to appeal to youths. “In no way, shape or form do I see brands trying to ingratiate children or underage users. There’s plenty of business in the adult market,” said Farley Cahen, the founder and CEO of Elevated Agency, which does marketing for cannabis companies.

Cahen said the California law legalizing recreational pot for adults came with strict packaging regulations that prohibit language or wrapping that could be attractive to children.

Some of the fruity smells in some cannabis oils come from the manipulation of terpenes, the compound responsible for the plant’s aroma, he explained. But he said that flavorings are in no way promoted like candy-like nicotine juices.

Nicotine liquids, also referred to as e-juices, come in thousands of flavors often with playful names such as fried cream cakes, booger sugar, candy cane and sundae drizzle.

Cannabis oils can come in preloaded cartridges — also called pods — that are inserted into vaping devices. One popular marijuana pen-and-pod device is the Pax Era, which is often referred to as the “iPhone of vapes” because of its high-tech features, said Stephan Lambert, a prevention coordinator at the Orange County Department of Education.

The Pax Era is manufactured by the parent company of the Juul, a vape pen for tobacco use that burst onto the teen scene within the past two years and has become a nightmare for schools because of its resemblance to a flash drive. The Pax Era looks similar to the Juul.

But teens are tech-savvy and aren’t necessarily buying devices made just for marijuana. For instance, Lambert said, they’re learning how to refill their Juul pods, the cartridges that contain e-juice, with different blends, including marijuana oils, with the help of video tutorials on YouTube.

“These oils are becoming very mainstream and very easy to access,” he said.

KHN’s coverage of these topics is supported by
California Health Care Foundation and
Heising-Simons Foundation

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

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Shifting Gears: Insuring Your Health Column — Born With The ACA — Draws To A Close

Until I started writing the Insuring Your Health column eight years ago, I had no idea what a medical loss ratio was, and I’d surely never used the words “benchmark silver plan” in a story. If asked, I would have guessed that “ACA” stood for the American Canoe Association (which is actually a thing, by the way).

Now I know better. Way better, having written once or twice a week for several years about how the Affordable Care Act has affected consumers’ health care coverage and costs.

I’ve delved into other coverage issues along the way as well, but the huge changes brought about by the 2010 health law have been a constant focus.

Now it’s time to shift gears. This is the last Insuring Your Health column. But it isn’t the last time you’ll hear from me at Kaiser Health News. I’ll continue writing regularly about consumer health care for KHN, just not every Tuesday. With the added flexibility I want to be able to now and then take a broader look at some of the consumer health areas I’ve been writing about over the years. I hope you will keep reading and giving me feedback.

I couldn’t do this work without a lot of help. Thanks to the many, many smart and thoughtful pros who’ve carved out time to talk with me again and again to help me understand the devil-in-the-details of medicine, health law and policy. I expect I’ll be calling on some of you this week to chat.

Thanks also to the amazing team of committed journalists at KHN who produce such great work day in and day out. They are an inspiration.

Most of all, I’d like to thank the many people who’ve shared their stories with me over the years and allowed me to write about them. People like Kristen Catton, who faced thousands of dollars in bills when her health plan changed how it covered her multiple sclerosis drug. Or Phyllis Petruzzelli, who avoided a hospital stay for pneumonia by being “admitted” to her living room through a hospital-at-home program. Those experiences explain health policy in personal terms for readers, and I’m so grateful to the many people who’ve trusted me to tell their stories.

And I hope you’ll keep on doing so! Hearing from real readers about their boots-on-the-ground experiences in the health care trenches, as it were, is invaluable.

Please let me know what’s on your mind and how the system is working for you. You can reach me at I look forward to hearing your thoughts and ideas.

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Heart benefits of fish oil, aspirin questioned in diabetics

(Reuters Health) – A new large study of fish oil and aspirin in people with diabetes has found that the oil supplements don’t prevent first-time heart attacks or strokes, yet aspirin does, although the benefit of aspirin therapy is canceled out by a higher risk of unwanted bleeding.

Nearly 15,500 volunteers were tested to see if either treatment made a difference. None of them had heart disease at the start of the study but all had diabetes, which typically increases the risk of cardiovascular problems two- to three-fold.

The results from the ASCEND study were reported Sunday at the European Society of Cardiology’s Annual Congress in Munich and online in The New England Journal of Medicine.

In the fish oil portion of the study, half the patients took a daily 1-gram capsule of n-3 fatty acids and the rest took a capsule containing olive oil as a placebo.

Participants were tracked for close to 7.5 years, on average. During that time, 9.2 percent of people taking the placebo died of heart disease, suffered a non-fatal heart attack or stroke, or experienced a mini-stroke known as a transient ischemic attack or TIA. The rate among fish oil recipients was 8.9 percent, a statistically insignificant difference.

Similarly, fish oil didn’t lower the risk of needing to have a blocked artery reopened. That procedure was done in 11.5 percent in the placebo group and 11.4 percent in the fish oil group.

When all causes of death were examined, the story was the same, with 9.7 percent in the fish oil group dying during the study compared with 10.2 percent with olive oil placebo, another insignificant difference.

“The study provides much-needed clarity regarding the benefits of fish oil supplements for people with diabetes but no history of cardiovascular disease,” said coauthor Dr. Louise Bowman in an email to Reuters Health. “The fish oil supplements were safe, but offered no added benefit.”

Dr. Bowman, a professor of medicine and clinical trials in the Nuffield Department of Population Health at the University of Oxford, said, “There are ongoing trials which are looking at the effects of higher doses, and so it remains to be seen whether a higher dose would be effective in preventing vascular events.”

But, she said, “a higher dose may not be so well-tolerated by patients.”

In the aspirin study, people who took 100 milligrams daily had a lower rate of cardiovascular events. The rates were 8.5 percent with aspirin and 9.6 percent with matching placebo – in this case a statistically significant difference.

But the odds of bleeding – including brain, stomach, eye or other serious bleeding – were higher as well: 4.1 percent with aspirin versus 3.2 percent with placebo.

Thus, while aspirin lowered the odds of serious cardiovascular events by 12 percent, it upped the risk of major bleeding by 29 percent.

“The absolute benefits were largely counterbalanced by the bleeding hazard,” said the team, led by Dr. Jane Armitage, Professor of Clinical Trials and Epidemiology at Nuffield.

The risk of fatal bleeding was the same in both groups.

The benefits of aspirin for people known to have heart disease are well established.

As for people without heart disease, “There is already good evidence that if you are healthy and not had any heart attacks, strokes or circulatory problems, the increased risk of bleeding from aspirin outweighs the small benefit from preventing heart attacks and strokes,” Dr. Armitage said. “We have now shown that the same applies to people with diabetes who have not had any circulatory problems.”

In general, the aspirin result “is good news for patients that they don’t have to take an extra tablet,” said Dr. Armitage. “This may allow some patients to stop aspirin and avoid the on-going risk of bleeding.”

Dr. Bowman said the ASCEND study is unique because it “ is one of the largest ever trials in diabetes and provides important information about two medical treatments, aspirin and fish oils. However, it was designed to be run extremely cost-effectively, using mail-based approaches, and so provided reliable information, relevant to the 400 million people in the world with diabetes, at a fraction of the cost of most large-scale clinical trials.”

SOURCE: and The New England Journal of Medicine, online August 26, 2018.

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Children taking multiple medications at risk for severe reactions

(Reuters Health) – Nearly one in five American children use at least one prescription medication, and roughly one in 13 kids takes more than one prescription drug, according to a new study.

And among the children taking more than one medication, one in 12 is at risk of a harmful drug interaction, researchers report in Pediatrics.

Adolescent girls are most at risk of adverse reactions, including a potentially deadly heart condition, the researchers found. In fact, one in five of those taking multiple medications were found to be at risk of a major drug-drug interaction.

“Currently, adverse drug events are the leading cause of injuries and death among children and adolescents,” said the study’s lead author, Dima Qato, of the College of Pharmacy at the University of Illinois at Chicago.

“Parents need to ask their pharmacist or pediatrician about potential side effects and interactions associated with the medications their children are taking,” Qato said. “Prescribers also need to be aware and to be proactive and to ask their patients and their patients’ parents about the medications being taken.”

Qato and her colleagues analyzed the medication use of 23,179 children and adolescents who were participants in the larger ongoing National Health and Nutrition Examination Survey (NHANES). For children under the age of 16, parents provided information on medication use. Those who were 16 or older answered for themselves.

Overall, 19.8 percent of children and adolescents had taken at least one prescription medication in the previous 30 days, with 13.9 percent using medications long-term and 7.1 percent using them for a short period of time.

Medication use increased with age, from 14.7 percent in children up to age 5 years to 22.8 percent among adolescents aged 13 to 19 years old. Short term use was most common among the younger children, who were less likely to be taking medications long term.

The most common medications were respiratory agents, usually for asthma, and psychotherapeutic agents, including stimulants and antidepressants.

The vast majority of potential drug-drug interactions involved antidepressants. The most common potential interaction was QT prolongation, an abnormal heart rhythm that can cause sudden death in otherwise healthy kids.

“QT could occur within days,” Qato said. “It can last more than a month after taking the drug. So even though a child may have used the drug for a week or a few weeks, the adverse effect can be a serious one.”

The study didn’t look at whether any of the children actually developed any of the potential side effects from their medications. It only looked at how many kids were at risk.

Still, the findings were a surprise to Dr. Nathan Samras, an assistant professor in the division of pediatrics and internal medicine at the University of California, Los Angeles.

“It was eye opening,” said Samras, who was unaffiliated with the new study. “I was surprised by the prevalence of prescriptions for all kids as well as the potential for drug-drug interactions.”

Samras said he hopes the new research will prompt parents to report all medications taken by their children – including those sold over-the-counter – to the children’s doctors.

While praising the study for raising awareness of possible dangerous drug interactions, Samras said he hoped it would not lead to parents and physicians “overreacting.”

“You don’t want people to be too scared to use medications when they have more potential benefits than risks,” he explained.

“The absence of data on actual outcomes makes the decision process more difficult,” Samras said. “But being aware of possible drug-drug interactions is important in making prescribing choices.”

SOURCE: Pediatrics, online August 27, 2018.

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A Jolt To The Jugular! You’re Insured But Still Owe $109K For Your Heart Attack

Drew Calver took out his trash cans and then waved goodbye to his wife, Erin, as she left for the grocery store the morning that upended his picture-perfect life.

Minutes later, the popular high school history teacher and swim coach in Austin, Texas, collapsed in his bedroom from a heart attack. He pounded his fist on the bed frame, violent chest pains pinning him to the floor.

“I thought I was dying,” the 44-year-old father recalled. He called out to the only other person in the house, his oldest daughter, Eleanor, now 7. Using his voice, he texted his wife, who was at the store with their youngest, Emory, now 6. A neighbor rushed him to the nearby emergency room at St. David’s Medical Center on April 2, 2017.

The ER doctors confirmed the trauma to Calver’s heart and admitted him to the hospital’s cardiac unit. The next day, doctors implanted stents in his clogged “widow-maker” artery.

The heart attack was a shock for Calver, an avid swimmer who had competed in an Ironman triathlon just five months before.

Despite the surprise, even from his hospital bed, Calver asked whether his health insurance would cover all of this, a financial worry that accompanies nearly every American hospital stay. He was concerned because St. David’s is out-of-network on his school district health plan. The hospital told him not to worry and that they would accept his insurance, Calver said.

The hospital charged $164,941 for his surgery and four days in the hospital. Aetna, which administers health benefits for the Austin Independent School District, paid the hospital $55,840, records show. Despite the difference of more than $100,000, with the hospital’s prior assurance, Calver believed he would not bear much, if any, out-of-pocket payment for his life-threatening emergency and the surgery that saved him.

And then the bills came.

Patient: Drew Calver, 44, a high school history teacher and father of two in Austin, Texas.

Total Bill: $164,941 for a four-day hospital stay, including $42,944 for four stents and $10,920 for room charges. Calver’s insurer paid $55,840. The hospital billed Calver for the unpaid balance of $108,951.31.

Service Provider: St. David’s HealthCare, a large hospital system in central Texas. It’s run by HCA Healthcare, the nation’s largest for-profit hospital chain, and two nonprofit foundations.

Medical Treatment: Emergency room treatment followed by four days in the hospital, most of it spent in the cardiac unit. During surgery, four stents were implanted to clear a blockage in his left anterior descending artery, the source of so-called widow-maker heart attacks, because they are so frequently deadly.

What Gives: St. David’s Medical Center is billing Calver for the $109,000 balance — an amount nearly twice his annual pay as a teacher.

The hospital’s billing company sent a notice June 26, urging him to take advantage of this “FINAL opportunity to settle your balance.”

“They’re going to give me another heart attack stressing over this bill,” Calver said. “I can’t pay this bill on my teacher salary, and I don’t want this to go to a debt collector.”

In the wake of his heart attack, Calver fell victim to twin medical billing practices that increasingly bedevil many Americans, even as legislators have tried to protect them: surprise bills and balance billing.

Surprise bills occur when a patient goes to a hospital in his insurance network but receives treatment from a doctor that does not participate in the network, resulting in a direct bill to the patient. They can also occur in cases like Calver’s, where insurers will pay for needed emergency care at the closest hospital — even if it is out-of-network — but the hospital and the insurer may not agree on a reasonable price. The hospital then demands that patients pay the difference, in a practice called balance billing.

The total bill for Drew Calver’s four-day hospital stay at St. David’s Medical Center in April 2017 was $164,941.(Callie Richmond for KHN)

His insurer paid $55,840, leaving Calver responsible for the unpaid balance of $108,951.31.(Callie Richmond for KHN)

Several states, including Texas (as well as New York, California and New Jersey) have passed laws to help shield consumers from surprise bills and balance billing, particularly for emergency care.

But there’s a huge loophole: Those state-mandated protections don’t apply to people, like the Calver family, who get their health coverage from employers that are self-insured, meaning the companies or public employers pay claims out of their own funds.  Federal law governs those health plans — and it does not include such protections.

About 60 percent of people with employer health benefits are covered by self-insured plans, but many don’t even know it, since employers typically hire an insurer to administer the plan and employees carry a card bearing the name of Blue Cross Blue Shield or another major insurer.

Drew Calver sits with his wife, Erin, and daughters Eleanor (left) and Emory (middle) in their Austin, Texas, home where he had a heart attack on April 2, 2017.(Callie Richmond for KHN)

This case “illustrates the dangers that even insured people face,” said Carol Lucas, an attorney in Los Angeles with experience in health care payment disputes. “The unfairness is especially acute when there is an emergency and the patient, who might ordinarily be completely compliant, has no say about the facility he winds up in.”

In a statement, St. David’s HealthCare defended its handling of Calver’s bill and sought to blame the school district and Aetna for offering such a narrow network.

“While we did everything right in this particular situation, the structure of the patient’s insurance plan as a narrow network product placed a large portion of the financial responsibility directly on the patient because our hospital was not in-network,” the hospital said.

Patients experiencing an emergency are particularly at risk of landing at an out-of-network hospital. St. David’s said once ER patients are deemed stable, it tries to transfer them to an in-network facility. “However, this is not always possible because the patient’s health must come first,” the hospital said.

This case also raises questions about the validity of the hospital’s charges.

Industry analysts and consumer advocates say St. David’s has a reputation for exorbitant billing and for trying to collect big payouts as an out-of-network provider. “This is a well-known, problematic provider. We’ve seen multiple bills from them and they are always highly inflated,” said Dr. Merrit Quarum, chief executive of WellRithms, which scrutinizes medical bills for self-funded employers and other clients nationwide.

WellRithms reviewed Calver’s bill in detail at the request of Kaiser Health News and determined that a reasonable reimbursement would have been $26,985. That’s less than half what Aetna paid.

Healthcare Bluebook, which offers cost estimates for medical tests and treatments, arrived at a similar conclusion. It said a fair price for a hospitalization in Austin involving four heart stents would be about $36,800. St. David’s Medical Center charged four times that amount.

Quarum and other analysts who reviewed the bill said several charges stood out, especially on the four stents, which were billed at $42,944. Coronary stents are typically metal mesh tubes implanted in arteries to improve blood flow. Most are coated with drugs to assist in healing.

St. David’s charged $19,708 apiece for two Synergy stents made by device giant Boston Scientific. Two other stents used were far cheaper.

The $20,000 price tag represents a significant markup of what U.S. hospitals typically pay themselves for stents. The median price paid by hospitals for the Synergy stent was $1,153 over the past year, according to the nonprofit research firm ECRI Institute.

“St. David’s charge of over $19,000 for those stents is absolutely outrageous,” Quarum said.

St. David’s declined to comment on its markup for the stents or what it actually paid the manufacturer.

Resolution: For now, Calver still faces a bill for $108,951.31, with none of the parties involved in his treatment or coverage providing significant redress.

In fact, the hospital’s debt collector sent the Calvers a letter Aug. 3 demanding payment in full.

After a reporter made inquiries, St. David’s said collection efforts were put on hold, and a hospital representative called Calver, offering to help him apply for a discount based on his income.

In a statement, St. David’s said “we work with all patients needing financial assistance to help determine their eligibility for this discount.”

Calver said that approach doesn’t address the balance billing or whether the charges were appropriate.

A spokeswoman for Aetna said “we are actively working to rectify the situation on behalf of the member.” But the health plan hasn’t shared any further details. The Austin school district declined to discuss this specific case.

Calver said the whole ordeal has been incredibly stressful for him and his wife.

“I am stuck in the middle of this convoluted, flawed system,” he said. “I’ve never owed a large amount like this or had credit card debt. What does it mean if this goes on my credit report?”

Drew Calver’s daughters visit him at the hospital in April 2017 after his heart attack and resulting emergency surgery.(Courtesy of the Calver family)

The Takeaway: Faced with a surprise bill or a balance-billing situation, don’t rush to pay any medical bills you receive. First, let the insurance process play out completely so you’re sure what the health plan is paying the hospital and doctors — and what you ultimately might be responsible for, in terms of coinsurance or copayments.

Ask for an itemized bill. Review the charges carefully and talk to your insurer, your employer and the hospital if the prices seem out of line. Arm yourself with estimates you can find online of the average prices charged in your area as you negotiate with all the players.

If the bills keep coming, talk to your employer’s benefits department or the state insurance department about your legal protections. The situation will vary depending on the type of health insurance you have and the state you live in. Tell any debt collection agencies that may contact you that you are contesting the bill.

With any of these entities, you can always appeal to reason, with this argument: You had no choice but to go to an out-of-network hospital in the case of a life-threatening emergency, so the insurer and the hospital should work out payment and hold you harmless from financially crippling bills.

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

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The Doctors Want In: Democratic Docs Talk Health Care On The Campaign Trail

Dr. Rob Davidson, an emergency physician from western Michigan, had never considered running for Congress. Then came February 2017. The 46-year-old Democrat found himself at a local town-hall meeting going toe-to-toe with Rep. Bill Huizenga, his Republican congressman of the previous six years.

“I told him about my patients,” Davidson recalled. “I see, every shift, some impact of not having adequate health care, not having dental insurance or a doctor at all.”

His comments triggered cheers from the audience but didn’t seem to register with Huizenga, a vocal Obamacare critic. And that got Davidson thinking.

Dr. Rob Davidson (Courtesy of Rob Davidson’s campaign)

“I’ve always been very upset … about patients who can’t get health care,” he said. But it never inspired him to act. Until this June, that is, when the political novice joined what is now at least eight other Democratic physicians running in races across the country as first-time candidates for Congress.

Democrats hope to gain control of Congress by harnessing what polls show to be voters’ dissatisfaction with both Capitol Hill and President Donald Trump. The president maintains Republican support but registers low approval ratings among Americans overall, according to news organization FiveThirtyEight. Democrats also see promise in candidates such as Davidson, a left-leaning physician who may have a special advantage: firsthand health system experience.

Polls by Quinnipiac University, The Wall Street Journal and the Kaiser Family Foundation suggest health care is among voters’ top concerns as midterm elections approach. (Kaiser Health News is an editorially independent project of the foundation.)

Of the Democratic doctors running for office, all but one are seeking House seats. In addition to the nine newcomers, there are two incumbents up for re-election. Each candidate is campaigning hard on the need to reform the health care system.

And they present a stark contrast to Congress’ current physician makeup.

Twelve of the 14 doctors now in Congress are Republicans. Three are senators. Half of the 14 practice in high-paying specialties such as orthopedic surgery, urology and anesthesiology.

By contrast, these stumping Democratic physicians hail predominantly from specialties such as emergency medicine, pediatrics and internal medicine, though one is a radiologist. They’re fighting to represent a mix of rural, urban and suburban districts.

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“Electing Democratic doctors would certainly change the face of medicine in Congress, and perhaps lend more credence in that body to more liberal health care policies,” said Dr. Matthew Goldenberg, a psychiatrist at Yale School of Medicine who has researched political behavior and advocacy among doctors.

Physicians once trended Republican. The infusion of female and minority doctors, experts said, has changed this. Now, more than 50 percent of party-affiliated doctors are Democrats, and the medical establishment has — following Republican efforts to undo Obamacare — emerged as a staunch defender of the law.

Indeed, many doctor-candidates point to the GOP’s repeal-and-replace efforts as their motivation.

“It’s at a boiling point for many of these physicians,” said Jim Duffett, executive director of the left-leaning Doctors for America, which supports universal health care.

While health care consistently emerges as a top issue, Democrats are more likely to rank it No. 1. For independents and Republicans, though, it’s neck and neck with the economy — and some political analysts question how effective it will be in flipping conservative districts.

“Democrat voters blame Republicans for the problems with health care right now. Republicans blame Democrats. Independents say, ‘A pox on both your houses,’” argued Jim McLaughlin, a Republican pollster working on several 2018 races who has previously worked with Trump. “They’re making a big mistake thinking they can run on [health care].”

That said, doctors can be effective messengers, especially in their communities.

Research suggests Americans hold their own physicians in high regard.

“Voters listen carefully to what physicians have to say about health policy,” said Jonathan Oberlander, a professor of social medicine and health policy at the University of North Carolina. “In a district that’s not so one-sided red or blue, there’s no question that the white coat confers prestige. It’s something physician candidates can speak to with authority.”

Dr. Kyle Horton (Courtesy of Kyle Horton’s campaign)

Davidson, for instance, supports a “Medicare-for-all”-style overhaul, an approach that involves expanding the federal insurance program for seniors and disabled people to all Americans. If elected, he said, he intends to join Democrats’ burgeoning support for a single-payer system, in which the government runs the sole health insurance program, guaranteeing universal coverage. He did not have a primary challenge and is running against Huizenga, the Republican incumbent, in the general election for Michigan’s 2nd Congressional District.

Or there’s Dr. Kyle Horton, an internist running in the North Carolina 7th District. She supports expanding Medicare, by lowering the eligibility age from 65 to 50. She also supports a “public option” health insurance plan sold by the government.

Dr. Hiral Tipirneni (Courtesy of Hiral Tipirneni’s campaign)

Dr. Hiral Tipirneni, an emergency physician in Arizona’s 8th Congressional District, asserts all Americans should be able to buy in to Medicare.

Physicians can have an advantage on other controversial topics, by casting them as public health issues, said Howard Rosenthal, a political scientist at New York University.

Davidson’s campaign, for instance, posts videos on Facebook in which he talks about topics such as health care access and gun violence. One — filmed after an overnight ER shift — has gotten 41,000 views so far.

Also spurring physicians: concerns about abortion access.

Dr. Cathleen London (Courtesy of Kathleen London’s campaign)

Dr. Cathleen London, a Maine doctor, launched her campaign against four-term incumbent GOP Sen. Susan Collins for the 2020 election. She said she had been considering a run, but the upcoming vote for a justice to replace Anthony Kennedy on the Supreme Court — which could have sweeping implications for reproductive health law — pushed her to declare.

“Doctors are really frustrated with Washington, frustrated with the lack of listening to us,” London said.

Many of these Democrats face steep climbs.

Dr. Kim Schrier (Courtesy of Kim Schrier’s campaign)

Of races featuring newcomer physicians, the Cook Political Report, which analyzes elections, rates only Arizona’s 2nd Congressional District as leaning Democratic, and the doctor in that race is just one of seven candidates in the primary. The outcome for Washington’s 8th District, where Dr. Kim Schrier, a pediatrician, is a candidate, is considered a toss-up and a Democratic pickup target.

Tipirneni is the only non-incumbent doctor to have a fundraising advantage so far, according to data from Open Secrets, a nonpartisan, nonprofit project tracking campaign-finance records.

Regardless of electoral results, many observers say the potential implications are sizable — even if few doctors go to Washington.

“They are planting a flag, and they’re going to be raising some important issues — not just health care, but health care is going to be front and center,” said Duffett, from Doctors for America. “That will help change the political debate and political landscape.”

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