Following Surgery To Remove Brain Tumor, Uninsured Patients May Be More Likely Than Insured To Die

Main Category: Health Insurance / Medical Insurance
Also Included In: Neurology / Neuroscience;  Medicare / Medicaid / SCHIP
Article Date: 21 Nov 2012 – 0:00 PST

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Following Surgery To Remove Brain Tumor, Uninsured Patients May Be More Likely Than Insured To Die

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Uninsured patients who undergo surgery to remove a brain tumor could be twice as likely to die in the hospital as those who have the same operation but are privately insured, new Johns Hopkins research suggests. In teaching hospitals, where most neurosurgical procedures take place, those with government-subsidized insurance in the form of Medicaid were found in the same study to have rates of survival closer to those who are privately insured.

“Although the absolute rate of death in both groups is relatively low, the numbers are telling us that there’s a disproportionate amount of mortality associated with not having any insurance at all,” says Alfredo Quinones-Hinojosa, M.D., a professor of neurosurgery and oncology at the Johns Hopkins University School of Medicine and leader of the study described in the November issue of the Archives of Surgery. “We have a finding that patients with no insurance whatsoever have worse outcomes, and we don’t have a medical explanation for why that is.”

Quinones-Hinojosa emphasized that the disparities uncovered in a review of more than 28,000 patient medical records were unlikely to be accounted for by a patient’s overall state of health, or the ability to access care, factors often cited to explain why the uninsured fare worse. In fact, the researchers found that in patients with no illnesses other than the brain tumor, the uninsured had a threefold higher risk of dying in the hospital compared to privately insured patients.

He says he was surprised to find that patients with state-supported insurance in the form of Medicaid did somewhat better than those with no insurance.

Approximately 612,000 people in the United States have a diagnosis of a primary brain or nervous system tumor. Malignant brain tumors cause roughly 13,000 deaths annually and those diagnosed have a five-year survival rate of about 35 percent.

In their study, Quinones-Hinojosa and his team analyzed data from 28,582 patients between the ages of 18 and 65 who underwent craniotomy (open-skull surgery) for a brain tumor between 1999 and 2008. The data were part of the Nationwide Inpatient Sample (NIS) database. Most of the patients with government insurance were on Medicaid and not Medicare because they were under the age of 65, when Medicare typically kicks in. The researchers found that the uninsured patients were twice as likely to die in the hospital as those who had the same operation but were privately insured.

In general, according to previous research, insurance status may influence health outcomes by affecting a patient’s overall health, the ability to access care (meaning they come to a doctor after a disease has become more serious) or the quality of the treatment delivered. Quinones-Hinojosa says the study did not eliminate the possibility that patients who are not able to see a doctor regularly have some medical conditions that are undiagnosed, and therefore are not listed as having other medical conditions in the database that was used. These patients may appear healthy “on paper,” but in reality, they could have any number of debilitating medical conditions and may be more likely to have a worse outcome after surgery.

Another possibility – that caregivers treat uninsured patients differently – is one that needs to be closely looked at, he says.

“This research raises more questions than it answers,” he says. “Do we treat these patients differently because they don’t have insurance? Are we more eager to withdraw care because the expense of caring for these patients falls on the shoulders of the hospital? I’m hoping that’s not the case, but it’s something we have to talk about. We need to be aware of these issues and make sure we are making decisions based on sound medical judgment and not some other factor.”

Other research has been done and has found that for other critically ill patients, patients without insurance are more likely to die than those with private insurance.

The research was funded by grants made to the authors by the Doris Duke Charitable Foundation, VSBfonds, the Prins Bernhard Cultuurfonds and the Robert Wood Johnson Foundation.

Other Johns Hopkins researchers involved in the study include Eric N. Momin, B.A.; Hadie Adams, M.D.; Russell T. Shinohara, M.Sc.; Constantine Frangakis, Ph.D.; and Henry Brem, M.D.

Johns Hopkins Medicine

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Improving Outpatient Management Could Reduce The High Rate Of Readmission Of Kidney Transplant Patients

Main Category: Transplants / Organ Donations
Also Included In: Urology / Nephrology;  Medicare / Medicaid / SCHIP
Article Date: 18 Oct 2012 – 0:00 PDT

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Three in 10 patients receiving a kidney transplant require readmission to the hospital within 30 days of discharge following surgery, according to a Johns Hopkins analysis of six years of national data.

The findings, published online in the American Journal of Transplantation, suggest more needs to be done to manage patients outside the hospital to keep them from costly and potentially preventable return visits. Readmissions are said to cost the U.S. health care system $25 billion a year. The Centers for Medicare and Medicaid Services has begun the process of decreasing reimbursements to hospitals with high readmission rates, using readmissions as a surrogate measure of hospital quality.

“We need to be aware that kidney transplant recipients have an extremely high risk of returning to the hospital in the first 30 days after discharge, and that readmissions may very well be prevented by putting in place better systems for outpatient management,” says study leader Dorry L. Segev, M.D., Ph.D., an associate professor of surgery at the Johns Hopkins University School of Medicine. “Some patients just need more intense monitoring.”

Segev and his colleagues examined data provided by the Organ Procurement and Transplantation Network, Medicare, and the United States Renal Data System from more than 32,000 patients who received kidney transplants in U.S. hospitals between Jan. 1, 2000 and Dec. 31, 2005. While 31 percent of transplant recipients required readmission within 30 days, the percent of patients returning varied by hospital, from 18 percent to nearly 50 percent, a variation that could not be accounted for by conventional issues of center volume or demographics.

Age, race, body mass index, diabetes, heart disease and several other factors were associated with early hospital readmission. African-Americans had an 11 percent increased risk of readmission, and obese patients had a 15 percent increased risk, while diabetic women were at a 29 percent increased risk. Interestingly, those patients who stayed in the hospital for five or more days at the time of their transplants were more likely to be readmitted within 30 days. Segev says this may be a sign that the more complex cases early on appear to remain complex and more likely to require additional care.

Patients who bounce back to the hospital are not returning only for complications related to their new organs – such as infections or problems related to immunosuppressant drugs they need to keep from rejecting the new organ – but often for problems related to other illnesses they had before they received their transplants. Segev says even though medical teams make sure that the heart disease or diabetes a transplant candidate may have is stable before a transplant takes place, those conditions can still cause complications after surgery. The entire medical team needs to be sure people with co-morbidities are very closely followed, he says.

“Kidney transplant is complex and the management of the first 30 days is complex,” he adds. “We will never get the readmission rate down to zero, but it’s highly likely we can get it down from nearly one-third.”

Segev says he hopes that transplant centers with higher rates of readmission can learn lessons from centers with lower rates. They may find that those centers schedule more frequent outpatient visits, offer more opportunities to communicate with clinicians via email or the telephone, or are better at coordinating services such as blood work that may be needed after discharge so that critical post-transplant medication adjustments can be made quickly before a readmission is required.

Other Johns Hopkins researchers involved in the study include Mara A. McAdams-DeMarco, Ph.D.; Morgan E. Grams, M.D., M.H.S.; Erin Carlyle Hall, M.D., M.P.H.; and Josef Coresh, M.D.
The study was supported by grants from the National Kidney Foundation of Maryland, the American Federation for Aging Research, the National Institutes of Health’s National Institute on Aging (K23AG032885) and NIH’s National Institute of Diabetes and Digestive and Kidney Diseases (R21DK085409).
Johns Hopkins Medicine
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Small Study Finds Preemies From Low-Income Families At High Risk For Dangerous Brain Bleeds

Main Category: Pediatrics / Children’s Health
Also Included In: Neurology / Neuroscience;  Medicare / Medicaid / SCHIP
Article Date: 15 Oct 2012 – 0:00 PDT

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Babies born prematurely to low-income parents have a disproportionately high risk for developing dangerous brain bleeds that require multiple surgeries and extensive follow-up, according to a small Johns Hopkins Children’s Center study.

The findings – published online in the journal Pediatric Neurosurgery and based on an analysis of 38 patients referred to Johns Hopkins for treatment of brain hemorrhages related to premature birth – offer a sobering reminder of the role socio-economic factors can play in health outcomes, the researchers say.

The link between poverty and premature birth has been well-documented, the investigators say, but the new findings go a step further and focus on the consequences of one particularly dire and fairly common complication of prematurity – brain hemorrhages.

“Our study shows just how detrimental and far-reaching the effects of prematurity can be, medically and otherwise, highlighting the critical need to better identify high-risk pregnancies and reduce the number of premature births,” says Edward Ahn, M.D., pediatric neurosurgeon and senior author on the research.

“Brain hemorrhages can have a lifelong impact on a child’s neurological and cognitive development, but also create a financial burden on the families, many of whom in our study were already economically challenged,” Ahn adds.

The premature brain’s blood vessels are highly vulnerable to rapid changes in blood and brain pressure that occur around birth. While some brain bleeds are small and contained within the blood vessel, others can spread further and significantly damage the brain, particularly if not diagnosed and treated promptly. Serious hemorrhages require surgery, intensive follow-up and, often, long-term care to deal with the neurological and developmental after-effects of the condition.

The study tracked 38 babies treated at Hopkins Children’s between 2007 and 2010 for complications of brain hemorrhages they had suffered during preterm birth. Most infants in the study (65 percent) were from low-income families and received public health insurance (63 percent). Household income is not part of a standard medical record, but the researchers used zip code and Medicaid status as proxies for income. Medicaid is the public health insurance program for low-income children.

In addition to the higher risk for brain bleeds, the study showed babies from lower-income homes and those with public health insurance had fewer scheduled follow-up appointments and more emergency room visits, compared with babies with private health insurance and with those from higher income homes. The researchers note the differences were clear, even though they didn’t reach statistical significance due to the small number of patients in the study.

“If a family foregoes a scheduled follow-up and instead ends up in the ER with a serious, yet likely preventable complication, the medical and financial consequences can be far worse not only for the family but for the health care system as a whole because ER care is more expensive than routine check-ups,” Ahn says.

The investigators said their findings need to be replicated on a wider scale in order to further tease out the reasons behind the disproportionate risk.

Other investigators on the study were Courtney Pendleton, Elizabeth Cristofalo, Gabriella Biondo, George Jallo and Alfredo Qui?ones-Hinojosa, all from Hopkins.
Johns Hopkins Medicine
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Knowledge Of The Biochemical Events Needed To Maintain Erection May Lead To New Therapies For Erectile Dysfunction

Main Category: Erectile Dysfunction / Premature Ejaculation
Article Date: 28 Sep 2012 – 0:00 PDT

Knowledge Of The Biochemical Events Needed To Maintain Erection May Lead To New Therapies For Erectile Dysfunction

For two decades, scientists have known the biochemical factors that trigger penile erection, but not what’s needed to maintain one. Now an article by Johns Hopkins researchers, scheduled to be published this week by the Proceedings of the National Academy of Sciences (PNAS), uncovers the biochemical chain of events involved in that process. The information, they say, may lead to new therapies to help men who have erectile dysfunction.

“We’ve closed a gap in our knowledge,” says Arthur Burnett, M.D., professor of urology at Johns Hopkins Medicine and the senior author of the study article. “We knew that the release of the chemical nitric oxide, a neurotransmitter that is produced in nerve tissue, triggers an erection by relaxing muscles that allow blood to fill the penis. We thought that was just the initial stimulus. In our research, we wanted to understand what happens next to enable that erection to be maintained.”

In a study of mice, Burnett and his colleagues found a complex positive feedback loop in the penile nerves that triggers waves of nitric oxide to keep the penis erect. He says they now understand that the nerve impulses that originate from the brain and from physical stimulation are sustained by a cascade of chemicals that are generated during the erection following the initial release of nitric oxide. “The basic biology of erections at the rodent level is the same as in humans,” he says.

The key finding is that after the initial release of nitric oxide, a biochemical process called phosphorylation takes place to continue its release and sustain the erection.

In a landmark study published in the journal Science in 1992, Burnett and his Johns Hopkins co-author, Solomon S. Snyder, M.D., professor of neuroscience (who is also an author on the current study), showed for the first time that nitric oxide is produced in penile tissue. Their study demonstrated the key role of nitric oxide as a neurotransmitter responsible for triggering erections.

“Now, 20 years later, we know that nitric oxide is not just a blip here or there, but instead it initiates a cyclic system that continues to produce waves of the neurotransmitter from the penile nerves,” says Burnett.
With this basic biological information, it may be possible, according to Burnett, to develop new medical approaches to help men with erection problems caused by such factors as diabetes, vascular disease or nerve damage from surgical procedures. Such new approaches could be used to intervene earlier in the arousal process than current medicines approved to treat erectile dysfunction.

In particular, Burnett says, “The target for new therapies would be the protein kinase A (PKA) phosphorylation of neuronal nitric oxide synthase (nNOS). Now that we know the mechanism for causing the ‘activated’ form of nNOS in penile nerves, we can develop agents that exploit this mechanism to help with erection difficulties.”

One of the agents studied by the researchers was forskolin, an herbal compound that has been used to relax muscle and widen heart vessels. They found that forskolin also ramps up nerves and can help keep nitric oxide flowing to maintain an erection.

“It has been a 20-year journey to complete our understanding of this process,” says Snyder. “Now it may be possible to develop therapies to enhance or facilitate the process.”

Article adapted by Medical News Today from original press release. Click ‘references’ tab above for source.
Visit our erectile dysfunction / premature ejaculation section for the latest news on this subject.
The new study, “Cyclic AMP Dependent Phosphorylation of Neuronal Nitric Oxide Synthase Mediates Penile Erection,” was funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), under grant number RO1DK067223.
In addition to Burnett and Snyder, the study article’s authors are K. Joseph Hurt from the University of Colorado, Sena F. Sezen, Gwen F. Lagoda and Biljana Musicki from Johns Hopkins, and Gerald A. Rameau from Morgan State University.
Johns Hopkins Medicine
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