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Events, Health Costs, Health Policy, In the News, Medicine and Society, Stanford News

Experts discuss high costs of health-care – and what it will take to change the system

Experts discuss high costs of health-care - and what it will take to change the system

4386861133_5e79734a6f_zNew York Times reporter Elisabeth Rosenthal, MD, visited Stanford this week for a Health Policy Forum, “Can we put a price on good health? Controlling the cost of health care,” with Stanford health-policy researcher Doug Owens, MD.

Those who attended looking for answers, easy fixes, or a master villain were out of luck. Instead, attendees gained insight into a convoluted system that all agree is broken, yet no one has the total power, or know-how, to fix. Here’s Rosenthal:

The issues and the problems are so diffuse… There’s the tendency to be very reductionist – ‘Oh, it’s the hospital, it’s the insurance companies, it’s pharma’… We’re all so codependent and it’s all so intertwined.

Finances dictate what we do and the incentives are so powerful. The message to patients is that we’re responsible too.

So that complimentary coffee you might get in a hospital lobby? Not actually free, Rosenthal said. She knows: While reporting for the well-known series “Paying Till It Hurts” she has talked to scores of patients and doctors and insurance representatives and policy-makers.

The main problems with the American health-care system are cost, quality and access, Owens said. The Affordable Care Act improved access, yet did little to lower costs or improve quality, he said.

And costs will continue to escalate if all the players remain most responsive to economic pressures, Rosenthal said. “Physicians feel like their income is being squeezed. Hospitals are better prepared to push back, and hospitals and physicians are looking to recoup some of that lost income in other ways. What’s lost in that very real tug of war is that patients are held hostage in the middle. That’s what’s distressing,” she said.

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Cancer, In the News, Nutrition, Patient Care, Surgery

“Prehab” routines before cancer surgery help patients bounce back faster

Surgery_flickr_thinkpanamaIf you’ve ever had surgery, especially an orthopedic one, you’ve probably had rehabilitation therapy. In recent years, orthopedic surgery plans have begun to include a period of “prehabilitation” exercise to help prepare patients for their procedure. Now, researchers have demonstrated that a pre-surgery work-out routine combined with some dietary changes may be able to help cancer patients regain their baseline strength levels sooner. A story on NPR’s Shots blog described the recent study:

Researchers from McGill University in Montreal studied 77 patients scheduled for colorectal cancer surgery. A kinesiologist gave the patients aerobic exercises and strength training to do at home. A registered dietitian gave them nutritional counseling and prescribed a whey supplement to make up any protein deficits, and a psychologist provided anxiety-reducing relaxation exercises.

Half of the patients were told to start the program before surgery – an average of about 25 days before – and to continue afterward for eight weeks. The other group was told to start right after surgery.

Not surprisingly, the group assigned to prehabilitation did better on a presurgery test that measured how far they could walk in 6 minutes. And it paid off.

Two months after surgery, the prehabilitation group walked an average of 23.7 meters farther than when they started the study. Rehab-only patients walked an average of 21.8 meters less than when they started. (A change of 20 meters is considered clinically significant.) And a greater proportion of the prehabilitation group was back to baseline exercise capacity by then.

Because of the methology the researchers used, it’s not clear how the diet or the exercise prescribed in the pre-surgery regimen affected the outcome. Previous studies that looked at exercise-only regimens did not show post-surgery improvements. A larger study with a more varied pool of patients is likely needed for definitive answers.

Previously: Wellness after cancer: Stanford opens clinic to address survivors’ needs and A call for rehab services for cancer survivors
Photo by thinkpanama

Global Health, In the News, Infectious Disease, Microbiology, Public Health

Exploiting insect microbiomes to curb malaria and dengue

Original Title: Aa_FC2_23a.jpgEvery year, more than 200 million people are affected by malaria and 50 to 100 million new dengue infections occur. Now, a group of scientists from Johns Hopkins University may have found a novel way of curbing both diseases: by “vaccinating” mosquitos against the parasite that causes malaria and the virus that causes dengue. The researchers are using the bacteria Chromobacterium, which prevents the pathogens from effectively invading and colonizing mosquito guts.

As Science magazine reported last week:

Like humans and most other animals, mosquitoes are stuffed with microbes that live on and inside of them—their microbiome. When studying the microbes that make mosquitoes their home, researchers came across one called Chromobacterium sp. (Csp_P). They already knew that Csp_P’s close relatives were capable of producing powerful antibiotics, and they wondered if Csp_P might share the same talent.

In another experiment, done with mosquitoes that weren’t pretreated with antibiotics, Csp_P-fed mosquitoes were given blood containing the dengue virus and Plasmodium falciparum, a single-celled parasite that causes the most deadly type of malaria. Although a large number of the mosquitoes died within a few days of being infected by the Chromobacteriumthe malaria and dengue pathogens were far less successful at infecting the mosquitoes that did survive, the team reports today in PLOS Pathogens. That’s good news: If the mosquito isn’t infected by the disease-causing germs, it is less likely to be able to transmit the pathogens to humans.

The bacteria also inhibited growth of Plasmodium and dengue in lab cultures, indicating that Csp_P is producing compounds that are toxic to both pests. One possible application of these toxins is to develop treatment drugs for people already infected with malaria or dengue. Real-world applications of this research are many years in the future, but it hints at a whole new way of dealing with otherwise intractable diseases.

Previously: Close encounters: How we’re rubbing up against pathogen-packing pestsClosing the net on malaria and Fighting fire with fire? Using bacteria to inhibit the spread of dengue
Photo by Sanofi Pasteur

Cancer, Events, In the News, Patient Care, Stanford News

A neurosurgeon’s journey from doctor to cancer patient

A neurosurgeon's journey from doctor to cancer patient

image.img.320.highEarlier this week, I had the chance to hear Stanford neurosurgeon Paul Kalanithi, MD, discuss living with advanced-stage lung cancer in a conversation with palliative care specialist Timothy Quill, MD. The idea for the night’s event, which was held on the Stanford medical school campus, was to provide a good example of how the doctor-patient relationship can help improve quality of life for the very sick. On stage before a packed audience, Kalanithi, prodded by Quill’s gentle but pointed questions, told the story of how serious illness changed his life. As I wrote in an online story posted yesterday:

“Are there things in particular that you worry about now?,” asked Quill… a professor of psychiatry and medical humanities at the University of Rochester School of Medicine and an expert in end-of-life decision making. “Not really,” [Kalanithi] said. “I am sad at not seeing my daughter grow up, at probably not being here long enough for her to have a memory of me. I try to worry about things that are actually changeable. I worry about getting my book finished. I’d like to have that done for my daughter to know me.”

What surprised Kalanithi most about his life after being diagnosed with lung cancer was just how hard it was dealing with those “existential” questions, he told Quill:

“Having to deal with questions like, ‘What am I going to do with my life?’ was exceedingly difficult. After realizing I wasn’t going to die in weeks or months, figuring out what I was going to do with that time was a struggle.”

Kalanithi has reorganized his priorities since his diagnosis in May 2013, setting new priorities for a much shorter lifespan than he once expected – planning for years instead of decades. He and his wife got their finances in order, they had their first child July 4. Kalanithi said he has found solace in his love of poetry, and through his writing. Kick-starting a writing career that he had planned to start in 20 years was one of those changes.

In January, he wrote an op-ed piece for the New York Times about his cross over from physician to patient titled: “How long have I got left?” He told the audience how surprised he was at the overwhelmingly positive response he received to the story. “My own thoughts on something very personal, really resonated with people. I still get an email every other day in response to the New York Times piece. It’s a great inspiration to me to remember why writing is important.” [Editor's note: Kalanithi's recent Q&A here on Scope has also drawn massive attention; it's already one of our most popular posts of the year.]

Kalanithi’s final message, particularly to those young physicians and medical students in the audience, was to listen to your patients. Take time to get to know them. Remember why it is that you went to medical school. When asked if he treats his own patients differently since his diagnosis, he was characteristically thoughtful. “I think I felt a depth that I didn’t before… But I had excellent role models. I was trained you don’t just go over what are the risks and benefits. You really try to convey as much as you can about what it’s going to feel like.” He told his favorite example of a pediatric oncologist who he observed talking to parents whose daughter had just been diagnosed with a brain tumor. The doctor’s advice: “You need to support each other. You have to prepare your patients as much as you can for that larger emotional experiential landscape. You have to get enough sleep.”

Previously: “Stop skipping dessert:” A Stanford neurosurgeon and cancer patient discusses facing terminal illness and No one wants to talk about dying but we all need to.
Photo by Norbert von der Groeben

Cardiovascular Medicine, Chronic Disease, In the News, Research, Science, Stanford News

How best to treat dialysis patients with heart disease

How best to treat dialysis patients with heart disease

523392_4923732760_zKidney failure patients on dialysis often have other chronic diseases – heart disease topping the list. They’re prescribed an average of 12 pills a day by physicians, according to Stanford nephrologist Tara Chang, MD, and they spend three-to-four hours at a treatment center three times a week connected to an artificial kidney machine.

For Chang, this makes it all the more important that any medication she prescribes for a patient on dialysis is both essential and effective.

The problem is, particularly in the case of treating kidney patients with heart disease, evidence-based treatment guidelines just aren’t available. Kidney doctors are left making best guesses based on guidelines written for the general population.

“Our patients might be different from patients not on dialysis,” said Chang. “Dialysis patients have a lot of heart disease, yet rarely does a cardiology study enroll patients on dialysis, so we just don’t know.”

This was part of the motivation behind Chang’s most recent study examining the use of anti-platelet drugs such as clopidogrel, one of the most commonly prescribed drugs for kidney patients. The researchers looked at the use of anti-platelet medications such as clopidogrel as treatment following stenting procedures to unclog arteries in the heart in 8,458 dialysis patients between 2007 and 2010. The data suggests that longer-duration of drug use may be of benefit to patients on dialysis who get drug-eluding stents but not those who get bare metal stents. Chang told me:

We found that for those who got drug-eluting stents who took the drug for 12 months compared to those who had stopped the drug at some earlier time point, there was a non-statistically significant trend towards lower risks of death and heart attacks. So for this group, following the same guidelines as for the general population may be appropriate. However, we found no indication of benefit with longer duration of anti-platelet drug use for patients on dialysis who got bare metal stents.

About half of the 400,000 patients in the U.S. on dialysis also have coronary artery disease, as referenced in the study. The number of those getting stents inserted to unclog arteries also has increased 50 percent in the past decade, the study states. The results of the study, while not definitive as to exactly how long doctors should prescribe the drug, does stress the need for more clinical research on patients with kidney failure to provide guidance on treatment strategies for heart disease.

“Because our study was not a randomized trial,” said Chang, “we tried to be very measured in how we interpreted the results. What it does point to is the fact that we can’t assume that what works in non-dialysis patients works in dialysis patients. Hopefully our study will help convince researchers to include our dialysis patients in their studies.”

The paper was published this week in the Journal of the American Heart Association.

Previously: Keeping kidney failure patients out of the hospitalStudy shows higher rates of untreated kidney disease among older adults and Study shows daily dialysis may boost patients’ heart function, physical health.
Photo by newslighter

Ebola, In the News, Myths, Science

The slippery slope toward “a dangerous dependence on facts”

The slippery slope toward "a dangerous dependence on facts"

220px-Sputnik_asmThe ever-funny Andy Borowitz has written in The New Yorker about a previously unreported challenge in the fight against Ebola: It might make Americans believe in science. He writes:

In interviews conducted across the nation, leading anti-science activists expressed their concern that the American people, wracked with anxiety over the possible spread of the virus, might desperately look to science to save the day.

“It’s a very human reaction,” said Harland Dorrinson, a prominent anti-science activist from Springfield, Missouri. “If you put them under enough stress, perfectly rational people will panic and start believing in science.”

For someone who left science to become a writer specifically to help explain science to the public, this piece is both funny and also so very not funny at the same time. Almost 20 years after I put down my pipette, Americans are, if anything, less willing to let science guide their health, energy, or environmental decisions than they were back when I started – thus the humor in Borowitz’ piece.

All of this makes me wonder if I could have spared myself several decades of worrying about clever analogies, agonizing about transitions, and racing the clock to make deadlines and done something less stressful with my life. Something fulfilling. Something where at the end of the day, my work would help people live happier, healthier lives rather than producing something people will ignore if it doesn’t fit their ideology.

Matthew Nisbet and Dietram Scheufele have written a number of articles about science communication and its effects on public perception of science. In the American Journal of Botony they write, “Often when the relationship between science and society breaks down, science illiteracy is typically blamed, the absence of quality science coverage is bemoaned, and there is a call put out for ‘more Carl Sagans.’”

In a nutshell, that sums up my career switch. I bemoaned the absence of quality science coverage and fully intended to fill that gap.

Then, they go on to shatter my reasons for writing by pointing out that at a period of time when the public’s regard for science was at it’s highest – soon after the Sputnik launch – science literacy was abysmal. In one survey at the time, just 12 percent of people understood the scientific method, yet 90 percent of people believed that science was making their lives better.

What that survey suggests is that even a scientific challenge like Ebola is unlikely to push Americans to be better educated about science. But perhaps with the perfect transition, or really outstanding analogy, those same scientifically illiterate Americans can be convinced that science is making life better and – I’m really dreaming here -should be funded?

If yes, maybe Borowitz’ fictional anti-science advocate will be proved right, and we will head down that slippery slope “in which a belief in science leads to a belief in math, which in turn fosters a dangerous dependence on facts.” One can hope!

Previously: Scientist: Just because someone’s on TV doesn’t mean they’re an expert

Immunology, In the News, Parenting, Pediatrics

Ivy and Bean help encourage kids to get vaccinated

Ivy and Bean help encourage kids to get vaccinated

Ivy and Bean2Last week, I took my two little boys to get their shots, including the MMR vaccine that protects against measles, mumps and rubella. Although, as a mom, it’s easy for me to understand the value of vaccines, I’m not sure my preschooler was completely convinced that getting poked in the arm was a great idea.

That’s why I am thrilled to see “Ivy and Bean vs. The Measles,” a set of posters and other educational materials that Sophie Blackall, the illustrator of the popular series of children’s books, has produced in collaboration with the Measles and Rubella Initiative. Blackall’s illustrations show Bean, one of the book’s two heroines, devising a series of unconventional strategies for avoiding the measles: wear a biohazard suit for the rest of your life, get adopted by a polar bear, or (my personal favorite) cover yourself in a 6-inch protective layer of lard.

“Or,” says Ivy, “get vaccinated!”

My son would probably be most interested in Bean’s suggestion to “Move to the moon!” He loves all things outer space-related, and I love the idea of finding something at our doctor’s office that would spark his interest and help me explain to him why he needs that brief poke in the arm.

Bravo, Ivy and Bean!

Via Shots
Previously: Side effects of childhood vaccines are extremely rare, new study finds, Measles is disappearing from the Western hemisphere and Tips for parents on back-to-school vaccinations
Artwork by Sophie Blackall

In the News, Microbiology, Public Health, Research

The end of antibiotics? Researchers warn of critical shortages

The end of antibiotics? Researchers warn of critical shortages

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Bacteria spark infection. Antibiotic kills most bacteria. Remaining bacteria evolve resistance. Second antibiotic wipes out all bacteria. Repeat. Repeat until, that is, there are no effective antibiotics, a scenario that looks increasingly likely, according to recent research from the Center for Molecular Discovery at Yale University led by Michael Kinch, PhD. Kinch now leads the Center for Research Innovation in Business at Washington University in St. Louis, which featured his work in a recent article:

The number of antibiotics available for clinical use, Kinch said, has declined to 96 from a peak of 113 in 2000. The rate of withdrawals is double the rate of new introductions, Kinch said. Antibiotics are being withdrawn because they don’t work anymore, because they’re too toxic, or because they’ve been replaced by new versions of the same drug. Introductions are declining because pharmaceutical companies are leaving the business of antibiotic use discovery and development.

Many of the major players like Pfizer, Eli Lilly, AstraZeneca and Bristol-Myers Squibb are no longer developing antibiotics, Kinch wrote in a recent article in Drug Discovery Today. In part, their disinterest is driven by a tight profit window. The drug approval process takes about 11 years, but a patent only provides 20 years of protection, leaving just nine years to recoup development costs, according to Kinch.

As outlined in the Washington University piece, at least two major initiatives are working to reverse this trend. The Infectious Diseases Society of America introduced the 10 x ’20 Initiative to spur efforts to create 10 new antibiotics by 2010. And Britain is sponsoring the Longitude Prize 2014, a £10 million award for a simple test that will quickly determine the type of bacteria causing an infection and therefore the most effective antibiotic.

Previously: Healthy gut bacteria help chicken producers avoid antibiotics, Free online course aims to education about “pressing public health threat” of antibiotic resistance and Side effects of long-term antibiotic use linked to oxidative stress
Photo by CDC Public Health Image Library

Aging, Health Policy, In the News, Neuroscience, Patient Care

The toll of Alzheimer’s on caretakers

The toll of Alzheimer’s on caretakers

Loving Hands Vannesa Pike-Russell FlickrMy last grandparent, my paternal grandmother, passed away earlier this year. She lived into her 90s and, like both my maternal grandmother and grandfather, she suffered mild to moderate dementia in the final years of her life. My mother cared for each of them as one by one their health declined. She had ample support from our extended family, but she was the one who had to bathe them and help them go to the bathroom or remind repeatedly them that so-and-so relative had died many years ago. My parents’ experience taking care of elderly family members who no longer had their full mental faculties lasted two to three years in each case, unlike people who care for family members with Alzheimer’s disease – a task that can last a decade or more.

Last week, Tiffany Stanley wrote a feature in the National Review about her experience caring for her ailing aunt, Jackie, who was diagnosed with early onset Alzheimer’s. Stanley’s father had been caring for his sister when his congestive heart failure made him too ill to continue, so his 29-year-old daughter stepped in. She was unprepared for the realities of caring for an Alzheimer’s patient, and she chronicles her experiences with touching anecdotes about her family’s experiences, as well as a detailed look at Alzheimer’s care in the U.S. She also details the impact the disease has on caregivers:

Alzheimer’s places a heavy toll on family caregivers. Their own health suffers. Dementia caregivers report higher rates of depression and stress than the general population. Some studies show they have an increased risk for heart disease and stroke as well as higher mortality rates. Their own use of medical services, including emergency-room visits and doctors’ appointments, goes up, and their yearly health care costs increase by nearly $5,000, according to research from the University of Pittsburgh and the National Alliance for Caregiving. “Caring for a person with dementia is particularly challenging, causing more severe negative health effects than other types of caregiving,” reads an article in the American Journal of Nursing.

Stanley also writes about the tension between funding a cure – to keep people from spiraling late stage dementia – and caring for those who are already sliding down that route:

Lost too often in the discussion about a cure has been a much more basic, more immediate, and in many ways more important question: How can we better care for those who suffer from the disease? Dementia comes with staggering economic consequences, but it’s not the drugs or medical interventions that have the biggest price tag; it’s the care that dementia patients need. Last year, a landmark Rand study identified dementia as the most expensive American ailment. The study estimated that dementia care purchased in the marketplace—including nursing-home stays and Medicare expenditures—cost $109 billion in 2010, more than was spent on heart disease or cancer. “It’s so costly because of the intensity of care that a demented person requires,” Michael Hurd, who led the study, told me. Society spends up to $56,000 for each dementia case annually, and the price of dementia care nationwide increases to $215 billion per year when the value of informal care from relatives and volunteers is included.

The story is equal parts frustrating and heart-wrenching, but I came away much better informed about what a diagnosis entails, not just for the patients, but the families connected to them.

Previously: No one wants to talk about dying, but we all need to, Mindfulness training may ease depression and improve sleep for both caregivers and patients, Can Alzheimer’s damage to the brain be repaired?The state of Alzheimer’s research: A conversation with Stanford neurologist Michael Greicius and Exploring the psychological trauma facing some caregivers
Photo by Henry Rabinowitz

Ebola, Global Health, In the News, Infectious Disease

Ebola: A look at what happened and what can be done

Ebola: A look at what happened and what can be done

As of September 28, the World Health Organization (WHO) estimates that, so far, more than 7,100 people have been infected with and more than 3,300 have died from the Ebola virus. These estimates of what has happened are almost certainly far too low; the estimates of what will happen are terrifyingly high. The current Ebola epidemic may well become the worst human disaster in this century. And we are not doing enough about it.

Ebola is unlikely to become a major problem in the developed world. But… it seems increasingly likely that hundreds of thousands, and quite possibly millions, of men, women, and children will be struck down by this ghastly plague

What happened?

Researchers will be trying to answer that question for years. This is the 24th known outbreak of Ebola virus disease since it was first recognized in 1976. All of the other outbreaks burned themselves out quickly, after between one and 425 people had been infected. Over nearly 40 years, fewer than 2,500 people are known to have become infected and fewer than 1,500 to have died. The outbreaks were all in Central Africa; they killed people in scattered villages, with few Western connections and fewer Western media on site.

However, the current outbreak started in West Africa, not Central Africa. I suspect this change in location will prove to be the key change, not so much in how it has affected human responses but how it has affected human susceptibility. Yes, the health infrastructures in Guinea, Liberia, and Sierra Leone were very poor (and are now far worse), but they were no worse than those in the Democratic Republic of Congo, South Sudan, or Uganda, the sites of most of the earlier outbreaks. But the lands where this outbreak start are more densely populated and better connected. Instead of burning out in one or two villages, hidden away in dense jungle, the virus spread from village to village, from village to town, and eventually from town to city. When it hit Monrovia, the slum-ridden, million-person capital of Liberia, an explosion was probably inevitable. (It has recently begun to expand in Freetown, the capital of Sierra Leone, as well as Conakry, the capital of Guinea.)

The growth of the epidemic has brought with it the growth of terror and the destruction of already tenuous trust, both in governments and in modern health care. It has also brought death from other, treatable conditions that cannot now be treated in health care systems that Ebola has collapsed. It has brought restricted transportation and supplies and, as a result, in some places, sharply higher food prices. It may eventually bring, in spots, starvation.

Recriminations have already started. Why didn’t the West provide powerful help in March 2014, when the epidemic (already about a year old) began to be noticed? Or why hasn’t Western science, expensively pursuing the latest “me too” drug for common Western conditions, produced a treatment, cure, or vaccine for Ebola? These critiques seem too harsh. No previous epidemic has ever ballooned like this one, even in Central Africa. And the chance of an epidemic outside those traditional regions, let alone in the West, appeared remote.

And while some have pointed fingers at the West, others have focused on the behavior of the affected West African populations. Much has been made of their reluctance to abandon traditional methods of burying their dead, their lack of trust in modern medicine, and even their physical attacks on health care workers. But before blaming the victims for their poor infection control measures, put yourself in their shoes. A five year old – perhaps your five year old – is feverish and vomiting. She is crying and holding her arms out to you for comfort, for help. In West Africa you would not have the chance to telephone for an ambulance, with well-protected professionals to treat the child. Touching her could kill you. But what would it do to you – what would it make of you – to ignore her? As Benjamin Hale wrote in Slate, Ebola is a fantastically cruel disease, turning against us our own compassion, care, and love.

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