Doddering Doctors: Hospitals Take a Stab at Weeding Them Out

Image result for PAPA, the University of California, San Diego's PACE Aging Physician Assessment program

Screening programs take shape in San Diego as nationwide trend gains steam.

Interventional cardiologist Jerrold Glassman, MD, spent the first week of March schussing down Park City’s powdery slopes. He even braved black diamond runs, belying the fact that this July, he’ll be 69 years old.

“A 60-year-old today is not the 60-year-old of three decades ago,” he said proudly. “Skiing is my passion and I’m going back up tomorrow.”

He and his ski buddies, older physicians like himself, dodge moguls some 30 days a year. A new app tracks his stats, like altitude, speed and distance, and said he did 25 downhill miles that day.

Glassman has no plans to retire from the cath lab — or from skiing — anytime soon. But in coming weeks, medical executive committees for his 3,000-physician Scripps Health system in San Diego are expected to require screening for all physicians age 70 and older for cognitive impairment, among other things. It’s to be a condition for recredentialing every two years.

Doctors up for review will sit in a room alone, with no pencil or mobile aid, while they answer dozens of questions in the MicroCog, a computer-based test also used by the Air Force. The test scores thinking skills, such as the ability to solve simple math problems, count backwards from 100, or find similarities among shapes or pictures.

Following the computer test comes history, physical, and mental health screens that review issues like substance use and tests for hearing and vision. They fill out a form that asks about sleep patterns, continuing medical education, patient load, and typical hours at work. The entire process takes about three or four hours.

The policy is a major change for the system, acknowledged James LaBelle, MD, chief medical officer for Scripps Health. “About 150 physicians 70 or older are due to be recredentialed in 2019 and all would be subject to the policy,” he said. LaBelle did not respond when asked whether the two-year recredentialing cycle would subject a similar number to mandatory screening in 2020 — which would bring the total to about 10% of Scripps’ medical staff.

An undisclosed number of allied health professionals such as dentists and optometrists who seek status as a Scripps staff member are also covered by the policy, LaBelle said.

For most hospitals around the country, “this is pretty new. I do think Scripps is leading in trying to understand how to manage the aging physician,” he said, adding, “I hope it’s going to be easier than I think it’s going to be.”

Failing the MicroCog won’t automatically end a physician’s credentialing at Scripps. But it will flag him or her for further evaluation, perhaps prompting recommendations for more rigorous fitness-for-duty review lasting several days. Physicians who perform poorly there would see their ability to practice limited or revoked.

Come to PAPA

For Scripps and many other organizations, the plan is for screening to be done by PAPA, the University of California, San Diego’s PACE Aging Physician Assessment program — said to be the largest to provide this service in the nation. (PACE is an acronym for Physician Assessment and Clinical Education.) Many other organizations perform various screenings in house, with or without cognitive computer tests, or are working on plans to contract with four other service providers.

Surgeons and interventionalists like Glassman will likely also undergo PAPA’s 15-minute dexterity screen — in which they must correctly place shaped pegs into grooves in a board.

Although leadership’s commitment to a uniform policy is set at Scripps, some details are still being worked out, like how the system’s peer review committees will repurpose those long-time senior physicians who fail the tests but can still provide value to the workforce. LaBelle suggested the exact process Scripps will adopt “is a moving target” that may change, but added, “I have no doubt we’re going to learn a lot over the next few years around how to do this right.”

PACE is a multiple-day testing program which began 22 years ago to assess doctors referred by the Medical Board of California after negligence or behavioral issues threatened their license. Of the 1,000 physicians referred to PACE, an undisclosed number had age-related cognitive impairment that resulted in colleagues’ concerns, but the physicians continued to practice because the complicated peer review process takes a long time, and doctors don’t want to report on each other.

“In all honesty, when we started PAPA, it was because we saw so many wonderful careers that ended in disgrace and tragedy,” said PACE/PAPA director David Bazzo, MD. “Time and time again, the message we heard was ‘Gosh, I wish I had known, or I wish I had stopped or retired one case sooner,’ maybe because of a cognitive issue or dexterity issue. The regret is there.”

Absent screening, procedures for dealing with accusations of physician impairment, can take years. For example, a California medical board filing indicated that concerns about one gastroenterologist with a tremor were expressed internally in 2015, including that he “had forgotten that he was on call … exhibited occasional forgetfulness and confusion and had shown up on at least two occasions at the wrong surgery center.” The medical board didn’t receive a complaint until January 2017, however, and another 15 months elapsed before his license was revoked.

So it’s understandable that proactive screening is gaining traction. “I know it provokes a lot of anxiety, but in the end, it’s really around assessing how much deeper a doctor needs to be looked into, or doesn’t need to be looked into,” LaBelle said. It’s not a slam dunk that they would be sent packing — unless they refuse the tests, LaBelle said. “That’s a hard stop.”

Growth mode

With five PAPA contracts with healthcare organizations or medical groups now active and three more pending, Bazzo sees the demand for late career physician screening as a service line in growth mode. He gives talks about the process to hospitals and medical groups around the country, and estimates 10% of health systems now have some form of screening triggered only by a birthday, even if limited to certain departments. “It’s on the national radar,” he said.

Outside San Diego, other hospitals and health systems have also begun screening their senior clinicians, with or without the MicroCog. Among them are Stanford Hospital, Clinics in Palo Alto, and Eisenhower Medical Center in Rancho Mirage, California; Driscoll Children’s Hospital in Corpus Christi, Texas; and the University of Virginia Health System in Charlottesville. Many others have policies they declined to discuss with MedPage Today.

An American Medical Association report discussed at the November interim meeting noted that 300,752 physicians were 65 years or older in 2017, up from 241,641 in 2013, and 120,000 were “actively engaged in patient care,” up from 97,000. The literature is clear, an AMA report said, that cognitive and physical skills generally decline with age, and physicians are not excepted.

That report urged delegates to adopt principles to guide screening senior physicians for competency. “It is critical that physicians take the lead in developing standards … to head off a call for nationally implemented mandatory retirement ages or imposition of guidelines by others that are not evidenced based,” it said. The suggested guidelines failed to win approval but are being rewritten.

Clearly the issue is a touchy one at many organizations around the country, especially those with many clinicians who’ve long served as their hospitals’ elder statespeople and may serve on influential committees.

Asked if UCSD’s hospitals and clinics screened their senior physicians, a communications director replied, “UC San Diego Health is in discussion on a potential policy, however, it hasn’t established one because the science on the topic is unsettled.”

That prompted a strongly worded retort from William Perry, PhD, vice chair of the UCSD department of psychiatry and a PACE program psychologist.

Robust data

The data is fairly robust in two domains,” regarding the impact of age on physician care, Perry told MedPage Today, emphasizing that the communications director’s message was patently incorrect. “Abilities decline after a certain age and, as one gets older, adverse outcomes increase,” he said, citing unpublished data from PACE and other studies. “There’s no denying it; as we get older a lot of our functions decline.”

Perry said that these days, he’s receiving calls every week from around the country wanting him to give talks. “Organizations in North Carolina and New Jersey are putting together policies. It’s not a question of if, it’s a question of when this will become standard,” he said.

“I’m struck by how much science has demonstrated a connection between aging and impaired physician practice,” said Richard Barton, an attorney who represents physicians, medical groups, and hospitals and helped author a paper on the topic in 2015 for a Sacramento-based physician wellness group. In San Diego alone, Barton knows of three organizations, including Rady Children’s Hospital and UCSD Medical Center, who are also working on late career screening policies due to concern that some older physicians are at higher risk for causing patients harm.

Glassman, who has practiced at 655-bed Scripps Mercy Hospital since 1979 and was chief of staff for four years, said most older Scripps physicians favor the idea. “It’s kind of mom and apple pie. How can you say a physician who is not competent should be allowed to practice?” The big question is, after a clinician fails, which follow-up tests correctly determine whether an experienced physician can still practice?

One of Glassman’s fellow skiers, Jeff Sandler, MD, a Scripps endocrinologist, will be 72 this June and supports the idea of screening doctors his age. “If you think you shouldn’t be screened, maybe you shouldn’t be practicing,” he said. “It sounds discriminatory, but we have to protect the public from bad actors.”

But the issue remains controversial because screening based solely on age smacks of illegal discrimination and the age cutoffs are inherently arbitrary.


Segment 8 – Applying Our Values & Philosophy to Healthcare Reform

Segment 8 – Applying Our Values & Philosophy to Healthcare Reform


This segment reviews traditional American values and philosophical principles that can help resolve the core dilemma that has stopped us from fixing US healthcare for years – the unresolved conflict between “social justice” and “market justice.”

In the first six Segments, we reviewed the relentless growth of healthcare spending. And how rising costs are literally built into the system as it is now.

In Segment 7 we talked about some landmines that lurk beneath the surface of fixing healthcare – power and politics.

In this Segment, we will look at traditional American values and at philosophical principles that can help us resolve the core dilemma that has stopped us from fixing US healthcare all these years.

Let’s start with the American traditions. Some of these have been a bit romanticized in our imagination. So we’ll look at each of them in more detail.


Freedom of the individual is pretty clear. It brings to mind the pioneer spirit of early adventurers and settlers.


There is a presumption for rugged individualism and against government entanglement. But even by the time of the Revolutionary War and Constitutional Convention growing colonial cities were developing governmental and civic services like fire departments and sanitation programs.

Free enterprise is a core American value. But here again, there are examples from earliest Colonial days of collective projects, such as the Boston Commons, schools, and toll roads that stood alongside freestanding farms and shops.


Next is “Yankee ingenuity.” Americans are entrepreneurs, innovators, practical problem solvers. We have never been bound by tired old ideas from Europe or elsewhere. We come up with our own ideas and forge ahead with progress. We’ll come back to these concepts.

There is an American tradition to distrust government. But if we look more closely at what this meant to the Founding Fathers, it was not government itself that they distrusted. In fact, Americans never embraced anarchy; they always set up orderly civic structures in every settlement and colony. What they abhorred was tyranny, the concentration of power in the hands of a sometimes capricious and self-serving autocrat. Further, they distrusted any individual person wielding authority. And so the Constitutional Framers crafted a government with the right balance between too much and too little authority, separate branches, and checks and balances. Today’s institutions – including healthcare – will do well to build in the same kind of accountability, transparency and checks and balances, especially since so much money and power is involved.

And so I am going to rename this tradition, Distrust of Tyranny (and of Human Fallibility).

Lastly is our tradition to protect under the law outcasts, the weak, and the vulnerable. Colonial settlers were often themselves oddballs or failures, seeking the opportunity for a new life in America. They enshrined protections for themselves in law, notably the Bill of Rights.

Since a large group of Americans today express misgivings that government involvement in healthcare would be a betrayal of our Founding traditions, I would like to offer several more reflections.

Look at the principles listed in the Declaration of Independence and the Preamble to the Constitution – life, liberty and pursuit of happiness.





More perfect union, justice, domestic tranquility, general welfare, and the blessings brought by liberty to ourselves and our posterity. These sound to me like values that would flow from a people who don’t worry about getting care when they become sick, and who willingly embrace practical healthcare reforms that advance the common good. This is a far cry from the notion that the Framers would have wanted to freeze us into their time – 1788, to be exact. I have a feeling that the Founding Fathers were too practical minded, ingenious and adaptable to lock themselves into even their own ideas. Rather, I think they would try to honor American traditions, compromise over seemingly different viewpoints, seek solutions that bring us together and bind us together, promote the common good, and maximize our freedom, wellbeing (or “welfare,” to use their terminology), and stewardship of our great blessings.


Not to belabor this point, but I’d like to look back at Dr. Benjamin Rush, who we met in Segment 2 as a prominent doctor in the Revolutionary period who signed the Declaration of Independence. Recollect that he received his medical training at University of Edinburgh, the foremost medical school of that time, which in the European system was state-run. He supported publicly-funded mental asylums and is considered to be the father of American psychiatry. In 1794 he was inducted as a foreign member of Swedish Academy of Medicine, which is the historic root of Sweden’s modern-day national healthcare system. Rush supported public health and sanitation initiatives, such as rerouting Dock Creek and draining its surrounding swamp on the east side of Philadelphia to eliminate mosquito breeding grounds. He established a public dispensary for low income patients. And he founded the Pennsylvania Prison Society to protect rights of prisoners and promote their humane treatment.




Based on this profile, I don’t think it’s a stretch to believe that this 18th century Founding Father might support innovative public and private partnerships ensuring healthcare for all citizens if a time machine could transport him into the 21st century.

Now let’s now look at what some healthcare philosophers in this century say about fair ways to run the system. The basic principles of healthcare ethics are autonomy (which is self-determination), justice (fair distribution of costs and benefits), beneficence (the most good for all), and professional integrity (meaning that society has a stake in the independence of doctors).


One philosopher who has applied these principles to modern healthcare is Paul Menzel from Pacific Lutheran University in Washington state.


He has been writing on the ethics of the healthcare system since 1983, when he came to Washington DC to apply his philosopher’s methodology to the issue, until his retirement in 2012. Here are his view of the features of a fair system of healthcare delivery and financing.

  1. The system should provide costworthy care, and costworthy care only, no wasteful treatments.
  2. The system should provide financial protection to sick individuals who need care.
  3. The system should make health care equitably accessible to all.
  4. The system should equitably distribute the costs of care between the ill and the well
  5. The system should justly allocate the costs of care between the rich and the poor.
  6. The system should respect autonomy of patient choice.
  7. The system should respect provider choice.

Two other philosophers, one an ethicist and the other a doctor, have laid out fair, publicly acceptable ways to set limits on healthcare spending. There needs to be:

  1. Open, transparent deliberations
  2. Use of relevant criteria agreed on by all
  3. An appeals procedures for individual extenuating cases.
  4. Uniform standards and regulations applying to all delivery and financing systems.

Let’s end on a key philosophical controversy in the US – market justice versus social justice. Market justice means, in starkest form, that consumers can buy only what they can afford, and that giving them something they have not earned is ethically and economically wrong. Social justice sees equitable distribution of health-care as a societal responsibility, without regard to ability to pay. (Note that I am purposely avoiding the loaded words – “rights” and “privileges,” which tend to inflame this controversy.)


It has been said that progress on healthcare reform is stymied by our country’s inability to choose one or the other – we’ve been caught between the two ideas of justice.

In the next Segment I will ask whether the two sides of the argument can come together. Does it need to be either-or? Or can we blend market justice and social justice? Can the US take what’s best from both the commercial business world and the public sector world?

My answer is Yes. And we’ll look at a successful plan that did just that 20 years ago.

I’ll see you then.




Washington is under a state of emergency as measles cases rise

Image result for Washington is under a state of emergency as measles cases rise

As of Sunday, there are 35 confirmed cases of measles in the state of Washington — an outbreak that has already prompted Gov. Jay Inslee to declare a state of emergency.

“Measles is a highly contagious infectious disease that can be fatal in small children,” Inslee said in his proclamation on Friday, adding that these cases create “an extreme public health risk that may quickly spread to other counties.”
There were 34 cases of the measles in Clark County, which sits on the state’s southern border, just across the Columbia River from Portland, Oregon. Officials said 30 of the cases involved people who have not had a measles immunization; the other four are not verified. Of the 34 cases, 24 are children between age 1 and 10. There are also nine suspected cases in Clark County.
There is also one case in King County, which includes Seattle. While the King County website says the patient, a man in his 50s, is a “suspected case,” the governor said in a news release it is a confirmed case of measles.
In a health alert from King County, it was said the man had recently traveled to Clark County.
Inslee’s proclamation allows agencies and departments to use state resources and “do everything reasonably possible to assist affected areas.”
A news release on the governor’s website says the Washington State Department of Health, or DOH, has implemented an infectious disease incident management structure so it can manage the public health aspects of the outbreak through investigations and lab testing.
The Washington Military Department, the release says, is organizing resources to assist the DOH and local officials in easing the effects on people, property and infrastructure.
Last week, a person infected with measles attended a Portland Trail Blazers home game in Oregon amid the outbreak. Contagious people also went to Portland International Airport, as well as to hospitals, schools, stores, churches and restaurants across Washington’s Clark County and the two-state region, county officials said.

Most patients with symptoms should call first

Measles is a contagious virus that spreads through the air through coughing and sneezing. Symptoms such as high fever, rash all over the body, stuffy nose and red eyes typically disappear without treatment within two or three weeks. One or two of every 1,000 children who get measles will die from complications, according to the US Centers for Disease Control and Prevention.
In 1978, the CDC set a goal to eliminate measles from the United States by 1982. Measles was declared eliminated — defined by absence of continuous disease transmission for greater than 12 months — from the United States in 2000.
But there has been a recent rise in unvaccinated children. The proportion of children receiving no vaccine doses by 2 years old rose from 0.9% among those born in 2011 to 1.3% among those born in 2015, the CDC reported in October.
The CDC recommends people get the measles, mumps and rubella vaccine to protect against those viruses. The typical recommendations are that children should get two doses of MMR vaccine, the first between 12 to 15 months of age and the second between 4 and 6 years old.

Bill de Blasio’s Grand Health Care Illusion

Image result for Bill de Blasio's Grand Health Care Illusion

Mayor Bill de Blasio announced Tuesday a plan to “guarantee health care to all New Yorkers.” Responding to what he described as Washington’s failure to achieve single-payer health insurance, the mayor laid out a “transformative” plan to provide free, comprehensive primary and specialized care to 600,000 New Yorkers, including 300,000 illegal immigrants. “We are saying the word ‘guarantee’ because we can make it happen,” he announced, pledging to put $100 million toward the new initiative.

If spending an additional $100 million is all it takes to pay the health costs of a half-million people, you may wonder why New York City Health + Hospitals (HHC) is going broke spending $8 billion annually to treat 1.1 million people. The answer: Mayor de Blasio is not really proposing anything new; nor is he planning to expand services or care to anyone currently ineligible. All of New York City’s uninsured—including illegal aliens—can go to city hospitals and receive treatment on demand. The mayor is trying to do what some of his predecessors attempted—shift patients away from the emergency room and into primary care, or clinics. In 1995, for instance, then-mayor Rudy Giuliani empaneled a group of experts to address the future of the city’s public hospitals. The panel concluded, in the words of a Newsday editorial, that “for patients, emphasis would be on primary care instead of hurried emergency-room sessions and days of hospitalization.”

The tendency of a segment of the population to avoid the health-care system until a critical moment, relying in effect on emergency rooms for primary care, has been the knottiest problem in public health for decades. Letting simple problems fester makes them more expensive to treat. Using ERs designed to handle resource-intensive trauma situations for basic medical problems is inefficient and wasteful. The city has spent lots of money trying to convince poor, often dysfunctional people to develop regular medical habits by signing up for Medicaid and getting a primary-care doctor.

De Blasio makes it sound as though illegal immigrants have not been able to get health care until now. But in 2009, Alan Aviles, then the city’s hospitals chief, spoke of “hundreds of millions of dollars in federal funds that cover the costs of serving uninsured patients including undocumented immigrants.” Aviles said that the city was renowned for its “significant innovations in expanding access to care for immigrants, including our financial assistance policies that provide deeply discounted fees for the uninsured, our comprehensive communications assistance for limited English proficiency patients, and our strictly enforced confidentiality policies that afford new immigrants a sense of security in accessing needed care.”

In 2013, Lincoln Hospital in the Bronx announced a new “Integrated Wellness Program” targeting seriously mentally ill people with chronic health problems—the same population that tends to be uninsured, to neglect their own care, and to wind up in the emergency room when their diabetes or cardiovascular disease catches up with them. “At Lincoln, we aim to establish best practices that combine physical and mental health—two services which have historically been treated separately,” said Milton Nuñez, then as now Lincoln’s director—words not much different from what Chirlane McCray said at Tuesday’s “revolutionary” press conference.

HHC director Mitchell Katz practically admitted that the mayor’s announcement of guaranteed health care for all is just fanfare, amounting to more “enabling services” for already-existing programs. Asked if uninsured people—largely illegal immigrants—can get primary care now, Katz explained, “you can definitely walk into any emergency room, you can go to a clinic, but what is missing is the good customer service to ensure that you get an available appointment. . . . that’s what we’re missing and the mayor is providing.”

Dividing $100 million by 600,000 people comes to about $170 per person—perhaps enough money to cover one annual wellness visit to a nurse-practitioner, assuming no lab work, prescriptions, or illnesses. Clearly, the money that the mayor is assigning to this new initiative is intended for outreach—to convince people to go to the city’s already-burdened public clinics instead of waiting until they get sick enough to need an emergency room. That’s fine, as far as it goes, but as a transformative, revolutionary program, it resembles telling people to call the Housing Authority if they need an apartment and then pretending that the housing crisis has been solved. Mayor de Blasio is an expert at unveiling cloud-castles and proclaiming himself a master builder. His “health care for all” effort seems little different.



How government shutdown is hampering some federal health efforts — 5 takeaways

Related image

Despite a meeting between President Donald Trump and various members of Congress, officials have not come to an agreement to end the partial government shutdown, which began Dec. 22. While the majority of the federal government’s public health efforts are continuing as usual, several agencies, including the FDA, are at a loss for funding as long as the temporary closure is in placeKaiser Health News reports.

Here are five things to know:

1. Congress has already passed five major appropriations bills, which were responsible for funding roughly 75 percent of the federal government, including HHS and the U.S. Department of Veterans Affairs. However, seven bills are still outstanding, including bills funding the Interior, Agriculture and Justice departments, the report states.

2. While the government’s flagship programs, like Medicare, Medicaid and the ACA, are insulated from the effects of the shutdown, other public health agencies are beginning to feel the squeeze from narrowing funding streams. For example, the FDA’s food safety operations are funded through the Department of Agriculture, which has been affected by the shutdown. The FDA’s contingency plan states that in the event of a shutdown, roughly 40 percent of the the agency’s workforce is furloughed.

3. Funding for the Indian Health Service — which is funded by the Department of the Interior — has also not been approved, meaning that the only IHS’ services currently available are those that meet the “immediate needs of the patients, medical staff, and medical facilities,” according to the agency’s contingency plan cited by Kaiser Health News. Many IHS facilities across the country remain open, with staffers reporting to work because they are necessary employees and  “excepted” from the furlough, an agency spokesperson told the publication.

4. The Department of Homeland Security’s Office of Health Affairs has also been scaling back its resources to survey threats posed by infectious diseases, pandemics, and biological and chemical attacks, the report states.

5. Roughly 800,000 federal employees nationwide have been affected by the shutdown and have found themselves in financial uncertainty, a New York City-based New York University professor told CNBC. One IRS employee told CNBC he cannot afford his more than $200 insulin prescription because he doesn’t know when he will begin work again.


Yes, Doctors ‘Stay In Their Lane’ on Gun Policy

Yes, Doctors 'Stay In Their Lane' on Gun Policy

What kind of ignorant troglodyte would tell a doctor to mind his own business?

This was, in essence, the question an incredulous media was asking after the National Rifle Association disparaged the American College of Physicians (ACP) for promoting an array of gun-control regulations last week. “Someone should tell self-important anti-gun doctors to stay in their lane,” the NRA tweeted. “Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves.”

Read Full Article »





Doctors Start Movement in Response to NRA

Doctors Start Movement in Response to NRA

The feud between the National Rifle Association and the medical community still rages on, with the latest round coming from physicians who released an editorial saying they disagree with the NRA, published in the journal Annals of Internal Medicine on Monday.

In a tweet this month, the NRA told “anti-gun” doctors to “stay in their lane” after a series of research papers about firearm injuries and deaths was published in the Annals of Internal Medicine, including new recommendations to reduce gun violence.

Read Full Article »



The 2017 Flu Killed 80,000 in the US. Get a Flu Shot!

Image result for Healthcare Triage: The 2017 Flu Killed 80,000 in the US. Get a Flu Shot!

Influenza killed 80,000 people last year in the United States. That is the highest number of deaths since the CDC started keeping records in the 1970s. Help protect yourself and those around you. Get a flu shot!

Percentage of young U.S. children who don’t receive any vaccines has quadrupled since 2001

A small but increasing number of children in the United States are not getting some or all of their recommended vaccinations. The percentage of children under 2 years old who haven’t received any vaccinations has quadrupled in the last 17 years, according to federal health data released Thursday.

Overall, immunization rates remain high and haven’t changed much at the national level. But a pair of reports from the Centers for Disease Control and Prevention about immunizations for preschoolers and kindergartners highlights a growing concern among health officials and clinicians about children who aren’t getting the necessary protection against vaccine-preventable diseases, such as measles, whooping cough and other pediatric infectious diseases.

The vast majority of parents across the country vaccinate their children and follow recommended schedules for this basic preventive practice. But the recent upswing in vaccine skepticism and outright refusal to vaccinate has spawned communities of undervaccinated children who are more susceptible to disease and pose health risks to the broader public.

Of children born in 2015, 1.3 percent had not received any of the recommended vaccinations, according to a CDC analysis of a national 2017 immunization survey. That compared with 0.9 percent in 2011 and with 0.3 percent of 19- to 35-month-olds who had not received any immunizations when surveyed in 2001. Assuming the same proportion of children born in 2016 didn’t get any vaccinations, about 100,000 children who are now younger than 2 aren’t vaccinated against 14 potentially serious illnesses, said Amanda Cohn, a pediatrician and CDC’s senior adviser for vaccines. Even though that figure is a tiny fraction of the estimated 8 million children born in the last two years who are getting vaccinated, the trend has officials worried.

“This is something we’re definitely concerned about,” Cohn said. “We know there are parents who choose not to vaccinate their kids . . . there may be parents who want to and aren’t able to” get their children immunized.

Some diseases, like measles, have made a return in the United States because parents in some areas have failed or chosen not to vaccinate their children. Last year, Minnesota suffered a measles outbreak, the state’s worst in decades. It was sparked by anti-vaccine activists who targeted an immigrant community, spreading misinformation about the measles vaccine. Most of the 75 confirmed cases were young, unvaccinated Somali American children.

The data underlying the latest reports do not explain the reason for the increase in unvaccinated children. In some cases, parents hesitate or refuse to immunize, officials and experts said. Insurance coverage and an urban-rural disparity are likely other reasons for the troubling rise.

Among children aged 19 months to 35 months in rural areas, about 2 percent received no vaccinations in 2017. That is double the number of unvaccinated children living in urban areas.

The new data shows health insurance plays a significant role, as well. About 7 percent of uninsured children in this age group were not vaccinated in 2017, compared with 0.8 percent of privately insured children and 1 percent of those covered by Medicaid.

Those differences are concerning because uninsured and Medicaid-insured children are eligible for free immunizations under the federally funded Vaccines for Children program.

“Parents may not be aware of this, so this may be an education issue,” Cohn said.

Other issues, such as child care, transportation and a shortage of pediatricians in rural areas, are also likely to affect vaccination coverage.

A second report on vaccination coverage for children entering kindergarten in 2017 also showed a gradual increase in the percentage who were exempted from immunization requirements. (The exemptions do not distinguish between one vaccine versus all vaccines.)

Eighteen states allow parents to opt their children out of school immunization requirements for nonmedical reasons, with exemptions for religious or philosophical beliefs.

The overall percentage of children with an exemption was low, 2.2 percent. But the report noted “this was the third consecutive school year that a slight increase was observed.” The report does not provide a breakdown, but the majority of exemptions are nonmedical, according to data reported by the states.

Saad Omer, a professor of global health, epidemiology and pediatrics at Emory University, said that an analysis he and colleagues conducted a few years ago found the rate of increase in nonmedical exemptions had appeared to stabilize by the 2015-2016 school year after many years of increase.

But the latest CDC data appears to reflect a change, he said. “It seems that in recent years, exemptions are going up, and the trend is likely due to parents refusing to vaccinate,” he said.

In the 2017-2018 school year, 2.2 percent of U.S. kindergartners were exempted from one or more vaccines, up from 2 percent in the 2016-2017 school year, and from 1.9 percent in the 2015-2016 school year, according to the CDC report.

Reasons for the increase couldn’t be determined from the data reported to CDC, the agency said. But researchers said factors could include the ease of obtaining exemptions or parents’ hesitancy or refusal to vaccinate.

States such as West Virginia and Mississippi, which do not allow nonmedical vaccine exemptions, have higher percentages of children getting vaccinated, said Mobeen Rathore, a pediatric infectious disease physician in Jacksonville, Fla., and a spokesman for the American Academy of Pediatrics (AAP).

Earlier this year, researchers from several Texas academic centers identified “hotspots” where outbreak risk is rising in 12 of the 18 states that allow nonmedical exemptions because a growing number of kindergartners have not been vaccinated.


Suicide rates rise sharply across the United States, new report shows


Suicide rates rose in all but one state between 1999 and 2016, with increases seen across age, gender, race and ethnicity, according to a report released Thursday by the Centers for Disease Control and Prevention. In more than half of all deaths in 27 states, the people had no known mental health condition when they ended their lives.

In North Dakota, the rate jumped more than 57 percent. In the most recent period studied (2014 to 2016), the rate was highest in Montana, at 29.2 per 100,000 residents, compared with the national average of 13.4 per 100,000.

Only Nevada recorded a decline — of 1 percent — for the overall period, although its rate remained higher than the national average.

Increasingly, suicide is being viewed not only as a mental health problem but a public health one. Nearly 45,000 suicides occurred in the United States in 2016 — more than twice the number of homicides — making it the 10th-leading cause of death. Among people ages 15 to 34, suicide is the second-leading cause of death.

The most common method used across all groups was firearms.

“The data are disturbing,” said Anne Schuchat, the CDC’s principal deputy director. “The widespread nature of the increase, in every state but one, really suggests that this is a national problem hitting most communities.”

It is hitting many places especially hard. In half of the states, suicide among people age 10 and older increased more than 30 percent.Percent change in annual suicide rate* by state, from 1999-2001 to 2014-2016 (Centers for Disease Control and Prevention)

“At what point is it a crisis?” asked Nadine Kaslow, a past president of the American Psychological Association. “Suicide is a public health crisis when you look at the numbers, and they keep going up. It’s up everywhere. And we know that the rates are actually higher than what’s reported. But homicides still get more attention.”

One factor in the rising rate, say mental health professionals as well as economists, sociologists and epidemiologists, is the Great Recession that hit 10 years ago. A 2017 study in the journal Social Science and Medicine showed evidence that a rise in the foreclosure rate during that concussive downturn was associated with an overall, though marginal, increase in suicide rates. The increase was higher for white males than any other race or gender group, however.

“Research for many years and across social and health science fields has demonstrated a strong relationship between economic downturns and an increase in deaths due to suicide,” Sarah Burgard an associate professor of sociology at the University of Michigan, explained in an email on Thursday.

The dramatic rise in opioid addiction also can’t be overlooked, experts say, though untangling accidental from intentional deaths by overdose can be difficult. The CDC has calculated that suicides from opioid overdoses nearly doubled between 1999 and 2014, and data from a 2014 national survey showed that individuals addicted to prescription opioids had a 40 percent to 60 percent higher risk of suicidal ideation. Habitual users of opioids were twice as likely to attempt suicide as people who did not use them.

High suicide numbers in the United States are not a new phenomenon. In 1999, then-Surgeon General David Satcher issued a report on the state of mental health in the country and called suicide “a significant public health problem.” The latest data at that time showed about 30,000 suicides a year.

Kaslow is particularly concerned about what has emerged with suicide among women. The report’s findings came just two days after 55-year-old fashion designer Kate Spade took her own life in New York — action her husband attributed to the severe depression she had been battling.

“Historically, men had higher death rates than women,” Kaslow noted. “That’s equalizing not because men are [committing suicide] less but women are doing it more. That is very, very troublesome.”

National Institute of Mental Health director Joshua A. Gordon explains some of the latest research surrounding suicide rates in the U.S. 

Among the stark numbers in the CDC report was the one signaling a high number of suicides among people with no diagnosed  mental health condition. In the 27 states that use the National Violent Death Reporting System, 54 percent of suicides fell into this category.

But Joshua Gordon, director of the National Institute of Mental Health, said that statistic must be viewed in context.

“When you do a psychological autopsy and go and look carefully at medical records and talk to family members of the victims,” he said, “90 percent will have evidence of a mental health condition.” That indicates a large portion weren’t diagnosed, “which suggests to me that they’re not getting the help they need,” he said.

Cultural attitudes may play a part. Those without a known mental health condition, according to the report, were more likely to be male and belong to a racial or ethnic minority.

“The data supports what we know about that notion,” Gordon said. “Men and Hispanics especially are less likely to seek help.”

The problems most frequently associated with suicide, according to the study, are strained relationships; life stressors, often involving work or finances; substance use problems; physical health conditions; and recent or impending crises. The most important takeaway, mental health professionals say, is that suicide is an issue not only for the mentally ill but for anyone struggling with serious lifestyle problems.

“I think this gets back to what do we need to be teaching people — how to manage breakups, job stresses,” said Christine Moutier, medical director of the American Foundation for Suicide Prevention. “What are we doing as a nation to help people to manage these things? Because anybody can experience those stresses. Anybody.”People without known mental health conditions were more likely to be male and to die by firearm. (CDC)

The rates of suicide for all states and the District of Columbia were calculated using data from the National Vital Statistics System. Information about contributing circumstances for those who died by suicide was obtained via the National Violent Death Reporting System, which is relatively new and in place in only 27 states.

“If you think of [suicide] as other leading causes of death, like AIDS and cancer, with the public health approach, mortality rates decline,” Moutier said. “We know that same approach can work with suicide.”