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Tag Archives: Public Health
How investing in public health could cure many health care problems
Now that the Cassidy-Graham bill has been pulled, it’s a good time to think about concrete ways to improve health and health care in our country. Despite advances in medicine, U.S. health care spending grew to US$3.2 trillion in 2015, or 17.8 percent of the nation’s gross domestic product. To contain health care costs, the U.S. needs to invest in strengthening the public health system and reconsider approaches to making all Americans healthier.
Making Americans healthier should not be a partisan issue. Conservatives and progressives alike should agree on the importance of keeping Americans healthy – both on principled and financial grounds. The sicker the American people, the more expensive their care, and much of that cost will inevitably be borne by Medicare and Medicaid. Yet major challenges loom.
As the Dean of Columbia University’s Mailman School of Public Health, I have dedicated my career to the health of populations, using science and evidence to transition to a world where health and health care are collective priorities for all. My research and that of others suggests that this situation can be improved, but it will require a major national strategy and commitment to invest in public health – one that can be highly cost-effective.
Just the facts
Take, for example, the toll of chronic disease in the U.S. As of 2012, about half of adult Americans were living with one or more chronic health conditions, according to the Centers for Disease Control and Prevention, and one in four adults had two or more. Treating people with chronic diseases accounts for most of our nation’s health care costs. Eighty-six percent of the nation’s annual health care expenditures are for people with chronic and mental health conditions.
This problem will only grow as the U.S. population increases. And the census projects that the population will increase by 98 million between 2014 and 2060.
At the same time, America’s crumbling infrastructure is putting many Americans’ health at risk. The country’s drinking water systems, which are foundational to health, received a D grade on the 2017 Infrastructure Report Card of the American Society of Civil Engineers. Hazardous waste management and wastewater treatment earned only D+ grades.
The connection between health and infrastructure is strong: Infrastructure greatly affects access to healthy lifestyles. While access to clean drinking water and waste treatment are paramount, there are other examples, too.
Sidewalks and bike lanes encourage physical activity; public parks provide space for exercise and rejuvenation; and public transit is crucial to getting people out of cars, encouraging walking and, of course, reducing pollution and congestion. Subways and buses also enable older adults to reach needed services and remain in their homes longer.
Improvements to infrastructure are typically one-time expenses with recurring benefits. For example, one new sidewalk benefits an entire generation of walkers and runners. Research shows that every $1,300 New York City invested in building bike lanes in 2015 provided benefits equivalent to one additional year of life at full health over the lifetime of all city residents.
Other studies also have shown that preventing illness is far less expensive than paying for treatment. Trust for America’s Health estimates that “an investment of $10 per person per year in proven community-based programs to increase physical activity, improve nutrition, and prevent smoking and other tobacco use could save the country more than $16 billion annually within five years. This is a return of $5.60 for every $1.” With ever-rising health care costs, how can we overlook such opportunities?
Prevention policies and cessation help
The focus of American health care and health-related research needs to be shifted to include prevention, not just treatment. The “Cancer Moonshot,” which has strong bipartisan support, is a vital step in this direction, providing $1.8 billion in funding over seven years.
Cancer prevention must be a high priority, and the success of this effort could inspire a national consensus around future commitments to tackle other diseases and conditions.
Another prevention priority should be healthy aging. Today there are more than 46 million Americans aged 65 years or older; and by 2060, the number of seniors is expected to more than double, according to the Department of Health and Human Services and the Census Bureau. Promoting healthy aging for older Americans should, therefore, be paramount.
And healthy aging begins far earlier than 65 or 70. Obesity, in particular, may be determined in early childhood, even before. According to research by my Mailman School colleague Andrew Rundle, prenatal exposure to air pollution raises risk for obesity in childhood. His research shows that children who are overweight or obese at age five are more likely to be overweight or obese by age 50. We also know that these adults, and increasingly children too, will be more likely to have diabetes, high blood pressure and high cholesterol.
Efforts at smoking cessation should also be increased. The total economic cost of smoking in the United States is more than $300 billion a year in direct medical care and lost productivity, according to the CDC.
That’s more than we’re spending on the Cancer Moonshot annually.
Thinking big
America has extraordinary research capability. The NIH invests nearly $32.3 billion annually in medical research for the American people. Targeted cancer therapies, for instance, are the focus of much anticancer drug development, according to the National Cancer Institute. Precision Medicine is a top priority at the NIH and other research agencies. Even at $32 billion, Americans are investing in the NIH only 1 percent of what we spend on health care annually. The U.S. should build its advantage by increasing research funding to enhance the potential of breakthroughs in preventing known diseases as well as future threats.
There is reason for optimism. The good news stems in large part from the fact that chronic diseases and conditions – such as heart disease, stroke, cancer, Type 2 diabetes, obesity and arthritis – are among the most preventable of all health problems. At least half of these diseases could be prevented, and we are making strides. Death rates from heart disease, the No. 1 cause of death in America, have been reduced by nearly half, for instance, since 1990, according to the American Heart Association.
The growth and aging of the U.S. population and the epidemic of chronic diseases and conditions pose major challenges for America’s health care costs, no matter how health care is constructed. But a relentless focus on public health – and disease prevention in all its dimensions – is the best way to reduce pressure on costs.
Diabetic Amputation Rates Soar in California, Nationally
https://www.medpagetoday.com/Endocrinology/Diabetes/68086?xid=fb_o_
No clear cause, but experts suggest numerous possibilities.
Over the past 7 years, California clinicians have been amputating toes, feet, ankles and legs of patients with diabetes-related ischemia with much greater frequency than before, and public health officials, diabetes clinicians, and surgeons said they’re puzzled by the trend.
Statewide, there was a 31% increase in these non-trauma amputations after adjusting for changes in population from 2010 to 2016. Adjusted increases reached 66% in San Diego County, with a population of 3.3 million.
In other populous areas of the state, Riverside County (population 2.4 million) had a 62% increase in diabetes amputations among residents. San Bernardino County (2.1 million) had a 61% increase. Sacramento County (1.5 million people), 47%. And Los Angeles County, with more than 10 million people, saw a 20% increase.
By raw numbers statewide, there were 12,490 diabetes-related amputations in 2016, up from 8,980 in 2010, with almost all counties seeing steady increases year over year.
The data — filtered for more than 100 ICD-9 and ICD-10 codes by county, hospital, body part surgery, and payer — was requested from the Office of Statewide Health Planning and Development, the California agency that collects diagnostic codes for inpatients treated by all hospitals within the state. It was then analyzed to adjust for changes in population.
Asked for comment, officials for the California Department of Public Health responded with one sentence, saying it “does not have information” on possible reasons.
CDC Taking Note
Edward Gregg, chief of epidemiology and statistics for the CDC, said the trend is troublesome. National statistics for 2010 to 2014 show a 27% increase; before 2009, amputation rates had been dropping.
Gregg said that from a public health standpoint, “the rate of amputations is a very important indicator of overall diabetes care. If we see it going down, then it’s a good sign, because so many aspects of good diabetes care in theory are affected. And when you see it going up, that’s a concern,” he said.
He couldn’t say definitively why rates have been increasing, adding that the CDC will be working on the issue. But he and others offered theories.
For starters, the nation is aging, and advancing age is a risk factor for diabetes, and more people are being diagnosed with diabetes. But neither explanation can account for much of the recent increases, Gregg said. For one thing, rates in the diabetic population are increasing too, even after adjusting for age: from 2.7 per 1,000 in 2009 to 4.1 in 2014.
Clinician Factors
Though amputations can stop infection and save lives, diabetes-related amputations deprive patients of independence, increase the need for social services, and add to disability and medical costs. On occasion, they must be repeated when infections spread and amputation incisions don’t heal. But amputations are drastic, and should be performed only when other remedies fail, many experts stressed.
But too many clinicians are impatient, said Caesar Anderson, MD, a University of California San Diego diabetes wound and emergency medicine specialist, who said he was “shocked” by the data. He pointed to emergency room personnel and surgeons who he sees rushing to amputate “even when the wound is not that alarming.”
Anderson blamed a “culture of frustration” among clinicians who say to the patient “you’ll never get better; we’ll probably just save you the headache and just amputate … and we have some fantastic protheses we can get you into … let’s just get it over with.”
Misty Humphries, MD, a vascular surgeon and diabetes-related amputation researcher at the University of California Davis, also noticed the increase with data she collected between 2010 and 2013. She suggested hospitals may be more diligently coding patients with diabetes because of payment rule changes that increase reimbursement when health services involve patients with multiple comorbidities.
But that appeared unlikely, at least for parts of the California. According to the state’s data, the number of patients admitted to any San Diego hospital for any reason who were coded for diabetes increased only one-fifth of 1 percent from 2010 to 2016.
Humphries said that better medication and devices such as pacemakers are keeping people with high blood pressure and cardiac disease alive longer, but those medical advances don’t “protect the rest of their body from age-related deterioration” of blood vessels in their lower limbs. “We do see an increase in amputations for that particular group of patients who are now elderly, non-ambulatory, and not really doing as much but they are still alive.”
Patient Factors
Humphries said she believes a big part of the problem is how common diabetes now is, with an estimated 29 million nationally with the disease. Being diabetic may have become so much the norm, patients think they “can just take a pill … and you don’t really have to change your diet.”
Benjamin Cullen, MD, a foot and ankle surgeon with Scripps Mercy Hospital, noted that many patients may delay care until a family member notices the wound, and rushes them to the emergency room.
California’s data underscored Cullen’s point: At least in San Diego County, more than 76% of the patients who received an amputation entered the hospital through the emergency room, suggesting that patients waited, or even didn’t recognize a problem, until it became acute.
“With diabetes, patients have neuropathy, so they can’t feel their foot,” Cullen said. “They get a wound, don’t know it’s there, the wound gets infected and they don’t realize it. The first sign that they have is a foul odor coming from their foot, or a family member notices drainage.”
Often, the infection has gotten into the bone, he said, leaving “no choice but to go ahead with the amputation” to try to save other parts of the limb.
Cullen and others noted that after patients with diabetes-related infections or other wounds are seen by a doctor or at a hospital, surgeons often perform revascularization procedures to restore circulation.
Then, patients are often referred to wound clinics and given prevention instructions going forward.
System Factors
But those strategies don’t work for everyone, said James Longobardi, DPM, chief of surgery at Scripps Mercy’s Chula Vista campus, just north of the Mexican border, and one who specializes in diabetes-related foot care.
He blamed the increase at his hospital on health literacy. Many of his patients — for a variety of cultural, dietary and other reasons — “can’t grasp the seriousness of the situation, and it’s very, very frustrating to many of our clinicians.”
Gregg speculated that the American Diabetes Association’s 2010 recommendation that clinicians use A1c tests to diagnose diabetes may be capturing patients with “worse heath status, higher blood pressure, worse circulation” than fasting glucose tests. “That could affect rates of amputations too,” he said.
Other factors include less attention to risk factor management by patients or clinicians, and perhaps some subgroups getting screened later or less often than recommended, Gregg said.
Linda Geiss, director of the CDC’s diabetes surveillance section, postulated some of the increase may be delayed fallout from the 2008 recession, when people lost jobs and health insurance, and perhaps skipped medical care for several years. The Affordable Care Act’s health coverage expansions could explain increases from 2014 to 2016, but not those between 2010 and 2013.
In California, many clinicians had numerous explanations for higher numbers, especially in certain counties.
Jonathan Labovitz, DPM, a Pomona foot and ankle surgeon and podiatry researcher affiliated with the UCLA Center for Health Policy Research, blamed the state Medicaid program’s policy change in July 2009, and documented his reasons in this June policy brief.
That cost-cutting move excluded podiatry services from being reimbursed, except in certain situations. That may have reduced wound and foot care services that allowed conditions to worsen, said Labovitz, who also is assistant dean at Western University of Health Sciences College of Podiatric Medicine.
State health officials confirmed the policy change, but declined to comment on whether it increased amputations.
David Armstrong, DPM, MD, PhD, of the University of Southern California’s Keck School of Medicine, theorized that a small portion of the increase might be due to the American Diabetes Association’s broadened definition of diabetes in 1997, from at least 140 mg/dL fasting glucose to at least 126 mg/dL.
That lower threshold resulted in healthier people being captured in the denominator, and made the rate of amputations among people with diabetes appear to drop over the next decade or so, he said. It’s possible that over the next 10 to 20 years, as those people with diabetes progressed, more developed severe blood circulation problems that since 2010 resulted in them having to undergo limb surgery, Armstrong suggested.
But if that indeed is an important factor, the increased rates of amputations would not be as dramatic since 2010, he acknowledged. In the California data, the denominator is hospitalized patients with diabetes, not all diabetes patients.
“It’s just as likely, if not more so, that the economic funk in 2009, [which also was] when podiatric care was eliminated for people with diabetes, contributed to a bump in amputation rates,” he said.
Anne Peters, MD, director of the University of Southern California Clinical Diabetes Program, blamed regional impediments to access to care.
For example, she said, San Diego has no county hospital, like Los Angeles and many other large counties. She stressed the need for better access to care and stronger prevention messages, “letting people know what to look for and where to go should they develop a small lower extremity lesion so it can be treated before it becomes an amputation.”
Could more amputations be better?
Several diabetes specialists and public health officials suggested the increase in amputations could be a good thing, a sign that persistent diabetes-related wounds are not being allowed to fester. Maybe with more distal amputations of toes, and feet, ankles and legs are being spared, they said.
It could be “more a marker of success than failure,” said Philip Goodney, MD, a vascular surgeon and limb amputation researcher with the Dartmouth Institute in New Hampshire, which analyzes Medicare data to see health trends.
While it’s hard to know what California’s data means without more complicated analyses, Goodney said amputations of toes and transmetatarsal procedures across the foot may spare the ankle and leg, and still maintain enough of the foot so patients can still walk.
“I tell my patients that the toes are there for decoration. If we can help you keep your foot, then you can live at home and live independently. It’s when you get your below-knee amputation or your above-knee amputation that the sort of major impacts on quality of life starts to happen,” Goodney said.
The CDC’s Gregg, however, was doubtful. “It’s hard to buy the argument that an increase is good,” he said.
Investigations about safety issues result in few meaningful consequences for hospitals
Investigations into hospital safety issues rarely result in consequences that spark meaningful improvements, according to USA Today. That can leave patients in the dark and vulnerable to unnecessary infections.
An article in USA Today outlines a system stacked against public admissions of safety issues and potential risks of infection. A recent investigative report on sewage leaking down the walls and floor of an operating room in MedStar Washington Hospital Center represented the first public glimpse of a health department investigation into the matter.
In a statement, the president of MedStar Washington Hospital noted the hospital had corrected its plumbing issues, but Lisa McGiffert, director of the Safe Patient Project run by Consumer Reports, says the system as it stands does little to demonstrate public accountability. She suggests that hospitals must be forced to undertake internal and external audits following safety lapses.
Larry Muscarella, author of the Discussions in Infection Control blog, told the newspaper that penalties or fines issued in such cases rarely provide enough incentive for substantive change. In some cases, he says, hospitals face “little or no consequence” from citations by state agencies.
That leaves patients without information that could be crucial when it comes to deciding where they want to go to seek treatment. This compounds a related issue where, despite a general trend toward increased transparency intended to give patients information to make informed choices about their care, some hospitals have dragged their feet on releasing quality data.
Concentrating on short-term financial incentives that lead hospitals away from more substantive quality improvements actually could end up hurting the bottom line in the long run, according to trauma and emergency surgeon David Kashmer, M.D. He points out that hospitals that implement error-prevention programs see a median savings of $250,000.
“We have advanced quality tools available, but unfortunately we see some centers where, because of the culture or the situation, [they] don’t use them,” he says.
If you have anything bad to say about kids today, just shut up
If you have anything bad to say about kids today, just shut up
I guess you could find something wrong with some kid, somewhere, but come on. Data are from the 2016 National Survey on Drug Use and Health. In each of these charts, kids 12-17 are the RED LINE.
Things don’t look good for all age groups, but for adolescents – the red line – we’re pretty much at the lows. Not to mention teen pregnancy rates and teen births continue their all time lows. What more do you want from them?
Harvey pounded the nation’s chemical epicenter. What’s in the foul-smelling floodwater left behind?
http://www.latimes.com/nation/nationnow/la-na-houston-chemical-plant-20170831-story.html
The pounding rains of Hurricane Harvey washed over the conduits, cooling towers, ethylene crackers and other esoteric equipment of the nation’s largest complex of chemical plants and petroleum refineries, leaving behind small lakes of brown, foul-smelling water whose contents are a mystery.
Broken tanks, factory fires and ruptured pipes are thought to have released a cocktail of toxic chemicals into the waters. Explosions that released thick black smoke were reported at the Arkema Inc. chemical plant, where floods knocked out the electricity, leaving the facility outside Houston without refrigeration needed to protect volatile chemicals.
Meanwhile, emissions into the air have soared as the petrochemical industry shut down and then started up chemical operations, a cycle that causes an uptick in releases.
The potential health problems were magnified by overflowing sewers, inoperative treatment plants and the residues of animal waste, including carcasses.
Nobody is sure how much long-term health impact, if any, will result from the tidal wave of toxins and bacteria that swept through the nation’s fourth largest city.
Exhaustive investigations by the Environmental Protection Agency and the National Academy of Engineering after Hurricane Katrina, in which floodwaters languished in New Orleans for about six weeks, showed that toxic concentrations and the resulting exposures were too low to cause significant long-term health problems.
That festering flood caused a stench for weeks that left soldiers gagging for air as they flew helicopters 2,000 feet over the city. The Army Corps of Engineers had to pump the water out of New Orleans, much of which lies below sea level.
A report by the National Academy of Engineering in March 2006 said the floodwaters contained elevated levels of contaminants. The inorganic compounds were below drinking-water standards, while arsenic levels, attributed in part to lawn fertilizer, were above those standards.
The EPA took 1,800 samples of residue and soil from across the New Orleans area after Hurricanes Katrina and Rita and found that generally “the sediments left behind by the flooding from the hurricanes are not expected to cause adverse health impacts to individuals returning to New Orleans.”
The situation is far different in Houston, where the floodwaters are receding much faster.
But because Houston is far more industrialized, Harvey could have a much larger potential for leaving a toxic trail.
Without question, air emissions rose significantly during and after the storm, said Elena Craft, a toxicologist and senior scientist at the Texas branch of the Environmental Defense Fund.
The industry shutdown and startup cycle released 2 million pounds of pollutants, equal to 40% of all the emissions from 2016, Craft said, based on reports the industry made to the Texas Commission on Environmental Quality.
“In a few days, we have had months of exposure,” Craft said.
Marathon Oil, for example, reported to the state that heavy rain had pounded the roof of a storage tank so hard that it tilted, exposing gasoline to the air.
The emissions reports also included such carcinogens and suspected carcinogens as benzene and butadiene.
Craft said that sewage treatment plants in Beaumont went off line. A pipe carrying anhydrous hydrogen chloride was compromised in La Porte. Harris County’s 26 federal Superfund toxic waste sites may have been affected, including one that contains dioxins from a former paper mill along the San Jacinto River.
The fire at the Arkema chemical plant in Crosby released organic hydrogen peroxide, which officials said is an irritant but not toxic.
Tommy Newsom, who lives about 7 miles from the plant, said he felt fine but wondered what other chemicals might be involved. “Who knows how much of what they’re telling us is true?” he said.
“I think the wind’s in my favor,” said Newsom, a 60-year-old port worker, pointing to Texas state and U.S. flags at the entrance to his housing development.
Jennifer Sass, a senior scientist with the Natural Resources Defense Council’s health program, said the situation in Houston is a perfect breeding ground for hepatitis and tetanus.
“The flood is so large and slow-moving and the area is packed with dirty industries that are poorly regulated. Because the oil and gas industries down here are not as safe, we are concerned those toxins and chemicals are leaking,” she said.
Texas regulators urged caution. “Floodwaters may contain many hazards, including infectious organisms, intestinal bacteria, and other disease agents,” the Texas Commission on Environmental Quality said in a statement. “Precautions should be taken by anyone involved in cleanup activities or any others who may be exposed to floodwaters.”
The American Chemistry Council said its members are in constant communication with state and federal regulators about the status of their operations.
“Hurricane Harvey has presented extreme and unique challenges for the city of Houston and the surrounding areas in southeast Texas and Louisiana, warranting an unprecedented response effort, including that by local industry,” the trade group said in a statement.
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Hospital floors, sinks pose deadly infection risks
Hospital floors and sinks may pose infection risks, ones that could be overlooked when trying to control the spread of disease.
The floors in patient rooms may be contaminated by bacteria like methicillin-resistant Staphylococcus aureus (MRSA) or Clostridium difficile, according to a new study published in the American Journal of Infection Control. These pathogens, which can cause potentially deadly infections, can be spread when items are dropped on the floor, the researchers noted.
The research team swabbed a number of surfaces, including the floors, clothing, call-buttons and other high-touch items, in 159 rooms at five Cleveland hospitals, according to the study. The study included C. difficile-isolated rooms, and researchers found floors were often tainted by bacteria, most commonly with MRSA, C. difficile and vancomycin-resistant enterococci (VRE). The researchers also found that in 41% of these rooms, at least one high-touch object came in contact with the floor.
The study team said it hopes the results bring more attention to the infection risk posed by floors, which are not often considered in the conversation on infection control.
“Although healthcare facility floors are often heavily contaminated, limited attention has been paid to disinfection of floors because they are not frequently touched,” lead study author Abhishek Deshpande, M.D., Ph.D., an internal medicine physician for the Cleveland Clinic, said in an announcement. The results of our study suggest that floors in hospital rooms could be an underappreciated source for dissemination of pathogens and are an important area for additional research.”
Another recent study noted that hospital sinks may frequently host drug-resistant superbugs like MRSA or VRE. The research, which was published in Applied and Environmental Microbiology, set up five identical sinks in a lab that replicated sinks at the University of Virginia’s hospital in Charlottesville. The researchers then contaminated the sinks with E. coli bacteria, and though colonization began in drain pipes, it inched toward sink strainers before water spread it in the sink.
“This type of foundational research is needed to understand how these bacteria are transmitted, so that we can develop and test potential intervention strategies that can be used to prevent further spread,” Amy Mathers, M.D., an associate professor of medicine at pathology at University of Virginia, told HealthDay.
12 superbugs that pose the greatest danger to human health
The World Health Organization has released a list of 12 antibiotic-resistant superbugs that pose the greatest danger to human health.
The purpose of the list of “priority pathogens,” according to WHO, is to promote continued research and development of drugs that can be used to treat patients with these resistant infections.
The agency has divided the list according to the urgent need for new antibiotics. The bacteria considered the most critical pose a particular threat to hospitalized patients who may require blood catheters or ventilators. These bacteria, which can cause severe and deadly infections, such as bloodstream infections and pneumonia, are also resistant to drugs designed as a last line of defense for patients.
“This list is a new tool to ensure R&D responds to urgent public health needs,” Marie-Paule Kieny, Ph.D., assistant director-general for health systems and innovation at the WHO, said in an announcement. “Antibiotic resistance is growing, and we are fast running out of treatment options. If we leave it to market forces alone, the new antibiotics we most urgently need are not going to be developed in time.”
Three bacteria resistant to carbapenem, an antibiotic that often treats bacteria that are resistant to other drugs, are listed as critical. Six bacteria are ranked as high-priority and the final three are listed as medium-priority. Bacteria listed as high- or medium-priority are increasingly becoming resistant to different antibiotics and are producing hard-to-treat strains of common conditions, such as gonorrhea and salmonella.
One of the three critical bacteria, carbapenem-resistant Enterobacteriaceae, or CRE, resulted in the death of a Nevada woman last year, and estimates suggest the infection may be more widespread than previously thought.
Global health experts have increasingly warned that superbugs are poised to be a significant threat to patient health. In the next decades, drug-resistant infections could kill more people than cancer. Providers can do their part by focusing on antibiotic stewardship. National healthcare organizations, including the Centers for Medicare & Medicaid Services, have offered guidelines.
Here is the complete list compiled by WHO:
HENRY KOTULA 