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Amid Smoking Decline, Look Who's Still Lighting Up

3 hours 33 min ago
Amid Smoking Decline, Look Who's Still Lighting Up July 31, 2014 4:20 PM ET Listen to the Story 4 min 0 sec   i i

Tobacco giant Reynolds American is buying Lorillard and acquiring Newport, a popular menthol cigarette. In a shrinking market, Newport is one of the few U.S. brands gaining market share. It is particularly popular among African-American smokers.

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Robin Koval is making a career of her changed tobacco habit.

"I'm a child of a smoker — my father was a heavy smoker," Koval says. "Really typical to the way the story goes, I started smoking when I was 15."

Now she is president and CEO of Legacy, a foundation devoted to preventing tobacco use.

Koval is working in a rapidly changing landscape. Earlier this month, Reynolds American announced plans to buy its rival Lorillard for $27.4 billion. This move alters the U.S. tobacco market and comes as the number of smokers in the U.S. continues to decline.

In the 1960s, more than 40 percent of Americans smoked. Now, that's down to 18 percent. Not only are fewer people smoking, heavy smokers are consuming fewer cigarettes.

"We are winning the war," Koval says. "I guess from my perspective, we'd rather win the war faster."

She says the overall numbers mask a huge cultural variation.

"I live in Washington, D.C.; we have a low smoking rate here. But if you go to a place like West Virginia, which has the highest smoking rate in the country, the behavior feels completely normalized," Koval says.

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Smoking is far more common among those living below the poverty level, those with GED-level education, and among American Indian or Alaskan Natives, according to the Centers for Disease Control and Prevention. Rates are also much higher in the lesbian, gay and transgender community.

So Legacy trains educators and targets its anti-smoking message to these populations.

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But Koval says companies like Reynolds and Lorillard know their market well.

"I think this merger, for instance, is very much about menthol," she says. "While menthol usage is declining with all cigarette usage, it's declining at a much slower rate, about half the rate, I believe, than regular-flavored cigarettes."

And because menthol, a mint-flavored additive, is popular among African-Americans, the companies focus ads and coupons there.

David Howard, a spokesman for R.J. Reynolds, a subsidiary of Reynolds American, acknowledges menthol is a factor in the merger. In the deal, Reynolds acquires Lorillard's Newport, the best-selling menthol cigarette and one of the few U.S. brands gaining market share. But Howard says the driving force is what he calls "smokeless" products.

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"For R.J. Reynolds, the focus is on innovation and providing innovative, smoke-free alternatives for adult tobacco consumers to consider," Howard says.

Electronic cigarettes are a small but growing share of the market. Surprising some analysts, Reynolds will sell Lorillard's e-cigarette, Blu, to rival Imperial Tobacco Group. Instead, Reynolds is focusing on its own e-cigarette product, Vuse, that was rolled out nationally in June.

Howard says he expects the market for e-cigarettes, snuff and nicotine patches could grow as traditional cigarettes continue to fall out of favor.

Iris DeLutro, who is 63 and from Queens, N.Y., typifies the changing habits of smokers these days.

"I've cut down dramatically," she says. "I used to smoke a pack and a half."

She says she used to smoke while working at her desk. But times have changed, and so have her own attitudes. Now, she's hoping to use a patch to try to quit altogether.

"I don't smoke indoors at all — my apartment is smoke-free," DeLutro says. "I don't let my grandson see me smoking."

There are still enclaves where smoking is alive and well. The Midwest, where Sheila Martin lives, has a higher smoking rate than other areas and nearly double the rate in the West.

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"My parents smoked when I was growing up," Martin says. "I didn't know anyone whose parents didn't smoke."

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Martin owns a tavern in Hutchinson, Kan., which still permits smoking — it was grandfathered in under a state smoking ban. And Martin wants very much to keep it that way.

"In a country where people have the right to assemble, you know, as long as tobacco is sold and sanctioned by the government, and they're making a lot of money on it, people ought to be allowed to choose," she says.

But even a die-hard smoker like Martin says she may consider e-cigarettes.

"If I decided I didn't enjoy it anymore, I probably would try the e-cigs," she says.

There may come a time, she says, when she'll take up a smokeless alternative like some of her customers. But that day has not yet come.

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Hospitals Fight Proposed Changes In The Training Of Doctors

7 hours 25 min ago
Hospitals Fight Proposed Changes In The Training Of Doctors July 31, 201412:28 PM ET

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Chief Medical Resident Dr. Julia Vermylen (right) critiques interns during an "intern boot camp," held at Chicago's Northwestern Memorial Hospital in June.

Stacy Thacker/AP

An influential report that urges sweeping changes in how the federal government subsidizes the training of doctors has brought out the sharp scalpels of those who would be most immediately affected.

Shots - Health News Report Says Big Changes Are Needed In How Doctors Are Trained

The reaction also raises questions about the sensitive politics involved in redistributing a large pot of money –mostly from Medicare — that now goes disproportionately to teaching hospitals in the U.S. Northeast. All of the changes recommended would have to be made by Congress.

The report for the Institute of Medicine, released Tuesday, called for more accountability in the distribution of the federal funds earmarked for doctor training — $15 billion annually. About two-thirds of that cash comes from Medicare. The report also called for an end to providing the money directly to the teaching hospitals and to dramatically alter the way the funds are paid.

The money in question is for graduate medical education — the training of medical school graduates that's required before these interns and residents can be licensed to practice in any state.

"We recognize we are causing some disruption," said Gail Wilensky, a health economist and co-leader of the panel that produced the report. "But we think we are doing so in a thoughtful and careful way," including recommending phasing in the payment changes over 10 years.

Some of the major players in medical education don't see it that way, however.

"Today's report on graduate medical education is the wrong prescription for training tomorrow's physicians," the American Hospital Association said in a written statement, adding that the group's leaders were "especially disappointed" to see the suggestion that funding from Medicare should be shifted away from hospitals toward some clinics that even don't treat Medicare patients.

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In its report, Wilensky's panel explained why it proposed shifting funding toward community clinics, writing, "Most, if not all residencies must train physicians to treat a wide range of patients — many of whom are under age 65 and not eligible for Medicare coverage."

The American Academy of Family Physicians welcomed the proposal to move funding away from a hospital-based system to more community-based training sites. "By giving these organizations more control over how they train residents, the financial investment will better align with the health needs of a community," the group's president, Reid Blackwelder, said in a statement.

But the broader-based doctor group, the American Medical Association, reacted negatively, saying: "Despite the fact that workforce experts predict a shortage of more than 45,000 primary care and 46,000 specialty physicians in the U.S. by 2020, the report provides no clear solution."

“ People talk about the third rail of politics as not touching Social Security. I have found that if you touch anything dealing with medical education you get bombarded.

Wilensky says that's because her panel didn't agree with studies that project there's going to be a shortage of doctors. Rapid changes in medical practice, she says — including the greatly increased use of nonphysician health professionals, such as physician assistants and nurse practitioners — might be enough to provide care to aging baby boomers and people now getting insurance coverage under the Affordable Care Act.

And even if a shortage does occur, the medical education system needs to better manage training since it now produces more specialists than primary care providers, and leaves major areas of the country with too few doctors, said Malcolm Cox, who recently retired from running the medical education program for the Department of Veterans Affairs. "Will an unregulated expansion produce the right physicians with the right skills in the right areas of the country?" he said at a panel discussion of the report.

Wilensky, who ran Medicare when Congress overhauled the physician payment system in the early 1990s, said the chances for making such changes depend very much on lawmakers from states that currently get less funding — which is most of them.

Given the fact that a disproportionate amount of current funding goes to institutions "in New York, New Jersey, and Massachusetts," Wilensky says she's surprised "that everyone else has tolerated this peculiar distribution of funds" for so long.

Whether change happens will depend on "whether some of the have-not states are willing to say 'wait a minute,' " she says.

The New York teaching hospitals, in particular, are well-known for their clout on Capitol Hill.

"They are fantastically great in terms of their protection of their turf," said Bill Hoagland, a longtime Senate Republican staffer and now senior vice president of the Bipartisan Policy Center. "People talk about the third rail of politics as not touching Social Security. I have found that if you touch anything dealing with medical education you get bombarded."

By far the most heated criticism of the report's recommendations came from the Association of American Medical Colleges, which represents medical schools and the teaching hospitals they affiliate with.

"While the current system is far from perfect, the IOM's proposed wholesale dismantling of our nation's graduate medical education system will have significant negative impact on the future of health care," said the group's president and CEO, Darrell Kirsh. The proposed redistribution of funding, he says, "will slash funding for vital care and services available almost exclusively at teaching hospitals, including Level 1 trauma centers, pediatric intensive care units, burn centers, and access to clinical trials."

Still, those supporting the IOM's recommendations say the way we train doctors is in major need of change. "The current system is unsustainable," said Edward Salsberg, a former top official at the Bureau of Health Workforce at the Department of Health and Human Services. "Health care is moving to the community, but our system of financing graduate medical education is tied to inpatient care."

Copyright 2014 Kaiser Health News. To see more, visit
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What Somebody's Mummy Can Teach You About Heart Disease

14 hours 41 min ago
What Somebody's Mummy Can Teach You About Heart Disease July 31, 2014 5:12 AM ET i i

Eduard Egarter-Vigl (left) and Albert Zink (right) sample Italy's mummified iceman for genetic analysis in November 2010. Previous research suggests he, too, was predisposed to heart disease.

Samadelli Marco/EURAC

We think of heart disease as a modern scourge, brought on by our sedentary lifestyles and our affinity for fast food.

But a few years ago, a team of researchers discovered something puzzling — CT scans of Egyptian mummies showed signs of hardened, narrow arteries. Further scans of mummies from other ancient civilizations turned up the same thing.

How could it be that these preindustrial people without doughnuts or desk jobs suffered from atherosclerosis, a condition we know to be associated with smoking, unhealthful diet and lack of exercise? And what does that tell us about heart disease today?

We may be getting closer to understanding. In a study published this week in Global Heart, researchers conclude that factors like inhaling smoke from open fire pits and inflammation triggered by dirty living conditions may be to blame.

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While inflammation isn't considered one of the main risk factors for heart disease today, studies have found that it's associated with atherosclerosis. And ongoing clinical trials are testing whether reducing inflammation might help reduce risk of heart disease.

The researchers behind this report pored over autopsies of mummies from the various communities they've studied — including ancient Peruvians and Native Americans in the U.S. Southwest, as well as in Alaska's Aleutian Islands. Many of the mummified people, they discovered, had endured a host of infections known to exacerbate inflammation — including malaria and tapeworms.

Since female mummies showed more evidence of atherosclerosis than male mummies, the scientists also theorize that exposure to smoke from fire pits played a role. "In each of the cultures we studied, the women were cooking," says Dr. Greg Thomas, a cardiologist who led the study. These ancient peoples also used fires to keep warm and ward off insects, he says, "So they were exposed to a lot of smoke." In many ways, inhaling billowing smoke from a fire pit can be as harmful to the heart as smoking cigarettes or breathing highly polluted air, Thomas notes.

"The data presented here are quite provocative," says Nathan Wong, a professor of cardiology and epidemiology at the University of California, Irvine. "It gives us more of an appreciation for factors we don't think about as much these days."

The findings suggest that atherosclerosis may be baked into our genes more than we thought, Thomas says.

"It's incredible," he says, that people from both ancient and modern times, with a range of different diets and lifestyles, all suffered from the same condition.

Of course, in general, the atherosclerosis found in the mummies wasn't too severe. "It was really pre-clinical," Thomas notes. Modern humans who want to stave off heart disease should continue to exercise and watch what they eat, he says, but, "When I see a patient now who has a heart incident, I assure them that this is a problem that's been with us since before writing — so they shouldn't blame themselves too much."

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Problem Drinking In Midlife Linked To Memory Trouble Later

Wed, 07/30/2014 - 1:54pm
Problem Drinking In Midlife Linked To Memory Trouble Later July 30, 2014 1:54 PM ET i i

How much is too much?

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To ward off big memory problems in your 70s and beyond you may want to cork the bottle more often now.

In a study of 6,500 people published this week, adults with a midlife history of drinking problems were more than twice as likely as those without alcohol problems to suffer severe memory impairment decades later.

Researchers from the University of Exeter Medical School, in Exeter, England, analyzed the records of more than 6,542 American adults who had been tracked for 19 years as a part of the Health and Retirement Study.

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The drinking assessment was based on a questionnaire mailed in 1992 to the study participants, who were then between the ages of 51 and 61. Instead of directly asking the volunteers how much they typically drank each day, the questions fished for other, subtler indicators of an alcohol problem. The questionnaire asked if participants ever felt that they should cut down on drinking; if they had ever been annoyed by someone criticizing their drinking; and if they ever had a drink first thing in the morning.

"If you're saying yes to these questions you may be at risk," Iain Lang, a public health specialist and author of the study, tells Shots. "Current recommendations about drinking are about the numbers: 'Do not drink this amount of [alcohol] per day,' " he says. "We wanted to draw attention to people's own feelings on their drinking and to the responses of others."

After submitting the questionnaire, participants took a series of tests of memory and thinking. They underwent follow-up tests in 1996 and every two years thereafter.

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In one test participants were asked to recall a list of 10 words, such as "mountain," "forest," and "light," immediately after it was read to them. Then they were given an activity to perform, and asked to repeat the words again. Other tests had the participants count back from 20 or recall the names of the current American president and vice president.

All participants did worse on the memory tests as the years went on. But those with histories of alcohol problems had a sharper decline. The findings appear in the current issue of American Journal of Geriatric Psychiatry.

"If you're having problems with a test like that, I'm sure it carries through to your daily life," says Clare Walton, a neuroscientist from the Alzheimer's Society in the United Kingdom, who was not involved in the study.

Research shows nobody likes to own up to how much he drinks, so any study like this that's based on self-reported answers has limits, Walton says.

She points out that although answers to those three subjective questions can effectively point out an alcohol abuser about 70 percent of the time, they are still misidentifying people 30 percent of the time. Exactly how much alcohol it takes to do such damage, and over what time period, are still unknown.

Still, she says the work reinforces what other research has been showing: Drinking too much can increase a person's chances of developing serious memory problems and even dementia, which affects 13.9 percent of people over age 70.

"Taking this paper with previous evidence," she says, "people who are concerned with dementia should consider their drinking habits in midlife."

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California Pharmacists Resist Translating Medicine Labels

Wed, 07/30/2014 - 4:59am
California Pharmacists Resist Translating Medicine Labels July 30, 2014 4:59 AM ET


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California's Board of Pharmacy is considering requiring all pharmacies in the state to provide bilingual labels on prescription medicines.

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Every Saturday morning, a steady stream of Chinese and Vietnamese patients line up at the Paul Hom Asian Clinic in Sacramento. Most of them speak little or no English.

Patient Assistance Director Danny Tao says people come here to get free medical consultations and drug prescriptions. But when patients take those prescriptions to be filled, he says, they don't understand the instructions on the label.

"They go pick them up, and we don't exactly know if they're taking it or not — or if they know how to take it," Tao says.

Tao says drug labels at most pharmacies in California are printed only in English. That puts patients in danger of making any number of errors — taking too much medicine or not enough, or taking it at the wrong time of day. Such mistakes can cause serious harm or even death.

Tao says that all the drugs his clinic supplies directly to patients have a bilingual label — English and Chinese, or English and Vietnamese.

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"By the time they get home," he says, "they know exactly how to take the medication, because it's in their own language."

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This week California's Board of Pharmacy will discuss new regulations that would require all pharmacies in the state to provide translated labels on prescription drug bottles. Statewide, 44 percent of Californians speak a language other than English at home. New York approved a similar rule last year to make it easier for people who don't speak English to avoid costly mistakes when taking medicine.

But the board's executive officer, Virginia Herold, says the move is very controversial. For starters, there is a concern that requiring translated labels would require larger bottles of pills, too, in order to have room for the extra text. Patients don't like larger bottles, she says.

"They decant the drug out of the large container, put it in a baggie or someplace else," Herold says. "There, you've separated the drug from the container; now the instructions on how to take it have been separated."

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Pharmacists don't like the proposal because they say it opens them to liability if there's a mistake in the translation.

"If the label is translated into Russian and there's an error, and I'm a pharmacist that does not speak Russian, I cannot verify that that error exists," says Brian Warren, of the California Pharmacists Association. He says that could increase the cost of malpractice insurance.

"It's an expense that will ultimately make its way down to consumers," Warren says, "and like all other health care costs, will eventually result in higher premiums."

For now, the state's board of pharmacy includes on its website translations of basic instructions such as "take one pill at bedtime" in five languages: Chinese, Korean, Russian, Spanish and Vietnamese. But both Herold and Warren say pharmacists never took to using them.

Proponents of translating the labels say any concerns about the change are outweighed by problems that patients who speak limited English are facing under the status quo.

"There's a risk right now," says Sarah de Guia, director of government affairs for the California Pan Ethnic Health Network, an advocacy group. The expansion of insurance under the Affordable Care Act puts even more urgency on the issue in California, she says, by adding 1.5 million more people who have limited English to the health care system.

The discussions are in the earliest stages. If new regulations go forward, many details still remain to be worked out, such as how many languages would be included, and who would be responsible for the translation.

This story is part of a partnership between NPR, KQED and Kaiser Health News.

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Report Says Big Changes Are Needed In How Doctors Are Trained

Tue, 07/29/2014 - 2:06pm
Report Says Big Changes Are Needed In How Doctors Are Trained July 29, 2014 2:06 PM ET

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Proposed changes in medical training would shift money away from big teaching hospitals to clinics.


The way American doctors are trained needs to be overhauled, an expert panel recommended Tuesday, saying the current $15 billion system is failing to produce the medical workforce the nation needs.

"We recognize we are recommending substantial change," says health economist and former Medicare Administrator Gail Wilensky, co-chairwoman of the nonpartisan Institute of Medicine panel that produced the report. "We think it's key to justifying the continued use of public funds."

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The federal government provides more than $11 billion a year in payments to support the training of doctors who have graduated from medical school, mostly through the Medicare program. Most of that goes to the hospitals that sponsor interns and residents. States, through the Medicaid program, contribute nearly $4 billion more annually.

"The scale of government support for this phase of physician education is unlike that given to any other profession in the nation," said the report, which was funded by a dozen foundations with the support of a bipartisan group of members of Congress.

Even though the system has operated this way for decades, there are few data on how those funds are spent and how well they contribute to the preparation of a medical workforce needed for the 21st century, the panel found.

Despite a growing public investment in graduate medical education, there are persistent problems. They include uneven geographic distribution of physicians, too many specialists and not enough primary care providers, and a lack of cultural diversity in the physician workforce, the report found.

Not only that, the authors note, "a variety of surveys indicate that recently trained physicians in some specialties cannot perform simple procedures often required in office-based practice and lack sufficient training and experience in care coordination, team-based care and quality improvement."

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The committee proposes a sweeping overhaul of the entire financing program for graduate medical education, with the goal of shifting the program "to a performance-based system," rather than one that merely funnels money to any facility with an accredited training program.

The current Medicare medical education payment system would be phased out over 10 years. At the end of the phase-out, policymakers would reassess whether Medicare should continue to subsidize doctor training at all, and if so, to what extent.

The panel calls for spending the same overall amount from Medicare over the next decade, adjusted for inflation. But it would be distributed much differently, with a declining share providing direct subsidies to teaching programs. An increasing share would go instead to a "GME transformation fund" that would finance new ways to provide and pay for training, and to fund training positions "in priority disciplines and geographic areas."

The funds would still be distributed through the Medicare program, but a new "GME Policy Council" would be created under the office of the secretary of health and human services to oversee workforce issues and commission research on how well the federal dollars are being spent. The committee recommended that states impose similar requirements for Medicaid training funds.

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Major teaching hospitals in the Northeast would be most immediately affected, since they account for a disproportionate amount of Medicare medical education funding and number of doctors in training. The panel called for an end to the current system of payments that favor those hospitals. Instead it said that Medicare should make a flat "per resident" payment to training sponsors based on the national per resident amount, adjusted for location.

It's time to close the open checkbook for teaching hospitals, the panel said.

"The statutes governing Medicare's GME financing were developed at a time when hospitals were the central — if not exclusive — site for physician training," the report said. But by doing that, "the Medicare payment system discourages physician training outside the hospital, in clinical settings where most health care is delivered."

Members stopped short, however, of recommending that Medicare stop funding graduate medical education altogether, at least for the near future.

The rapid evolution of the health care sector, said Wilensky, "was an important rationale for potentially using the leverage provided by government funding to try to train the health care workforce we needed for a 21st century delivery system."

But the panel also did not recommend lifting the current cap on the number of residencies that Medicare supports. That cap was imposed in the 1997 Balanced Budget Act.

"Increasing the number of physicians per se is not likely to solve important workforce issues," Wilensky said, "particularly with regard to specialty distribution or geography."

All of the changes proposed in the report would have to be made by Congress, because government support for graduate medical education is written into Medicare and other laws. The politics, however, are unclear because the changes would produce winners and losers among programs training interns and residents.

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Getting Hospice Care Shouldn't Have To Mean Giving Up

Tue, 07/29/2014 - 12:00pm
Getting Hospice Care Shouldn't Have To Mean Giving Up July 29, 201412:00 PM ET

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Patients who get the comforts of palliative care as well as disease treatment live longer, studies show, than those who only get treatment for the disease.

Annette Birkenfeld/iStockphoto

It's a painful dilemma for seriously ill Medicare patients: To receive the extra support, counseling and care provided by the program's hospice benefit, they have to agree to stop receiving curative treatment for their disease.

Faced with that stark either-or choice, many forgo hospice care until the last days of their lives. The median length of time a Medicare patient was in hospice in 2012 was just 19 days, according to the National Hospice and Palliative Care Organization.

Now an experimental project, set to enroll 30,000 people over the next few years, will allow some hospice-eligible Medicare patients to get treatment for the disease and hospice care at the same time.

"I think it's a recognition that this forced choice between palliative care and life-prolonging treatment is irrational," says Dr. Diane Meier, director of the Center to Advance Palliative Care.

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The comforts of palliative care focus on treating the pain, stresses and symptoms of serious illness, aiming to maximize the quality of life for people and their caregivers at any stage of illness, says Meier, a professor of geriatrics and palliative medicine at Mount Sinai in New York City. Under the traditional Medicare program, she says, the hospice benefit provides palliative care services only if doctors have certified the patient has less than six months to live if the disease follows its natural course, and if the patient agrees to stop receiving curative treatment for it.

Hospice and palliative care overlap, and Meier explains the difference this way: "All hospice care is palliative care — but not all palliative care is hospice." In palliative care, she says, "the emphasis is on need, not prognosis or how long you might have to live."

“ My prediction is that it will actually be less expensive to provide both approaches at the same time, precisely because it will lead to less need for costly emergency and crisis care.

Under the experimental Medicare Care Choices Model, people with advanced cancers, chronic obstructive pulmonary disease, congestive heart failure or AIDS will be able to receive a range of hospice services, even as they continue to see their regular health providers for treatment of the illness. Hospices selected to participate in the program will be responsible for coordinating their patients' care.

Medicare expects 30,000 patients to take part in the program, from at least 30 rural and urban hospices that have applied to participate. Medicare administrators will announce the names of the hospices within the next several months.

Patients in the program might, for example, continue to receive radiation and chemotherapy to treat a tumor that's pressing on bone and causing pain. It treats their cancer but it also makes them feel better, says Meier.

Allowing people to receive both types of care may actually save money, she says. Several studies have shown that patients who receive both palliative care and disease treatment actually live longer than those who receive only disease treatment.

"It makes sense," says Meier. "People aren't in excruciating pain; they're not depressed. And if, very importantly, people are able to avoid the very real risks of hospitals, it's no surprise that they live longer."

"My prediction is that it will actually be less expensive to provide both approaches at the same time," she says, "precisely because it will lead to less need for costly emergency and crisis care."

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Athletes Should Fear The Heat More Than The Heart Attack

Tue, 07/29/2014 - 7:47am
Athletes Should Fear The Heat More Than The Heart Attack July 29, 2014 7:47 AM ET i i

Some marathons are warning runners when conditions increase the risk of heatstroke.


When a runner's heart stops during a marathon, it gets a lot of press — even though it's actually a pretty rare event. A more common killer among runners, and a condition that needs more prevention efforts, is heatstroke, according to a study by Israeli researchers.

During a 2011 running race, physicians at a Tel Aviv hospital noticed there were far more heatstroke victims admitted than cardiac patients. They wondered if this was an anomaly, so they analyzed local races from March 2007 to November 2013, encompassing 137,580 runners.

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Across those races, there were two serious cardiac events, neither of which was fatal or life threatening. But there were 21 serious heatstroke cases, including two fatalities and 12 that were life threatening.

There's a continuum of heat illnesses, ranging from milder heat cramps all the way to heatstroke, which is defined as a fever above 104 degrees and symptoms including dry, hot skin, rapid breathing and unconsciousness. When the body gets that hot, the kidneys, brain and other organs can fail.

One caveat: It gets hot in Tel Aviv. It's possible that not every race site will face the same heatstroke danger, though "it's reasonable to assume that heat stroke is just as common in other countries with similar climate," Dr. Sami Viskin, senior author of the study and a cardiologist at Tel Aviv Medical Center, told Shots via email. (And heatstroke can occur in mild climates too.)

It's important for racers to be prepared for heat. That means acclimatizing to warmer weather — though that can take up to two weeks, so it's not always practical. The authors say it may be better to schedule races during the summer, when participants are used to the heat, rather than the spring. People also should beware of racing if they've recently had a fever, since that can reduce the body's ability to ward off heatstroke, the authors say.

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The National Athletic Trainers' Association also recommends drinking enough fluids before, during and after exercise to help avoid overheating.

And race organizers need to be able to diagnose heatstroke quickly by taking a runner's body temperature rectally on site, so they can provide proper cooling, most effectively by immersing the person in a cold water bath.

Heatstroke is a big problem, says Dr. George Chiampas, a Northwestern Medicine emergency medicine physician. He's also medical director of the Chicago Marathon, which made some changes after the 2007 race was halted amid high temperatures that sickened hundreds. (The single death that year was actually a result of a heart condition, not the heat.)

Now runners see green, yellow, red or black flags along the route to indicate whether the conditions, including weather, are good, less than ideal, potentially dangerous or so bad that the race has been stopped, Chiampas tells Shots. Post-race surveys show that runners run more slowly and adjust their strategy if conditions are yellow or red, he says.

And medical personnel near the finish line are trained to talk with runners to see if their mental status has been affected — a sign of heat illness.

The study was published Monday in the Journal of the American College of Cardiology.

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Medicare's Costs Stabilize, But Its Problems Are Far From Fixed

Mon, 07/28/2014 - 3:43pm
Medicare's Costs Stabilize, But Its Problems Are Far From Fixed July 28, 2014 3:43 PM ET

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Medicare's Hospital Insurance Trust Fund, which finances about half of the health program for seniors and the disabled, won't run out of money until 2030, the program's trustees said Monday. That's four years later than projected last year, and 13 years later than projected the year before the passage of the Affordable Care Act.

But that's not the case for the part of Social Security that pays for people getting disability benefits. The Disability Insurance Trust Fund is projected to run out of money in 2016, just two years from now, unless Congress intervenes, the trustees said.

"Medicare is considerably stronger than it was just four years ago," Health and Human Services Secretary Sylvia Burwell said Monday. She noted that slower growth of the program's spending will very likely mean that the Medicare Part B premium charged to beneficiaries — currently $104.90 per month — remains the same for the third year in a row. "That's a growth rate of zero percent," she noted.

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All the trustees, however, including the secretaries of HHS, Treasury and Labor and two public members, stressed that Medicare's financial problems are far from fixed, particularly as 78 million baby boomers are on the precipice of joining.

"Notwithstanding recent favorable developments, both the projected baseline and current law projections indicate that Medicare still faces a substantial financial shortfall that will need to be addressed with further legislation," the report said.

And "the sooner lawmakers face that reality, the better," said Robert Reischauer, a public trustee and former head of the Congressional Budget Office.

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For the first time, the Medicare report deviates from current law and does not assume that scheduled deep cuts in reimbursements to physicians who treat Medicare patients will occur. Congress has suspended the cuts each year since 2003, and in this report the trustees assume that will continue until Congress fixes the formula, known as the sustainable growth rate, or SGR.

The change "should make the Part B cost projections more useful than they have been in the past," said Reischauer. Part B pays for most physician and outpatient costs. It technically does not have a trust fund because it is financed by a combination of general tax revenues and beneficiary premiums, but the trustees make projections for its spending each year.

The trustees opted not to wade into the ongoing debate over the extent to which the slowdown in Medicare's spending increases can be attributed to changes to the program made in the 2010 health law.

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"No one knows and certainly there is an active debate," said Charles Blahous, the other public trustee and lone Republican on the panel. "And that's not something the trustees are going to settle," said Blahous, a fellow at the conservative Hoover Institution.

But whatever the reason, no one contests that the slowdown has been dramatic. Medicare, which covered an estimated 52.3 million people in 2013, spent $582.9 billion, "and, for the second year in a row, per beneficiary costs were essentially unchanged," the report said.

The financial picture for Social Security's disability insurance fund, by contrast, is much more dire.

"The projected reserves of the DI Trust Fund decline steadily from 62 percent of annual cost at the beginning of 2014 until the trust fund reserves are depleted in the fourth quarter of 2016," the Social Security report said. After that, the program would be able to pay only 81 percent of scheduled benefits.

The disability program has seen a dramatic increase in enrollment in recent years, yet Congress has not taken any action to change its financing, which is 1.8 percentage points of the overall 12.4 percent Social Security payroll tax paid by employers and workers.

Copyright 2014 Kaiser Health News. To see more, visit
Categories: NPR Blogs

With Men's Y Chromosome, Size Really May Not Matter

Mon, 07/28/2014 - 12:41pm
With Men's Y Chromosome, Size Really May Not Matter July 28, 201412:41 PM ET Listen to the Story 6 min 54 sec   i i

The human Y chromosome (left) holds the code for "maleness"; that's the X on the right.

Andrew Syred/Science Source

Basic biology has it that girls are girls because they have two X chromosomes — the things inside cells that carry our genes. Boys are boys because they have one X and one Y. Recently, though, there's been a lot of debate in scientific circles about the fate of that Y chromosome — the genetic basis of maleness.

Very early in the evolution of the Y chromosome, explains Dr. David Page, a geneticist at the Massachusetts Institute of Technology, something pretty dramatic happened: The ancestral Y lost most of its genes. And scientists basically ignored the little that was left.

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"The Y chromosome was essentially written off as the runt of the human genome," Page says, "as a sort of genetic wasteland that didn't really merit anyone's serious attention."

When the Y did get any attention, it wasn't good news. Some scientists, like geneticist Jennifer Graves at La Trobe University in Melbourne, Australia, speculated that the Y might be destined to just keep sort of ... rotting away.

“ The idea that the Y chromosome might disappear altogether, possibly taking men with it — I think that idea has now been firmly dismissed.

"As soon as it becomes a male-determining chromosome, then the rot sets in," Graves says. "That's kind of the kiss of death for that chromosome," meaning the Y chromosome could be headed toward oblivion — completely disappear.

But other scientists, including Page, say: Not so fast. Step away from my Y chromosome.

"I've really spent the better part of my career defending the honor of the Y chromosome in the face of insults of this sort," Page says.

For the Y, size really doesn't matter, he says. Page has done a detailed analysis of the chromosome's evolution and says the string of genes has been solidly stable now for millions of years.

“ When I give lectures about the demise of the Y chromosome, I see men sort of hunching up into this protective stance as though I'm physically attacking them.

"The idea that the Y chromosome might disappear altogether, possibly taking men with it — I think that idea has now been firmly dismissed," he says.

In fact, the relatively few precious genes that are left on the Y look like they're special — very special.

"There are genes on the Y chromosome that are active throughout every nook and cranny of the body," Page says. "The skin, the blood, the brain, the lungs — you name it. They look to be sort of global entrepreneurs within the human genome. They are sort of master regulators."

Still, Graves remains skeptical.

"I don't think that one can assume that just because they're there and they do something useful they'll be there forever and ever," she says. "A small accident could tip it over the edge, or the evolution of a new sex-determining system that works better."

Graves says she is always surprised by the ferocious reaction she gets to any suggestion that the male chromosome might be vulnerable.

"I've been accused in print of being, you know, a ball-breaking feminist," she says. "Well, no — not really. I'm just pointing out that things change, and evolution is wonderful, and it can do things lots of different ways."

Graves has a theory about why the reaction is so intense, especially among men.

"There's some deep-seated insecurity that men have about their Y chromosomes," she says, half-joking. "When I give lectures about the demise of the Y chromosome, I see men sort of hunching up into this protective stance as though I'm physically attacking them."

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And there's a twist in all this. Even if the Y chromosome is here to stay, that may be something of a double-edged sword for men. Even if those master genes on the Y chromosome are important, they may also help explain why men are more prone to certain diseases than women are — and tend to live shorter lives.

Jan Dumanski, of Uppsala University in Sweden, and his colleagues recently reported, for example, a possible link between the Y chromosome and an increased risk for lots of cancers. He sees the human Y chromosome as "the Achilles' heel for men."

"It's making us men," Dumanski says, "but also causing us some trouble when we are getting older."

Clearly, our relationship with Y continues to be complicated. And it's not all about size.

Copyright 2014 NPR. To see more, visit
Categories: NPR Blogs

People Who Feel They Have A Purpose In Life Live Longer

Mon, 07/28/2014 - 4:57am
People Who Feel They Have A Purpose In Life Live Longer July 28, 2014 4:57 AM ET Listen to the Story 3 min 44 sec   i i Maria Fabrizio for NPR

We know that happiness and social connection can have positive benefits on health. Now research suggests that having a sense of purpose or direction in life may also be beneficial.

To find out if having a sense of purpose has an effect on aging and adult development, Patrick Hill, an assistant professor of psychology at Carleton University in Ottawa, Canada, looked at data from the Midlife in the United States (MIDUS) study, which is funded by the National Institute on Aging.

Hill and his colleague Nicholas Turiano of the University of Rochester Medical Center looked to see how more than 6,000 people answered questions like "Some people wander aimlessly through life, but I am not one of them," and other questions that gauged positive and negative emotions.

They found that 14 years after those questions were asked, people who had reported a greater sense of purpose and direction in life were more likely to outlive their peers.

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In fact, people with a sense of purpose had a 15 percent lower risk of death,compared with those who said they were more or less aimless. And it didn't seem to matter when people found their direction. It could be in their 20s, 50s or 70s.

Hill's analysis controlled for other factors known to affect longevity, things like age, gender and emotional well-being. A sense of purpose trumped all that.

Hill defines it as providing something like a "compass or lighthouse that provides an overarching aim and direction in day-to-day lives."

Of course, purpose means different things to different people. Hill says it could be as simple as making sure one's family is happy. It could be bigger, like contributing to social change. It could be more self-focused, like doing well on the job. Or it could be about creativity.

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"Often this is individuals who want to produce something that is appreciated by others in written or artistic form, whether it's music, dance or visual arts," Hill says.

It's not exactly clear how purpose might benefit health. Purposeful individuals may simply lead healthier lives, says Hill, but it also could be that a sense of purpose protects against the harmful effects of stress.

An experiment in Chicago tested this theory. Anthony Burrow, a developmental psychologist at Cornell University, had college student volunteers of different races and ethnicities ride rapid transit through the diverse neighborhoods of Chicago, recording their emotions as individuals of different racial and ethnic groups boarded.

Earlier research has shown that when people are surrounded by people of different ethnic or racial groups than their own, their level of stress increases. Burrow wanted to know if thinking about their sense of purpose might reduce that stress.

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He had about half the students write for about 10 minutes about their life's direction. The other half wrote about the last movie they saw. They were all then given packets that listed the name of every stop. When they got to a stop, they were asked to assess how they felt and how much they felt that way by placing an "X" in a box next to negative emotions such as feeling scared, fearful, alone or distressed.

It turned out that the students who wrote about the last movie they saw experienced the expected levels of stress as the percentage of people of different ethnicity increased. But the students who wrote about their sense of purpose reported no feelings of increased stress at all.

More research is needed, but Burrow says his findings suggest that having "a sense of purpose may protect people against stress," with all of its harmful effects, including greater risk of heart disease. And that may explain why people with a sense of purpose live longer.

Copyright 2014 NPR. To see more, visit
Categories: NPR Blogs

Why We Think Ignorance Is Bliss, Even When It Hurts Our Health

Mon, 07/28/2014 - 4:40am
Why We Think Ignorance Is Bliss, Even When It Hurts Our Health July 28, 2014 4:40 AM ET Listen to the Story 4 min 53 sec   i i Lucinda Schreiber for NPR

Medical tests are rarely a pleasant experience, especially if you're worried that something could be seriously wrong. That's true even though we know that regular screenings and tests often help doctors catch issues early.

But of course, humans don't always behave rationally. Sometimes people will go to great lengths to avoid hearing bad news. Social scientists call this sort of behavior information aversion, or the ostrich effect (based on the old myth that ostriches bury their heads in the sand when they're scared). And it can have important implications for our health, researchers say.

In order to gauge how information aversion affects health care, one group of researchers decided to look at how college students react to being tested for a sexually transmitted disease.

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That's a subject a lot of students worry about, according to Josh Tasoff, an economist at Claremont Graduate University who led the study along with Ananda Ganguly, an associate professor of accounting at Claremont McKenna College.

The students were told they could get tested for the herpes simplex virus. It's a common disease that spreads via contact. And it has two forms: HSV1 and HSV2.

The type 1 herpes virus produces cold sores. It's unpleasant, but not as unpleasant as type 2, which targets the genitals. Ganguly says the college students were given information — graphic information — that made it clear which kind of HSV was worse.

"There were pictures of male and female genitalia with HSV2, guaranteed to kind of make them really not want to have the disease," Ganguly says.

Once the students understood what herpes does, they were told a blood test could find out if they had either form of the virus.

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Now, in previous studies on information aversion it wasn't always clear why people declined information. So Tasoff and Ganguly designed the experiment to eliminate every extraneous reason someone might decline to get information.

First, they wanted to make sure that students weren't declining the test because they didn't want to have their blood drawn. Ganguly came up with a way to fix that: All of the students would have to get their blood drawn. If a student chose not to get tested, "we would draw 10 cc of their blood and in front of them have them pour it down the sink," Ganguly says.

The researchers also assured the students that if they elected to get the blood tested for HSV1 and HSV2, they would receive the results confidentially.

And to make triply sure that volunteers who said they didn't want the test were declining it to avoid the information, the researchers added one final catch. Those who didn't want to know if they had a sexually transmitted disease had to pay $10 to not have their blood tested.

So what did the students choose? Quite a few declined a test.

And while only 5 percent avoided the HSV1 test, three times as many avoided testing for the nastier form of herpes.

For those who didn't want to know, the most common explanation was that they felt the results might cause them unnecessary stress or anxiety.

The researchers say that this study — and the growing body of evidence on information avoidance — has important implications.

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Many health screening messages urge people to get tested by reminding them how awful diseases can be. But these scare tactics might be a mistake, Ganguly says.

"Scaring people more about the implications may scare them away from getting tested," he says.

That lines up with previous research. In a 2009 study that looked at adolescents in a high school and at a juvenile detention center, scare tactics about sexually transmitted diseases proved to be unnecessary for teenagers who were receptive to health messages. And they were ineffective for teenagers who were indifferent to such messages.

There's a second approach to consider, Tasoff says. The ostrich effect is produced by anxiety. One way to keep anxieties at bay is to draw as little attention to tests as possible, to make them routine.

Of course, these ideas need more testing. Keeping people in the dark about their health doesn't square with our notions of patient choice and autonomy. And if you don't tell people how bad a disease can be, that can affect the incentive to get tested at all.

But one thing seems clear. If we want people to pay attention to their health, it doesn't make sense to stick our heads in the sand about the ostrich effect.

Copyright 2014 NPR. To see more, visit
Categories: NPR Blogs

New York Debates Whether Housing Counts As Health Care

Mon, 07/28/2014 - 4:36am
New York Debates Whether Housing Counts As Health Care July 28, 2014 4:36 AM ET


Listen to the Story 7 min 9 sec  

Lissette Encarnacion in her apartment at The Brook, a supportive housing complex in the New York City borough of the Bronx.

Natalie Fertig/WNYC

Standing outside her sixth-floor apartment in the Bronx, Lissette Encarnacion says she sometimes forgets the place belongs to her.

"I'm thinking I'm at somebody else's [house]," she says. "I'm ringing my own doorbell."

Encarnacion used to have a career in banking, and lived in a real home with her son and husband. Then one night everything changed, she says, when her husband came home drunk and angry, and threw her off a balcony.

"He came home, pulled me from the hair, and just started beating the hell out of me," she says. She was seven months pregnant with her second child, a boy.

Encarnacion suffered traumatic brain injury and was never the same. She and her sons moved in with her sister, but Encarnacion often wandered off.

Eventually she became homeless, she tells NPR affiliate WNYC, and remained that way for a decade. She suffered from epileptic seizures, and was frequently picked up by paramedics and taken to emergency rooms.

Then two years ago, she moved into The Brook, an apartment complex that provides supportive housing to its residents — more than half of whom are formerly homeless.

“ You know, we as a society are paying for somebody to be on the streets.

Now Encarnacion lives in a studio apartment, which she has decorated with stuffed animals and Christmas lights. And though the place is small, she likes to think of it as her "penthouse" apartment.

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Brenda Rosen, the director of Common Ground, the organization that manages the building, says The Brook offers a full range of services to keep its residents healthy: social workers, security, a doctor and even an event planner.

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And while these services don't come without a cost — an apartment at The Brook runs at about $24,000 a year — Rosen says they are cheaper than the estimated $56,000 per year that the city spends on the emergency room visits and stays at shelters and jails, where many people with severe mental illness end up.

"You know, we as a society are paying for somebody to be on the streets," says Rosen.

Few people would dispute that Lissette Encarnacion is better off in her studio apartment than she was when she was living under the bridge. And it's far cheaper if she has a doctor downstairs than if she has to show up regularly in the ER.

The question is, who pays for this kind of housing?

New York now has about 47,000 supportive housing units, and the state intends to invest $260 million Medicaid dollars over the next two years. But the federal government won't match it.

At the crux of this debate is the question of whether housing qualifies as health care.

“ Medicaid is supposed to be health insurance, and not every problem somebody has is a health care problem.

This past December, the outgoing New York State commissioner of health argued in an article in The New England Journal of Medicine that housing is health care. Providing housing to the chronically homeless saves health care money, he argues, so Medicaid should help pay capital costs.

New York State Medicaid Director Jason Helgerson went further, arguing that federal Medicaid money already pays for housing, through long stays in nursing homes and hospitals.

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But Bruce Vladeck, who formerly administered Medicaid and Medicare in the Clinton administration, says federal Medicaid dollars can't and shouldn't be used to pay for housing — it's not cost-effective.

"Medicaid is supposed to be health insurance, and not every problem somebody has is a health care problem," says Vladeck.

Instead, Vladeck argues that housing programs should be paid by housing agencies.

"As a society, both in the private sector and the public sector, we are really cheap and niggling and resentful about paying for social services, and we are much more generous when it comes to paying for health services," he says.

At the moment there is not enough housing money to go around for all the people who need it — people like Encarnacion, who are done living on the streets but still need support. For her, The Brook offers a place in between.

"I stuck it out, and it's good," she says. "And God's been real good to me. And the people that work here have been very good to me — and patient, because I am not easy. I am not easy."

To hear and read more about The Brook and other innovative initiatives in health care reform in New York, check out WNYC's series Prescription for the Bronx.

Copyright 2014 WNYC Radio. To see more, visit
Categories: NPR Blogs

How Well Does A Drug Work? Look Beyond The Fine Print

Fri, 07/25/2014 - 4:35pm
How Well Does A Drug Work? Look Beyond The Fine Print July 25, 2014 4:35 PM ET Listen to the Story 6 min 7 sec   i i

Traditional warning labels on medicine boxes tend to be long on confusing language, critics say, but short on helpful numbers.


Anybody who has ever seen a drug advertisement or talked over the pros and cons of a medicine with a doctor can be forgiven for being confused.

Sorting out the risks and benefits of taking a medicine can be complicated even for professionals.

i i

This 2007 ad for the sleeping pill Lunesta stresses insomnia relief — not the relative usefulness of the drug.


This spring, the Institute of Medicine convened a workshop with the Food and Drug Administration. The topic: How best to communicate to doctors and patients the uncertainty in the assessment of benefits and risks of pharmaceuticals.

The FDA not only approves drugs, it also approves the prescribing instructions that come along with them. For some drugs, the wad of paper filled with fine print about the risks and benefits of using the drug is accompanied by a medication guide that is supposed to summarize the main points.

During one question-and-answer session, Dr. Robert Temple of the FDA's Center for Drug Evaluation and Research, acknowledged that those guides are full of information. "But it's remarkably nonquantitative for the most part," he said. "And I think we should try to think about whether there are quantitative ways of presenting that stuff."

He then referred to Drs. Steven Woloshin and Lisa Schwartz, two of his fellow panelists, who have said it's possible to pull that off.

The husband-and-wife team from Dartmouth are on a decade-long mission. They have been pushing the FDA to get useful and readable quantitative data about drugs to doctors and their patients.

Schwartz and Woloshin have designed a format they call a drug facts box. It shows the gist of what they say is buried in all the fine print: How does the drug compare to a placebo?

i i

Drs. Lisa Schwartz and Steven Woloshin designed this "fact box" as a prototype to show how package inserts for medicines could be more helpful.

Courtesy of Dr. Steven Woloshin

That's in contrast to what usually happens, Schwartz says. "The prescribing info is written by industry, and then negotiated with FDA, and then FDA ultimately approves it. And we have documented examples where important info — like how well the drug works — is not in the label."

This drives Schwartz and Woloshin crazy.

Better Than A Sugar Pill

So, here's their experiment: They showed people ads for two competing heartburn drugs, one plainly more effective than the other.

They also showed people two of their drug facts boxes, one for each of those two heartburn drugs, showing how each drug fared against a placebo (a sugar pill) in testing.

"When the people are presented with the standard information they see — like a drug ad — about 30 percent of people chose the better drug," Woloshin says. "But when we showed them information in the drug facts box form, 68 percent of people were able to choose the objectively better drug. So that's a really dramatic improvement. It just shows you that if you show people information in a way that's understandable, they can use it, and it can improve their decision."

Using FDA data, Woloshin and Schwartz developed a drug facts box for the sleep aid Lunesta.

Two columns compare people with insomnia who took Lunesta and people with insomnia who, unknowingly, took a sugar pill.

The results? Those who used Lunesta took 30 minutes to fall asleep. Those who got a sugar pill took 45 minutes — a difference of 15 minutes. Those who took Lunesta stayed asleep 37 minutes longer than those who took a sugar pill.

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Woloshin and Schwartz say some people might consider those benefits worth taking the drug, and some might not.

"That's the whole point of the drugs facts box," Woloshin says, "to let people look at the evidence and come to their own judgments. But you can't make those judgments without the facts.

He and Schwartz believe passionately in the numeracy of patients. They say we can handle numbers, like percents. It's just that too often we're given incomplete or misleading information.

How Good A Deal Is That Sale?

For example, a claim that some drug reduces the likelihood of a particular disease by 50 percent can be misleading.

Woloshin explains why. "If you heard about a sale, and it said 50 percent off, would you travel a great distance to go to the sale? Well, you might if it was on things that are really expensive, like a flat-screen TV or something," he says. "But what if the thing that was on sale was gum, and you save only a couple of cents? So when you hear 50 percent reduction, you have to ask 50 percent of what?"

The doctors' dream is to get those drug facts boxes into health systems and electronic medical records, so that doctors and patients can study the information and decide what's best before the drug is prescribed.

"What we hope is that the box will encourage people to take drugs that are effective and that work, and discourage people from taking drugs that don't work or are just harmful," Woloshin says. "And also that just having this information in front of people will stimulate better drug research, because drug companies realize people are paying attention and looking at these numbers — and then we'd have a better quality of drug trials."

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Woloshin and Schwartz say medical information should be as quantitative as other information. And we digest quantitative data all the time.

"If you were reporting on an election, you wouldn't say Obama won by a little," he says. "You'd give the numbers. If you were reporting sports scores, you wouldn't say the Celtics, won, hopefully won, by a bit. You'd give the score."

Why should health care be different?

He and Schwartz are convinced that we can understand risk described by numbers, provided the numbers are clearly and honestly presented.

They have been lobbying the FDA to develop drug facts boxes, but say that seems unlikely. So they started their own company to do it — Informulary. It's funded by the Robert Wood Johnson Foundation, which also supports NPR.

This is the final part of an All Things Considered series on Risk and Reason.

Copyright 2014 NPR. To see more, visit
Categories: NPR Blogs

For Better Treatment, Doctors And Patients Share The Decisions

Thu, 07/24/2014 - 4:12pm
For Better Treatment, Doctors And Patients Share The Decisions July 24, 2014 4:12 PM ET Listen to the Story 9 min 13 sec   i i

When weighing the risk of heart disease, how the numbers are presented to patients can make all the difference.


Many of us get confused by claims of how much the risk of a heart attack, for example, might be reduced by taking medicine for it. And doctors can get confused, too.

Just ask Karen Sepucha. She runs the Health Decisions Sciences Center at Boston's Massachusetts General Hospital. A few years ago she surveyed primary care physicians, and asked how confident they were in their ability to talk about numbers and probabilities with patients.

"What we found surprised us a little bit," Sepucha says. "Only about 20 percent of the physicians said they were very comfortable using numbers and explaining probabilities to patients."

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Doctors, including Leigh Simmons, typically prefer words. Simmons is an internist and part of a group practice that provides primary care at Mass General. "As doctors we tend to often use words like, 'very small risk,' 'very unlikely,' 'very rare,' 'very likely,' 'high risk,' " she says.

But those words can be unclear to a patient.

"People may hear 'small risk,' and what they hear is very different from what I've got in my mind," she says. "Or what's a very small risk to me, it's a very big deal to you if it's happened to a family member."

Simmons and her colleagues are working on ways to involve their patients in shared decision-making. The initiative at Mass General gives patients online, written and visual information to help them. One of the goals is to make risk understandable — bridging the gap between percent probabilities and words.

Dots Help Decide

Simmons tried it with her patient Joe Bianco, 60, when talking over his risk for heart disease a few weeks ago. Rather than just using a number to tell him his risk for a heart attack, she made it visual with this statin/aspirin decision aid calculator, developed by the Mayo Clinic.

The calculator displays 100 green dots arranged in a 10-by-10 grid. Each has a little smile on it and symbolizes a person. Once a patient's information is entered, some of the green dots turn yellow and some smiles may turn upside down into frowns, indicating in the next 10 years, how many people are expected to have a heart attack.

i i

A tool to assess heart attack risks changes in response to treatment choices patients might make.

Courtesy of Mayo Clinic

When Bianco's profile is submitted, 12 dots turn yellow and 88 remain green — meaning 12 percent of men like him will have a heart attack within 10 years. "It looks like my chances are slim," he says.

Bianco had decided earlier not to take a cholesterol-lowering statin medicine to lower his risk of a heart attack. The dozen frowning yellow dots don't change his mind.

Next, Simmons enters another factor into the online calculator. What if all 100 men fitting Bianco's profile take a statin drug every day for the next ten years?

The number of yellow dots on the screen — the percent who will have a heart attack — changes for the better.

"That number goes down to seven — so five people are saved from a heart attack by taking a medication," Simmons says. "Some people look at that and say, 'Well that's almost cutting the risk in half.' Other people say, 'Well, that's still 88 people who didn't benefit either way. And only five who had a benefit.'"

For Bianco, seeing the graphic validated his previous decision not to take medicine. And for Simmons, as a doctor, it's made that conversation easier.

Numbers Still Valuable

But the graphics and words alone don't work for everyone. At Mass General's orthopedics department, Jim Westberg of Nashua, N.H., has come to see surgeon Andy Freiberg, who is in charge of hips and knees.

Westberg is very active at 59. He hikes, swims, skis and rock climbs when he's not at work, selling 3-D printers. He wants a hip replacement and in the course of examining him, his doctor cites some numbers.

"Your risk of infection is probably under 1 percent, probably half a percent," Freiberg tells him.

That the risk is less than 1 percent doesn't deter Westberg. Before his appointment, he had received a shared decision-making packet that included a booklet and a DVD, all about hip replacement. He also did some other research and — just as importantly — talked to people he knew who had had the surgery and were thrilled with the outcome.

For him, Westerberg says, the numbers and percent probabilities are still valuable.

"I think they're fairly important because I actually have an engineering degree," Westerberg says. "I have a technical background so maybe I'm a little biased, but numbers do mean something to me. The risk we talked about, half of 1 percent, really doesn't concern me that much."

What Is 'Very Common'?

The Food and Drug Administration also likes numbers and urges drug companies to give numerical values for risk — and to avoid using vague terms such as "rare, infrequent and frequent."

But the European Medicines Agency (a part of the European Union) has matched a scale of terms — very common, common, uncommon, rare and very rare — with numerical definitions for each of those five levels of frequency.

So, what percent of cases qualified for the top level "very common" side effect? You might think over 50 percent, but according to those EU definitions, a side effect is "very common" if occurs in more than 10 percent of cases.

And if a drug label says that a particular side effect was "very rare"? That means it occurs in fewer than one in every 10,000 cases.

This is part four of an All Things Considered series on Risk and Reason.

Copyright 2014 NPR. To see more, visit
Categories: NPR Blogs

U.S. Teens Still Lag In Getting Vaccinated Against HPV

Thu, 07/24/2014 - 4:02pm
U.S. Teens Still Lag In Getting Vaccinated Against HPV July 24, 2014 4:02 PM ET

Dr. Donald Brown inoculated Kelly Kent with the HPV vaccine in his Chicago office in the summer of 2006 — not long after the first version of the vaccine reached the market.

Charles Rex Arbogast/AP

Though the vaccine against human papilloma virus is highly effective in preventing certain forms of cancer, the number of preteens getting the vaccine is still dismally low, doctors from the Centers for Disease Control and Prevention announced Thursday.

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"One of the top five reasons parents listed is that it hadn't been recommended to them by a doctor or nurse," the CDC's Dr. Anne Schuchat told reporters at a press briefing.

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"Parents who aren't planning to vaccinate lacked knowledge and didn't hear a physician recommendation," said Schuchat, who directs the CDC's National Center for Immunization and Respiratory Diseases. "We don't think it's an issue of politics. This is something that parents seem to be open to."

Federal health officials have for several years been recommending that all preteen boys and girls be vaccinated around age 11 or 12 — before the initiation of sexual activity. That's when the vaccine has been shown to be most protective against HPV infections that can lead to cervical cancer, genital warts and oral and anal cancers.

But data from the national survey released Thursday, and published in this week's Morbidity and Mortality Weekly Report, suggest that only 57 percent of young women ages 13-17 — and only 35 percent of young men that age — have received one or more vaccine doses.

Every year more 27,000 people in the U.S. get cancer caused by HPV, Schuchat said.

“ We don't think it's an issue of politics. This is something that parents seem to be open to."

Protection against the virus did go up a little bit in 2013, the survey showed, compared with 2012, when 53.8 percent of young women and 20.8 percent of young men had received the vaccine. Still, more needs to be done, Schuchat said.

Doctors and nurses are missing many good opportunities to vaccinate for HPV, she said. For example, they are already successfully immunizing preteens at a high rate against tetanus, diphtheria and pertussis (Tdap), and against meningitis. Roughly 77 percent of 13- to 17-year-olds have been immunized against meningitis, and about 86 percent have received the Tdap vaccine.

The problem is not that doctors are reluctant to give the vaccine, Schuchat said; it's more often a problem of miscommunication. Surveys show many are actually forgetting to mention it to patients.

"Physicians need to know that the vaccines they give can prevent very serious cancers in the U.S.," she said.

At every appointment for adolescents, doctors should tell parents, " 'Today there are three recommended vaccines,' " Schuchat advised. Had shots against HPV been administered when other routine vaccines were given to preteens in the last several years, she says, about 91 percent of today's 14-year-old girls would be protected.

NIS-Teen, which collected information on more than 18,000 teens in the 2013 survey, has been collecting vaccination information since 2006 through use of random-digit-dialing of both landlines and cellphones. After a teen's parent or guardian provided permission to contact the teen's health provider, the survey team mailed the parents a questionnaire. Results from the survey were then verified via a check of medical records.

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When Federal Privacy Laws Protect Hospitals Instead Of Patients

Thu, 07/24/2014 - 11:43am
When Federal Privacy Laws Protect Hospitals Instead Of Patients July 24, 201411:43 AM ET

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A Missouri mother recently posted this video on YouTube of what she claims to be an encounter with hospital security after taking a picture of her son during an audiology test.

In the name of patient privacy, a security guard at a hospital in Springfield, Mo., threatened a mother with jail for trying to take a photograph of her own son.

In the name of patient privacy, a Daytona Beach, Fla., nursing home said it couldn't cooperate with police investigating allegations of a possible rape against one of its residents.

In the name of patient privacy, the U.S. Department of Veterans Affairs allegedly threatened or retaliated against employees who were trying to blow the whistle on agency wrongdoing.

When the federal Health Insurance Portability and Accountability Act passed in 1996, its laudable provisions included preventing patients' medical information from being shared without their consent and other important privacy assurances.

But as a litany of recent examples show, HIPAA, as the law is commonly known, is open to misinterpretation — and sometimes provides cover for health institutions that are protecting their own interests, not patients'.

"Sometimes it's really hard to tell whether people are just genuinely confused or misinformed, or whether they're intentionally obfuscating," said Deven McGraw, partner in the healthcare practice of Manatt, Phelps & Phillips and former director of the Health Privacy Project at the Center for Democracy & Technology.

For example, McGraw said, a frequent health privacy complaint to the U.S. Department of Health and Human Services Office of Civil Rights is that health providers have denied patients access to their medical records, citing HIPAA. In fact, this is one of the law's signature guarantees.

"Often they're told [by hospitals that] HIPAA doesn't allow you to have your records, when the exact opposite is true," McGraw said.

I've seen firsthand how HIPAA can be incorrectly invoked. In 2005, when I was a reporter at the Los Angeles Times, I was asked to help cover a train derailment in Glendale, Calif., by trying to talk to injured patients at local hospitals. Some hospitals refused to help arrange any interviews, citing federal patient privacy laws. Other hospitals were far more accommodating, offering to contact patients and ask if they were willing to talk to a reporter. Some did. It seemed to me that the hospitals that cited HIPAA simply didn't want to ask patients for permission.

The incident at the Missouri hospital, Mercy, began after Mandi Wilson took her son to an audiologist to get his hearing tested, according to the Springfield News-Leader. A security guard questioned her and asked to see her phone to confirm that she had deleted any photos. When she refused, the officer told her that she was "being trespassed for violation of HIPAA" and threatened to send her to jail if she came back, the paper reported.

A hospital spokesperson told the newspaper that it is reviewing how its photo and video policy is being enforced.

The Daytona Beach police chief filed a complaint to the Florida Agency of Health Care Administration saying that, based on HIPAA, "his detectives have been impeded from investigating a possible sexual battery of a 75-year-old resident at a local healthcare facility," the Daytona Beach News-Journal wrote.

Lawyers for the nursing home, Daytona Beach Health and Rehabilitation Center, told the paper that privacy laws prevented them from turning over information without a subpoena. An attorney hired by the home's parent company told the paper he found no evidence of any sexual assault.

The HIPAA issues involving the VA emerged as the department grappled with a scandal in which employees were accused of falsifying records to disguise how long veterans were waiting for appointments, drawing ire from veterans groups and lawmakers and prompting the ouster of senior leaders.

The Washington Post reported that the top lawyer for the American Federation of Government Employees cited several cases in which the VA invoked patient privacy restrictions to "stifle whistleblowers."

"We routinely hear from our members who wish to make disclosures about problems with the patient care system and other conduct within the VA," the union's lawyer wrote in a June letter to the VA's general counsel. "Most are reluctant to do so both because of a history of reprisals by VA management, and because of recent experience with laws designed to protect patients which are instead being used as a sword against employees by VA management."

The letter cited how two employees were unable to get a written HIPAA waiver in order to report information to the Office of Inspector General.

"VA routinely uses HIPAA as an excuse to punish into submission employees who dare to speak out," Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans' Affairs, told the Post.

McGraw said that HIPAA has specific allowances for police officers investigating crimes and for whistleblowers sharing information with government authorities.

"You certainly can disclose patient information for health oversight activities, including government oversight over government benefit programs," she said. "You certainly can disclose when a police officer comes and is investigating a crime. ... There are provisions in HIPAA that allow them to make a disclosure about a victim of crime as long as the victim has agreed or they're incapacitated."

What has been your experience with patient privacy? Email ProPublica Charles Ornstein at to let him know.

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A Simple Way To Reduce Stroke Risk: Take Your Pulse

Thu, 07/24/2014 - 7:57am
A Simple Way To Reduce Stroke Risk: Take Your Pulse July 24, 2014 7:57 AM ET i i

Sure, your doctor can do this. But you can, too. And for stroke patients, it could be a lifesaver.


An irregular heartbeat called atrial fibrillation is a big cause of stroke, especially for people who have recently had a stroke. But it's not something that most people can feel.

Doctors test for atrial fibrillation by hooking people up to an electrocardiogram machine at the office, or having them wear a Holter monitor for a day or a week. There are also implantable monitors to check for afib, but they aren't widely used.

Learning to take your own pulse may be as effective and a lot simpler, according to German researchers.

They trained 220 older people who had had a stroke to tell the difference between a normal pulse and the fluttery abnormal rhythm of afib.

The training was considered a success if the people were able to correctly measure their pulse twice in a row; 196 people aced the test, for an 89 percent success rate.

To find out if the amateurs' measurements actually detected afib, the patients also were being continuously monitored on an electrocardiogram. But they weren't able to see the ECG monitor while doing the self-test.

It found that 57 of the patients had irregular heartbeats.

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The patients who checked their own pulse rate provided reliable results 89 percent of the time. They identified irregular rhythms 54 percent of the time, and normal rhythms 96 percent of the time. They incorrectly thought they had afib just 3 percent of the time.

False positives are one downside of having people self-test, says Dr. Bernd Kallmunzer, a neurologist at Universitatsklinikum Erlangen in Germany who led the study. They typically would be told to go get an ECG test. But because there were only 6 people who thought they had afib when they didn't, "the number of 'unnecessary' ECG recordings are expect to be rather low," Kallmunzer said in an email.

Relatives also were trained to take the patients' pulses, and they did even better, identifying irregular rhythms 77 percent of the time.

The results were published online Wednesday in the journal Neurology.

"Many times people don't know they're in afib," says Dr. Ralph Sacco, chairman of the department of neurology at the University of Miami. "This group is trying to propose a more simple, cheap method that may work, having stroke patients and their caregivers monitor pulse.

"There's very little downsides other than maybe the extra anxiety if you thought there was something wrong if it wasn't," Sacco told Shots.

He can forsee the day when people would check their pulse rates the way they check their blood pressure, but notes that the test will be less useful in younger people and older people not at risk of stroke.

People with atrial fibrillation can be given medications that substantially reduce their risk of a blood clot and stroke.

Want to try it yourself? The American Heart Association has written instructions. Or check out this nifty video from the British Heart Foundation that also lets you hear the difference between regular and irregular heartbeats. Thanks to our perspicacious readers for flagging it!

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Federal Health Exchange Stays Busy After Open Enrollment Ends

Wed, 07/23/2014 - 4:52pm
Federal Health Exchange Stays Busy After Open Enrollment Ends July 23, 2014 4:52 PM ET

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Even after the open enrollment deadline, remained a popular destination.

J. David Ake/AP

For months, journalists and politicians fixated on the number of people signing up for health insurance through the federal exchange created as part of the Affordable Care Act. It turned out that more than 5 million people signed up using by April 19.

But perhaps more surprising is that, according to federal data released Wednesday to ProPublica, there have been nearly 1 million transactions on the exchange since then. People are allowed to sign up and switch plans after certain life events, such as job changes, moves, the birth of a baby, marriages and divorces.

The volume of these transactions was a jolt even for those who have watched the rollout of the ACA most closely.

"That's higher than I would have expected," said Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation. "There are a lot of people who qualify for special enrollment, but my assumption has been that few of them would actually sign up."

The impact of the new numbers isn't clear because the Obama administration has not released details of how many consumers failed to pay their premiums and thus were dropped by their health plans. All told, between the federal exchange and 14 state exchanges, more than 8 million people signed up for coverage by April 19. A big question is whether new members will offset attrition.

ProPublica requested data on the number of daily enrollment transactions on the federal exchange last year under the Freedom of Information Act because the Obama administration had declined to release this information, a key barometer of the exchange's performance, to the public. The administration also has not put out any data on the exchange's activity since the open enrollment period ended.

The data show so-called 834 transactions, which insurance companies and the government use to enroll new members, change a member's enrollment status or disenroll members. The data cover the 36 states using the federal exchange, which include Texas, Florida, Illinois, Georgia and Michigan.

When rolled out last fall, insurance companies complained that the information in the 834s was replete with errors, creating a crisis at the back-end of the system.

Between April 20 and July 15, the federal government reported sending 960,000 so-called 834 transactions to insurance companies (each report can cover more than one person in the same family). That includes 153,940 for the rest of April, 317,964 in May, 338,017 in June and 150,728 in the first 15 days of July. The daily rate has been fairly stable over this period.

It wasn't immediately clear how many of the records involved plan changes or cancellations and how many were for new enrollments.

An insurance industry official estimated that less than half of the transactions are new enrollments. The rest are changes: When an existing member makes a change to his or her policy, two 834s are created — one terminating the old plan and one opening the new one.

Charles Gaba, who runs the website that tracks enrollment numbers, estimates that between 6,000 and 7,000 people have signed up for coverage each day on the federal exchange after the official enrollment period ended. Gaba's predictions were remarkably accurate during the open enrollment period.

"That doesn't account for attrition. That doesn't mean that they paid," Gaba said. "That's been based on limited data from a half dozen of the smaller exchanges, extrapolated out nationally."

The federal data obtained by ProPublica confirm some other facts about the rollout of, which was hobbled initially by technical problems. The slowest day was Oct. 18, when no 834 transactions were sent. That was followed by Oct. 1, the day the website launched, when a grand total of six records were sent to insurers.

By contrast, the busiest day was March 31, which was supposed to be the end of open enrollment, when 202,626 of the so-called 834 reports were sent to insurers. The entire last week in March was busy.

About 86 percent of those who signed up for coverage on the federal exchange were eligible to receive government subsidies to help lower their monthly premiums. Those subsidies are being challenged by lawsuits in federal court contending they aren't allowed by the Affordable Care Act.

Two federal appeals courts came to conflicting decisions Tuesday on the permissibility of the subsidies (one said yes; the other no). They will remain in effect as the cases proceed in the courts, the Obama administration said.

The next time that the general public can sign up for coverage through the exchanges is from November 15 to February 15, 2015.

Click here to download the data released to ProPublica under the Freedom of Information Act.

Read ProPublica's previous coverage of the Affordable Care Act and share your story.

ProPublica is an independent, nonprofit newsroom that produces investigative journalism in the public interest.

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Does Your Dog Feel Jealous, Or Is That A Purely Human Flaw?

Wed, 07/23/2014 - 2:32pm
Does Your Dog Feel Jealous, Or Is That A Purely Human Flaw? July 23, 2014 2:32 PM ET i i

Oh, I don't wanna share you with nothing else, I gotta have you to myself.


When you kiss your husband, does your dog try to get your attention? And does that mean that your dog feels jealous? Threatened? Or are we just imagining that?

Many if not all dog owners are sure that their pets have feelings. And we've known for a while that animals exhibit behaviors that look like jealousy, guilt and shame. But it's hard to find out what animals are really feeling. And researchers say that understanding that could give us valuable insights into human emotions, too.

A study published Wednesday in PLOS ONE has brought us a tiny bit closer to proving that dogs do get jealous. Psychologists from the University of California, San Diego adapted a test that has been used on human infants to see whether dogs exhibit jealous behavior.

They videotaped how 36 dogs reacted to their owners ignoring them and instead petting and talking sweetly to a plastic jack-o'-lantern or an animated, stuffed dog. When their owners were interacting with the stuffed animals, over three-quarters of the dogs pushed or touched their owners. The dogs also tried to get in between the stuffed animal and the owners, or growled at the plush pets.

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The dogs seemed less jealous of the jack-o'-lantern. But 40 percent acted aggressive when their owners started talking to the plastic pumpkins.

Psychologist Christine Harris, who led the study, says she's been studying jealousy for many years — but in humans. "The motivation that you have when you're jealous is to really break up the liaison between your loved one and your rival," she told Shots.

The fact that these dogs seemed like they were trying to draw their owners away from the stuffed animal indicates that they're feeling something very similar to human jealousy, Harris says.

"This is really a landmark study," says Marc Bekoff, an emeritus professor of evolutionary biology at the University of Colorado in Boulder, and author of Why Dogs Hump and Bees Get Depressed. "It opens the door to a lot more research on animal emotion."

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Bekoff, who wasn't involved in the research, says that he's definitely seen what looks like jealousy in his work with not only dogs but also coyotes and wolves. But this study is one of the first controlled experiments that tries to show it.

Of course, the study still doesn't prove that dogs feel jealousy. "The problem is that [the researchers] didn't look at how dogs would react just to those objects," says Laurie Santos, director of the Canine Cognition Center at Yale University.

It could be that the dogs were jealous of the stuffed animal, Santos says. Or it could be that the dogs really distrusted the stuffed animal and were acting out of fear.

But this study does build on previous research that shows dogs react negatively when they're treated unfairly, she tells Shots. "This is a very new science. We are just developing new tools to better understand animal emotions."

In humans, jealousy can be a very complex emotion, Santos says. It can bring up a host of other emotions like anger and rejection. And when humans feel jealous, we start suspecting and speculating, she says. "We think, 'If my husband is talking to another woman, maybe he's cheating.' "

If we find out that dogs feel the same way, she says, "either jealousy is less complicated because animals show it, or animals are more complicated than we thought."

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