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Anthem Deal For Cigna Would Hasten Health Insurance Consolidation

Fri, 07/24/2015 - 3:14pm

Anthem, headquartered in Indianapolis, would become an even bigger provider of health insurance if its deal for Cigna goes through.

Aaron P. Bernstein/Getty Images

Anthem finally bagged its prey.

The Indianapolis-based health insurer Anthem reached an agreement Thursday to pay $54 billion for rival Cigna, based in Bloomfield, Conn. Cigna rejected a lower Anthem bid in June, calling it inadequate.

"We believe that this transaction will allow us to enhance our competitive position and be better positioned to apply the insights and access of a broad network and dedicated local presence to the health care challenges of the increasingly diverse markets, membership, and communities we serve," said a statement announcing the deal that was attributed to both companies' CEOs.

It's the second huge health insurance deal to be announced in a matter of weeks. In early July, Aetna agreed to buy Humana for $37 billion.

Both transactions are part of a wave of consolidation within the health insurance industry, and health care overall.

One reason these health insurers are seeking to get bigger is that the hospitals and doctor groups across the negotiating table have also gotten bigger.

There were 95 hospital mergers and acquisitions in 2014, according to management consulting firm Kaufman Hall. That's pretty much been the pace for the past few years. Deals that create larger health systems give the providers of health care more leverage in negotiating rates with private insurers.

In recent years, hospitals and health systems have added to their negotiating clout by employing more doctors directly and buying doctor practices. Some health systems have even started their own insurance businesses.

The hospitals, for what it's worth, generally say they need to combine forces because insurers had already bulked up in previous rounds of dealmaking.

Another factor in the two insurance megadeals announced this month is a grab for a bigger share of the market for lucrative, privately run Medicare Advantage plans.

Neither the Aetna-Humana deal nor the Anthem-Cigna deal is expected to close until the second half of 2016, the companies said.

The potential transformation of the commercial health insurance market is profound. And antitrust regulators will have to weigh in on the proposed deals, which would reduce the ranks of the top for-profit health insurers to three companies from five today. UnitedHealth Group, now the largest private health insurer, rounds out the lists.

Regulators have "never been faced with mergers of this significance," David Balto, an antitrust attorney and former Federal Trade Commission official, told Forbes' Dan Diamond. "When there are two deals of this size, you really end up in a hornet's nest. I think there's a pretty strong likelihood that these deals will be blocked."

The American Medical Association came out swinging Friday. "We have long cautioned about the negative consequences of large health insurers pursuing merger strategies to assume dominant positions in local markets," said a statement from AMA President Dr. Steven J. Stack. "Recently proposed mergers threaten to increase health insurer concentration, reduce competition and decrease choice."

The AMA said its own analysis of insurance markets had found "a serious decline in competition" among insurers, with almost 3 of 4 metropolitan areas already rated as highly concentrated under federal guidelines. Stack's statement also said that the AMA's analysis of the proposed Anthem-Cigna merger suggests it would be anticompetitive in many of the states where Anthem is licensed.

The AMA statement called on regulators to "take a hard look at proposed health insurer mergers" and to enforce antitrust laws to halt those that would be harmful to competition.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Well-Off Baby Boomers Know How To Binge Drink, Too

Fri, 07/24/2015 - 10:39am

Youngsters aren't the only ones who have an affinity for consuming a lot of alcohol in a short amount of time – in other words, harmful drinking. It turns out, the parents and grandparents of millennials know how to binge drink, too.

Adults over age 50 who are healthy, active, sociable and well-off are more at risk for harmful drinking than their peers, according to a study published in the BMJ on Thursday.

A higher income and a higher education level means someone's more likely to drink too much, the study found. People on the young end of the above-50 age group are also more likely to be risky drinkers. Loneliness and depression are not associated. Men who didn't eat healthily and women who are retired were also at higher risk.

Shots - Health News Your Drinking Habits May Be Influenced By How Much You Make

The team analyzed data from the English Longitudinal Survey of Aging from 2010 to 2011, which looked at roughly 9,000 adults 50 years or older living independently. It asked how much spirits, wine and beer people drank every week. Participants were also asked to provide information on their income, educational level, self-reported health, marital status and other factors.

The researchers then compared the survey data with British drinking guidelines. They recommend that people drink no more than 21 units of alcohol per week for men and 14 units for women. A unit is 10 milliliters of pure alcohol, which translates to a shot of hard liquor, about half of a beer or half a glass of wine.

Healthy, wealthy and fit people over 50 were more likely to engage in harmful drinking — 50 shots of hard liquor for men or 35 for women in a week.

Maybe the vibrant pub culture across the pond is to blame for these drinking problems?

Shots - Health News Drinking Too Much? One-Third Of Americans Say Yes

But data from the Centers for Disease Control and Prevention says it's not so different stateside.

"It's not just young people. The [binge drinking] problem is across the lifespan," Bob Brewer, head of the Alcohol Program at the CDC, tells Shots.

The CDC defines binge drinking as consuming five or more drinks in two hours. A standard drink in the U.S. means a can of beer (American cans are smaller in volume), a standard glass of wine, and a shot of hard liquor.

Binge drinking is most common among 18- to 24-year-olds, and they drink the most, averaging 9.3 drinks on a single occasion.

But people over age 65 stood out when it came to how often they drank too much, reporting binge drinking five to six times a month.

Binge drinking was common among those with an annual family income of $75,000 or more and some college education, according to a 2014 paper by the CDC. That echoes the British study. People with higher incomes tend to drink more, but also tend to moderate their drinking, according to a study published earlier this year.

There was a lot more variation in how much people drank if they had lower incomes, with some drinking heavily and others drinking not at all, the researchers found.

"Our data supports the notion that people drink well into the senior years," says Brewer, "and as a society we haven't done much to address it."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Why Disability And Poverty Still Go Hand In Hand 25 Years After Landmark Law

Thu, 07/23/2015 - 3:38pm
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  • Hide caption Emeka Nnaka, who uses a wheelchair, drives his new accessible van to meet a friend in Tulsa, Okla. The van allows the 27-year-old greater independence, making it easier to get to school and work and to have a social life. Six years ago, Nnaka, then a semipro football player, broke his neck during a tackle and was paralyzed. Previous Next Kenneth M. Ruggiano for NPR
  • Hide caption Nnaka has a discussion with fellow students during a class at Langston University's Tulsa campus. Previous Next Kenneth M. Ruggiano for NPR
  • Hide caption During lunch with his friend Jacquelyn Croudy, Nnaka asks the server for a tray so that he can keep his food in his lap; he says that's easier than trying to get his legs under the table. Previous Next Kenneth M. Ruggiano for NPR
  • Hide caption Nnaka runs into his friend Aaron Million in the parking lot of Tulsa's Center for Individuals with Physical Challenges. Previous Next Kenneth M. Ruggiano for NPR
  • Hide caption Just as Nnaka gets ready for his daily workout at the center, visitors show up for a tour. He volunteers to show them the gym and other facilities. Previous Next Kenneth M. Ruggiano for NPR
  • Hide caption Nnaka prepares to get into a "stander." The device puts him into a standing position, which allows him to bear weight during his workout. Previous Next Kenneth M. Ruggiano for NPR
  • Hide caption Nnaka arrives home to his apartment in South Tulsa after a long day. Previous Next Kenneth M. Ruggiano for NPR
  • Hide caption At left, a poster on the wall in Nnaka's room with inspirational messages. At right, a photograph taken moments before the accident that would change his life, decorated with signatures and messages from his Oklahoma Thunder teammates and friends. Previous Next Kenneth M. Ruggiano for NPR
  • Hide caption Nnaka and his father, Phillip, chat in Emeka's room. Previous Next Kenneth M. Ruggiano for NPR

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If you have a disability in the U.S., you're twice as likely to be poor as someone without a disability. You're also far more likely to be unemployed. And that gap has widened in the 25 years since the landmark Americans with Disabilities Act was enacted.

"Every man, woman and child with a disability can now pass through once-closed doors into a bright new era of equality, independence and freedom," President George H.W. Bush said when he signed the bill into law on July 26, 1990.

The ADA banned discrimination based on disability and was intended to ensure equal opportunity in employment — as well as government services and public accommodations, commercial facilities and public transportation.

But it hasn't always worked that way, especially when it comes to expanding economic opportunity for the 58 million Americans with physical and mental disabilities.

Paralyzed, But Still In Pursuit Of His Dreams

You just have to look at what 27-year-old Emeka Nnaka of Tulsa, Okla., goes through on an average day to understand some of the reasons why.

Six years ago, Nnaka was playing semipro football for the Oklahoma Thunder when he went to make a tackle and broke his neck.

"I remember players saying, 'Meka ... you gotta get up. Let's go.' And I remember telling them, 'Give me a second,' " recalls Nnaka. "And one second turned to two seconds turned to three seconds."

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He was paralyzed from his chest down. Today, Nnaka gets around in a motorized wheelchair, and has limited use of his hands.

But he still has big dreams. He plans to finish his undergraduate education this summer and start working on a master's degree in human relations. He wants to become a licensed counselor, and hopes someday to have a home and a family he can support.

One key to his success could be the new accessible van he received in December with help from the Oklahoma Department of Rehabilitation Services and a group of friends, who held an online fundraising campaign for him, #MakeMekaMobile.

Before the van, Nnaka had to rely on a special lift service provided by the city to get around. But those rides had to be booked at least a day in advance, and often involved long waits and complicated schedules.

"I'd spend about three hours in transportation daily when I was riding the lift. So think about three hours out of your day in which you're not doing anything," he says.

As a result, it was extremely difficult to get anything done. Without the van, Nnaka says, it would have taken him all day to run an errand he recently did in about an hour and a half: going to a staffing agency to fill out paperwork for a job.

Nnaka runs an errand at a local Wal-Mart before heading home in Tulsa. Before he got his own van, Nnaka had to rely on a special lift service provided by the city to get around.

Kenneth M. Ruggiano for NPR

The Problems Start In The Parking Lot

Just having a job is highly unusual for someone with a disability. Fewer than 1 in 5 disabled adults are employed, one reason so many are poor.

The local United Way has hired Nnaka for a part-time position to talk about the group's work with programs for disabled individuals, including at the Center for Individuals with Physical Challenges, where Nnaka volunteers.

But when he got to the staffing agency, he ran into a number of challenges that those with disabilities often face.

Additional Information: Related NPR Stories The Americans With Disability Act At 25 In Helping Those With Disabilities, ADA Improves Access For All NPR History Dept. Independence Day For Americans With Disabilities U.S. Subminimum Wages For The Disabled: Godsend Or Exploitation? U.S. Advocates Fight To Keep Sheltered Workshops For Workers With Disabilities Health People With 'Invisible Disabilities' Fight For Understanding

The problems started outside the building, where the strip next to the handicapped space where he parked was too narrow for the ramp he uses to unload his wheelchair. He had to park over the line on the other side to get out. He says if another vehicle had been parked in the adjoining space, he would have been stuck.

And when Nnaka wheeled up to the front door, he found that there was no button to push to open it automatically. The building was constructed before the ADA, and while ADA standards highly recommend automation of exterior doors, it's not required. He had to wedge the side of one arm under the handle, cracking the door open slightly. He then wiggled his chair back and forth like a crowbar to get in.

When Nnaka got into the tiny elevator, he couldn't turn his chair around to reach the buttons. Fortunately, there was another passenger to help.

Once inside the staffing agency, he had to move the computer mouse slowly with a clenched fist to fill out nine pages of forms.

This former athlete seems to struggle through even the smallest task. Still, Nnaka hopes to show employers that it's worth hiring him and others who face similar challenges, that they have a lot to offer. He says one problem facing people with disabilities is that many companies think they're not up to the job, or think hiring them is not worth the effort.

'Employers Are Scared To Hire Us'

And there is a vigorous debate over why so many individuals with disabilities are unemployed. According to the Employment and Disability Institute at Cornell University, 28.4 percent of disabled adults worked in 1990, compared with 14.4 percent in 2013.

Debbie Eagle, who's been blind since birth, is one of Nnaka's colleagues at the Center for Individuals with Physical Challenges. She volunteers there, teaching the visually impaired how to use technology.

Debbie Eagle, a 43-year-old who has been blind since birth, says she can't find work, even though she has a bachelor's degree in special education. She volunteers at the Center for Individuals with Physical Challenges in Tulsa.

Kenneth M. Ruggiano for NPR

She says she'd really like if either she or her husband — who is also visually impaired — could find a well-paying job so that they are "not dependent on the government."

But try as she might, the 43-year-old says, she can't seem to find work, even though she has a bachelor's degree in special education. Eagle blames employer ignorance — as well as the Americans with Disabilities Act.

"Employers are scared to hire us," says Eagle, "because they don't know what kind of accommodations we require. And if they don't meet what we consider to be reasonable accommodations, they're afraid we'll sue them."

Eagle says she can't prove that this is the reason, but she's pretty sure it is.

Michael Morris, executive director of the National Disability Institute in Washington, D.C., agrees that some employers are hesitant to hire people with disabilities.

"Attitudes change slowly," he says, adding that he doesn't think there's a single reason for the gap between the employment rate for those with disabilities and those without.

After a class Eagle teaches to the visually impaired on how to use technology, she helps her students navigate their way into the hall. In addition to her volunteer work, Eagle plays piano at the center.

Kenneth M. Ruggiano for NPR

'The System Is Not Set Up To Succeed'

Morris says a lack of accessible transportation is one big problem for disabled individuals trying to work or go to school. And he says that students with disabilities are less likely to graduate from high school and college, putting them at a disadvantage in a competitive workplace.

He says another obstacle to employment is that if recipients of federal disability payments save more than $2,000, they risk losing their benefits, including medical care.

"The decision becomes, 'Wow, I think I'm going to just stay put where I am.' Which is the equivalent of a life sentence of poverty," Morris says.

In fact, that asset limit was a big problem for Nnaka when donations began pouring in for his new van. At one point, he says, he kept $4,000 in cash in the closet of the small apartment he shares with his father. If he had put the money in the bank, he could have lost the $700 monthly disability check he needs to survive.

The irony, he says, is that the money was earmarked for buying a van that he would use to go to school and get a job — making him less reliant on government aid.

"The system is not set up to succeed," Nnaka says.

Nnaka's father, Phillip, asks him for help figuring out a problem he is having with his phone in the apartment they share.

Kenneth M. Ruggiano for NPR

Morris says the outlook is improving, though. Congress recently passed a law that will soon allow some disabled adults to save more money by establishing special accounts — exempt from the cap — in which certain savings can be placed. Federal contractors are also required to set goals for hiring more disabled workers. And Morris says a growing number of students with disabilities are earning degrees and getting internships.

"That actual experience does more to change attitudes, change perception, right through to their HR offices that say, 'Wow, hidden talent pool. Let's explore it,' " says Morris.

He thinks, though, that it could take another 25 years before the promise of economic independence envisioned by the ADA is achieved.

Nnaka agrees that many doors have been opened since the law was enacted, but he says it hasn't been enough.

"There's so much more that people with disabilities need, to be inclusive and included in this society. To have just the same opportunity that anybody else has," he says.

Unfortunately, he adds, the ADA has led many people to believe that all the barriers are gone.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Administration Prods States To Scrutinize Insurers' Rate Hikes

Thu, 07/23/2015 - 2:56pm
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There's a battle brewing behind the scenes to keep health plans affordable for consumers. The Obama administration weighed in this week, sending letters to insurance regulators in every state and Washington, D.C., that ask them to take a closer look at rate requests before granting them.

Under the Affordable Care Act, state agencies largely retain the right to regulate premiums. So far only a handful have finalized premiums for the coming year, for which enrollment begins in November.

In the administration's letter Kevin Counihan, the CEO of the federal health exchange, HealthCare.gov, said recent data suggest that rates shouldn't be allowed to go up as much as some insurers are proposing for plans sold to individuals on the health exchanges.

In Maryland, for example, the dominant insurer on the exchange, CareFirst, is asking for a rate increase of 30 percent for some of its plans. In Kansas, Blue Cross and Blue Shield of Kansas is seeking increases averaging 37 percent.

Still, wrote Counihan, "many issuers are reporting a decline in pent-up demand for services," which would support lower premiums. The letter also said that health care costs are not growing as fast as some had predicted, "even accounting for rapid growth in pharmaceutical costs."

Several recent studies bolster the administration's case.

An analysis of proposed rates by the consulting firm Avalere Health found that for a 50-year-old nonsmoker, premiums for the lowest-cost silver plan will rise by an average of 4.5 percent in the eight states they studied. Average premiums for the second-lowest silver plan will rise by only 1 percent. (Most analyses of premiums look at silver-level plans because they have been by far the most popular, attracting more than two-thirds of those who have signed up using the exchanges.)

A separate analysis by the Kaiser Family Foundation found similar results: increases should average about 4.4 percent for the two least expensive silver plans in the 10 major cities it studied. (Kaiser Health News is an editorially independent project of the Foundation.)

Both analyses, however, warn that consumers may only be able to avoid increases by changing insurers. "In these markets, consumers will need to balance continuity of care with lower monthly premiums when comparing their health insurance options," said Avalere Senior Vice President Caroline Pearson.

But insurance industry consultant and frequent Obamacare critic Robert Laszewski says that forcing people to change plans in order to avoid huge increases is just one problem of many. "There's big trouble in Obamacare land," he said. "The biggest carriers are losing their shirts" and thus seeking the biggest rate increases.

Why the disagreement? Mostly because there are outside factors pushing insurers to both raise and lower premiums.

For example, some insurers underestimated how many sick people would sign up, or how sick they would be. Those that guessed wrong and ended up spending more on care than they collected in premiums need an increase to make up the difference.

In some cases, state insurance regulators urged insurers to raise premiums in order to remain financially solvent. "For example," reported the Commonwealth Fund in a recent paper on premiums, "in approving final 2016 rates, the Oregon Insurance Division required some carriers to increase their rates. Tennessee's state insurance commissioner also suggested that a requested average increase of 32.6 percent by Community Health Alliance might not be sufficient to make the nonprofit co-op financially sustainable."

But other analysts say that because most of the sick people are already signed up, those who will join in the future will be healthier and use less care, which argues for lower premiums, or at least smaller increases. "The industry has unanimously and reasonably expressed the view that the least healthy people would sign up first – i.e. in 2014 – thus necessarily resulting in a healthier and less expensive pool of enrollees in 2015 and 2016," wrote Jay Angoff, a former Missouri insurance commissioner and former federal official, in comments opposing CareFirst of Maryland's proposed increases. "Nevertheless, (CareFirst) has assumed that its 2016 enrollees as a group will have worse health status and higher claims costs than its 2014 enrollees did. Even modestly more reasonable assumptions in this area could reduce (CareFirst's) proposed rate increase to single digits."

Some plans also appear to be trying to increase premiums for 2016 to protect against losses in 2017. That's when special programs included in the ACA to protect insurers from very high risks will expire. The Obama administration has been trying to reassure health plans that enroll unexpectedly expensive patients that not only does it have enough money to continue the programs through 2016, but that plans would get even more than they expected in some of these special payments.

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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Doctors Press For Action To Lower 'Unsustainable' Prices For Cancer Drugs

Thu, 07/23/2015 - 12:08pm

Skyrocketing costs for cancer drugs have triggered a backlash.

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Anyone who's fought cancer knows that it's not just scary, but pricey, too.

"A lot of my patients cry — they're frustrated," says Dr. Ayalew Tefferi, a hematologist at the Mayo Clinic. "Many of them spend their life savings on cancer drugs and end up being bankrupt."

The average U.S. family makes $52,000 annually. Cancer drugs can easily cost a $120,000 a year. Out-of-pocket expenses for the insured can run $25,000 to $30,000 — more than half of a typical family's income.

"These drug prices are completely unsustainable," Tefferi says. "Pharmaceutical companies are in greed mode, and it's sad. It's what I call completely unregulated."

According to a 2013 study, these steep drug prices cause about 10 to 20 percent of cancer patients to skip or compromise the prescribed treatment. Another study found that the launch price of cancer drugs, adjusted for inflation, increased by an average of $8,500 a year between 1995 and 2013.

To make the point, Tefferi recruited 117 other doctors from across the U.S. who share his concerns. Together, they agreed on seven recommendations to make cancer drugs affordable that they want the federal government to consider. The recommendations are laid out in a commentary Thursday in the journal Mayo Clinic Proceedings.

The proposals include allowing the importation of cancer drugs across the U.S. border. Drugs are cheaper in other countries, like Canada, they argue, so why not let people with cancer bring them in for personal use?

They also favor legislation that would stop drug companies from delaying access to cheaper generic versions of their drugs. Tefferi points to Gleevec, or imatinib generically, as an example. It's used to treat chronic myelogenous leukemia and some other cancers. "That drug should have gone generic three or four years ago," he says. "But Novartis is doing all sorts of maneuvers to prevent it."

The doctors recommend a change that could have an even bigger effect: creating a committee to review newly approved cancer drugs and propose a fair price based on their benefits.

"There are tons of drugs [out there] that are very expensive, but they don't work well," Teferri says. "There needs to be a body that does a critical assessment of a drug's value and helps determine what the price should be based on how much it really helps. It needs to be a true, honest and transparent discussion."

The doctors also argue that Medicare should be allowed to negotiate drug prices.

Unlike private insurance, current law prohibits the government-sponsored insurance program from negotiating the cost of drugs with pharmaceutical companies. That means the government program is overcharged and pays the high prices drug companies typically set.

For its part, PhRMA, the main trade group for drug industry, wrote a response to the doctors' commentary that said lowering drug prices would discourage innovation. The trade group also said that cancer drugs represent only one-fifth of total spending on cancer treatment.

But Leonard Saltz, an oncologist at Memorial Sloan-Kettering Cancer Center in New York, said the doctors' proposals are on target.

"I think they, like me and many others, have a deep concern that this is a serious problem that's interfering with access to care," says Saltz, who co-wrote an influential New York Times editorial on cancer drug prices in 2012 that explained why Sloan-Kettering wasn't using a new, more expensive medicine for colorectal cancer. Saltz didn't take part in the latest commentary.

But can a group of doctors voicing their concerns in a journal article really change anything? "This is going to be a very difficult issue to resolve," Saltz says. "No one effort will resolve it, but any effort to engage more people in the discussion and to raise awareness will be helpful."

Saltz adds, "Congress is the organization that's going to be able to make a difference here."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Medical Residents Are Indebted But Reasonably Happy

Thu, 07/23/2015 - 8:42am

Medical residents are the tweeners of health care.

They've got their medical degrees but still haven't finished the training they need to go forth and practice their chosen specialties.

Talking to residents is one way to get a bead on where medicine may be headed. Medscape, an online news source for health professionals, just released a survey of more than 1,700 medical residents that asked a slew of questions about their hopes, everyday experience on the job and finances.

We pulled some of the highlights from the results released Wednesday. (For the more detailed findings, check out Medscape's report "Residents Salary & Debt Report 2015: Are Residents Happy?")

Right off the bat, the survey shows that most resident are in debt. And some are deeply in debt — more than a third are at least $200,000 in the hole.

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Most residents work long hours, often in hospitals. But concerns about patient safety led to changes in work hours that put limits on the lengths of shifts. So how much time are residents clocking at the hospital each week? Overall, about 47 percent of residents are spending 60 or more hours a week in the hospital. The times vary by year of residency. Only 18 percent of resident said their hours were excessive.

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How are the working relationships between residents and their colleagues? Quite good, it seems, whether those colleagues are senior doctors or nurses and physician assistants.

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The answer were less glowing to the specific question of whether residents are satisfied with their treatment by attending physicians, the doctors who teach and supervise residents. Equal proportions responded that they were very satisfied or only somewhat satisfied with the way these doctors dealt with them. "Some attendings belittle us, curse at us, yell at us, don't teach, are unreasonable, and promote a negative work culture," as one resident told Medscape. "Others are fantastic to work with, patient, great teachers, and knowledgeable."

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Given all the fretting about whether we'll have enough doctors (and other) providers of primary care in the future, it's natural that Medscape asked the residents in primary care about their plans. A little less than half of them said they planned to stick with primary care. About an equal proportion said they have another specialty in mind. A smaller fraction said they'd already given up on primary care but hadn't figured out their ultimate specialty yet.

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On that note, primary care, which pays less than many other specialties, may be unappealing. When asked if potential earnings influence the choice of specialty, the vast majority of residents said it was a significant factor. Only 10 percent said future income potential didn't factor in at all.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Younger Adults With Alzheimer's Are Key To Drug Search

Thu, 07/23/2015 - 3:47am
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Giedre (left) and Tal Cohen in March 2013, while Giedre was still healthy. Since then, she's begun having symptoms of Alzheimer's disease. In Giedre's case, the illness is tied to a rare genetic mutation she inherited.

Courtesy of Tal Cohen

The face of Alzheimer's isn't always old. Sometimes it belongs to someone like Giedre Cohen, who is 37, yet struggles to remember her own name.

Until about a year ago, Giedre was a "young, healthy, beautiful" woman just starting her life, says her husband, Tal Cohen, a real estate developer in Los Angeles. Now, he says, "her mind is slowly wasting away."

People like Giedre have a rare gene mutation that causes symptoms of Alzheimer's to appear before they turn 60.

Until recently, people who inherited this gene had no hope of avoiding dementia and an early death. Now there is a glimmer of hope, thanks to a project called DIAN TU that is allowing them to take part in a study of experimental Alzheimer's drugs.

The project also could have a huge payoff for society, says Dr. Randall Bateman, a professor of neurology at Washington University in St. Louis. "It's highly likely," he says, that the first drug able to prevent or delay Alzheimer's will emerge from studies of people genetically destined to get the disease.

Giedre Cohen enrolled in the DIAN TU study in 2013, when she still had no symptoms of Alzheimer's, her husband says. Their story began more than a decade earlier.

In 2002, Tal Cohen was on a trip to Miami to attend a wedding. He met Giedre, who was born in Lithuania, and the two fell in love.

"I spent the next, basically, two years, flying back and forth every two weeks or so in a long-distance relationship, until I finally convinced her to come out to Los Angeles," Cohen says.

Inside Alzheimer's

"Life was going great," he says, until Giedre's older sister came out for a visit and seemed to be having memory problems. "She forgot that she lives in Connecticut," he says, "and I said, 'Something is fundamentally wrong here.' "

Shots - Health News Women's Brains Appear More Vulnerable To Alzheimer's Than Men's

What was wrong was that Giedre's sister had the gene mutation that causes Alzheimer's to develop very early. Cohen says he consulted a neurologist who told him the odds were 50-50 that his wife also had the mutation.

Tal and Giedre decided they had to do something. And pretty soon they found DIAN, the Dominantly Inherited Alzheimer Network, an international research project based at Washington University in St. Louis.

The network was created specifically for members of families affected by the mutation that causes early Alzheimer's. "Virtually 100 percent of the mutation carriers, even if they're asymptomatic now, are going to become symptomatic," says Dr. John Morris, DIAN's principal investigator and a professor of neurology at Washington University.

At first, DIAN's purpose was to study participants to learn more about Alzheimer's. But when potential drugs for Alzheimer's were ready to be tested in people, the network created DIAN TU (the TU stands for Trials Unit) to help participants get access to experimental drugs.

That effort now includes drug companies, the National Institute on Aging, the Alzheimer's Association and more than 400 members of families with the mutation.

(From left) Tal and Giedre Cohen chat with Carrie Richardson and Mary Salter during a break at the Alzheimer's Association International Conference in Washington, D.C., on Saturday.

Manuel Balce Ceneta/AP

When drug companies began to focus on preventing Alzheimer's a few years ago, they became very interested in people who had no symptoms but were certain to develop the disease. And DIAN TU gave them a way to reach these people.

Alzheimer's prevention trials would be very hard to carry out in the general population because Alzheimer's can take decades to develop, and many people never get it. People with this mutation, however, are virtually certain to develop Alzheimer's around the same age that one of their parents did.

Shots - Health News Alzheimer's Drugs In The Works Might Treat Other Diseases, Too

This type of genetically targeted drug testing has been done before: Several decades ago, for example, drug companies tested the first cholesterol-lowering drugs in a population of people who had a huge genetic risk for heart disease.

"These families had mutations that caused them to have heart attacks and strokes in their 30s, 40s and 50s," Bateman says. But the cholesterol drugs were able to "melt away cholesterol deposits" in these people and extend their lives by decades.

Now, people with the Alzheimer's mutation need a similar success, Bateman says.

"Time is running out for these families," he says. "As they and their siblings and their children advance in age, they're marching toward that inevitable certainty of Alzheimer's disease and death."

So far, the DIAN TU study has included two different drugs intended to reduce amyloid, the sticky substance that builds up in the brains of people with Alzheimer's.

Because of the way the study is structured, 75 percent of people participating are getting one of the candidate drugs, while 25 percent are getting a placebo. The study is "blinded," which means that Giedre and Tal Cohen don't yet know which of the drug candidates she's getting, if any.

They do know that Giedre's symptoms have continued to progress, her husband says.

"Every time Giedre gets dosed, I anguish," Tal says, "wondering if she is getting something that will help her — or just a saline solution that will do nothing, and I'm putting her through this needlessly."

Last weekend, the couple traveled to Washington, D.C., to attend the first ever meeting of DIAN families. It was held just before the annual Alzheimer's Association International Conference, which took place this week.

Cohen says it was comforting to meet families with the same tragic problem he and his wife are facing. But the meeting also gave him a forum to make an impassioned plea for better access to the latest experimental Alzheimer's drugs — drugs that might yet help his wife.

"We had the FDA there, the regulators; we had the pharma guys, we had the researchers," he says. "They heard me loud and clear."

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Leprosy From An Armadillo? That's An Unlikely Peccadillo

Wed, 07/22/2015 - 6:05pm

Public health threat, or just a very odd animal you're likely to see in the southern United States?

Richard Heathcote/Getty Images

Armadillos. Leprosy. Florida. It's hard to ignore news reports that fit all three words in the first sentence.

So when we heard that state health officials in Florida have reported nine people with leprosy and suggested that people avoid armadillos, we here at Team Shots just had to check it out.

Shots - Health News Mysterious Leprosy Cases Linked To Armadillos

Apparently all of the people who fell ill say they'd interacted with armadillos. That's not completely crazy; there are armadillos aplenty in the southern United States, and Florida averages about 10 cases of leprosy a year.

What's more, the hard-shelled mammals are the only other creature aside from humans that can be infected outside the laboratory with Mycobacterium leprae, aka Hansen's disease. The disease was feared for centuries for cruelly disfiguring its victims, but can now be treated with antibiotics if it's properly diagnosed.

Here's what's got me confused. The slow-moving bacterium can incubate in people for three to seven years before they get sick. How then could the Florida cases be definitively linked to consorting with armored wildlife?

To find out, I called up Dr. Richard Truman, acting chief of the laboratory research branch of the National Hansen's Disease Program in Baton Rouge, La. He's authored 31 articles on armadillos and leprosy, using them as an animal model to study the disease.

That includes a 2011 article in the New England Journal of Medicine showing that armadillos almost certainly infect people with leprosy, based on the genetic similarity of bacteria taken from armadillos and humans in the southern United States. Until then, it was thought leprosy could spread only among humans, most likely through sneezes. Knowing there's an animal reservoir helps explain why people continue to fall ill, even though the disease is rare in the U.S.

OK, back to Florida. When I asked Truman about the odds that those nine could all be armadillo-acquired, he quickly pointed out that he knew nothing about the specifics of those cases. But it's pretty clear that he's not fussed.

"For one, what kind of numbers are we talking about? That's not very different than what may be occurring over normal periods of time," Truman says.

What's more, genetics plays an incredibly strong role in susceptibility to the disease, he says, with 95 percent of humans completely immune.

That doesn't mean you should canoodle with an armadillo, he notes. But with just 150 to 200 new cases a year in the U.S., and most of those coming from people who were overseas in countries with much higher leprosy rates, even people who live in armadillo-rich environs needn't fret.

"Between Texas and Louisiana and the southern United States, many millions of people have direct or indirect exposure to armadillos every day," Truman says. And they don't get infected.

He's been working in the lab with armadillos for decades. Has he become fond of them? Truman just laughs. It's pretty clear that here is a man who doesn't get too worked up over armadillos. And he thinks we shouldn't, either.

"All wild animals can harbor infectious agents that are harmful to people," Truman says. "If we leave animals alone and exercise caution, they don't pose a risk to us."

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Intensive End-Of-Life Care On The Rise For Cancer Patients

Wed, 07/22/2015 - 1:04pm

Maximum care at the end of life for cancer patients has increased.

iStockphoto

Conversations about end-of-life care are difficult. But even though most people now take some steps to communicate their wishes, many may still receive more intensive care than they would have wished, a study published in July found.

The findings, published online in JAMA Oncology, came from an analysis of the Health and Retirement Study, a national survey of U.S. residents older than age 50. Researchers looked through the responses from the next of kin, usually a spouse or child, of 1,985 participants with cancer who died between 2000 and 2012.

The patients' family members responded to questions about how frequently patients had signed durable power of attorney documents or living wills or participated in end-of-life care conversations. Researchers then examined the association between those advance-care-planning activities and the treatment patients received at the end of life.

Over the study period, the use of durable power of attorney assignment, sometimes called a health care proxy, grew from 52 percent to 74 percent among participants. Small declines were reported in other planning activities — from 49 percent to 40 percent for living wills and 68 percent to 60 percent for end-of-life discussions. But those changes weren't statistically significant because the levels varied throughout the study period, says Dr. Amol Narang, a radiation oncologist at Johns Hopkins School of Medicine and the lead author of the study.

"Our hypothesis was that we'd see significant increases over the study period in advance directives," Narang says. "What we saw was that important aspects of advance care planning haven't increased."

At the same time, the proportion of patients who were reported to have received "all care possible" at the end of their lives increased substantially over the study period, from 7 percent to 58 percent, even though such intensive treatment may have been counter to their stated wishes.

A durable power of attorney allows consumers to appoint someone to make health care decisions for them if patients are unable to do so. Living wills describe the types of medical care people wish to receive (or don't wish to receive) if they're incapacitated. Neither requires a lawyer, and forms are often available online.

Simply signing a document isn't enough, however. There's no substitute for regular communication with friends and family about end-of-life preferences.

If patients "haven't discussed their preferences with that person the proxy may default to 'all care necessary,'" Narang says. In other words, lacking clear guidance, the health care proxy may choose to err on the safe side and approve more care rather than limit or withhold it.

Living wills spell out which treatments someone would want — specifying that they would want to be put on a ventilator, for example, or fed through a tube. But some experts say treatment-focused specificity may not serve patients' best interests.

Spelling out treatment preferences is only useful in context, says Dr. Diane Meier, director of the Center to Advance Palliative Care.

"Of course you would want to be put on a ventilator if it was going to return you to health," Meier says. The more important question is a qualitative one: What is the quality of life that is unacceptable to you? Would you want every measure taken to treat an illness or injury even if it meant enduring extreme pain with little likelihood of improvement? Or would you rather forgo such intensive treatment and be kept comfortable instead? Those are the conversations that need to happen, experts say.

The issue is front and center these days as policy makers debate the recent federal proposal to reimburse physicians for conversations with Medicare patients about advance care planning.

"It's a significant step in the right direction," says Jonathan Keyserling, senior vice president for health policy at the National Hospice and Palliative Care Organization. "Now that healthcare professionals can soon be reimbursed for these intimate and thoughtful conversations, I think we'll see changes in practice patterns and in decisions by family members."

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Health Effects Of Transitioning In Teen Years Remain Unknown

Wed, 07/22/2015 - 11:18am

Most transgender adolescents go through the same steps during the medical transition from one gender to another. They're given a drug that blocks or pauses puberty. Then, if they and their doctors are sure they want to continue, they are given sex hormones that will resume puberty and give them more male or more female bodies.

This has been going on for just under a decade. "But what are the benefits and adverse effects of starting young kids on these powerful [puberty blockers] and then hormones? We don't know," says Dr. Frederic Ettner, a physician who has worked with transgender patients for over two decades. Since hormone treatment began for transgender youth, there's been a paucity of data on what happens to them in the long term.

What is known about transgender youth health is pretty dismal. A 2007 paper showed that out of a survey of 55 transgender youth, about a quarter had attempted suicide at least once. Drug abuse and depression are common as are high blood pressure, obesity and diabetes. The lack of information also makes it hard for doctors and patients to decide on treatment options.

Many physicians who treat trans youth believe that not giving hormone treatment is unethical, because of the strains of going through their biologically programmed puberty. "There are very compelling data showing very high risk of depression, suicide ideation, suicide attempts, and other risk taking behavior," says Dr. Stephen Rosenthal, a pediatric endocrinologist at the University of California San Francisco Benioff Children's Hospital.

On the other hand, physicians want to be cautious in administering treatments like puberty blockers and hormones when they aren't sure what the consequences might be, or even the best way of administering treatment. "We have no way of assessing what would be the best way of caring for these people," Rosenthal says.

Researchers are starting to try to answer those questions. For one, it looks like teenagers and young adults who identify as transgender have hormone levels consistent with their birth gender, according to a paper published Tuesday in the Journal of Adolescent Health. The study, begun in 2011, enrolled 101 transgender adolescents between 12 and 24 years old who had not begun hormone or puberty blockade treatment and measured everything from depression to cholesterol and hormones.

Virtually all the participants had typical levels of estrogen and testosterone for non-trans people of the same age and genitalia. "There's this pervasive notion that if I gave a child more of the assigned sex hormone, then they will have that gender experience," says Dr. Johanna Olson, director of the Center for Transyouth Health at Children's Hospital Los Angeles and lead author on the study. Olson says this piece of data shows that's not true, and giving someone more testosterone isn't going to change their gender identity.

Olson has applied for grants to continue the study, plans to follow the group for as long as funding for the study is available. By measuring psychological and physical changes over time, "We're going to know more about these young people as they begin whatever interventions they're going to begin," she says.

Eventually she thinks that will provide insight into how well or poorly the treatments work.

Because the patients are beginning their transitions at different ages, Olson hopes the study will show whether it's a better idea to give trans youths hormones at an earlier age or wait.

At the moment, the Endocrine Society recommends starting at age 16, but Olson argues that's an inappropriately late time to begin puberty for most teenagers. "[We're] looking at the impact of early treatment and how that creates healthier lives," Olson says.

There are researchers who disagree. A paper published in 2008 showed that only a fraction of children who felt their assigned sex was different from their gender continued feeling that way as they grew older. Some researchers feel that means puberty should be blocked until at least age 16 so an individual could learn if they were truly transgender.

But Olson says it's ridiculous to think it would take individuals 16 years to determine their gender identity, and that it's unfair to assume that about transgender people. "That really doesn't apply to people who aren't transgender. You wouldn't ask somebody who's not transgender at 16 or 18 if you're sure you know your gender," she says.

Other gender researchers note that the study might be considered flawed since it assumed all gender-questioning children are the same and lumped them all together in the same analysis.

This paper doesn't put that debate to rest, though Olson is hoping that future data on her patients might help. At the moment, it simply gives something of a snapshot of how transgender youth are doing today through a slew of psychological and physical examinations.

For one, on average, Olson's patients said they knew they were transgender at age 8, but didn't tell anyone until they were 17. "Those years are very important developmentally, psychologically — if you wait to tell anyone about this for so long, that's going to lead to some negative psychological outcomes," says Colt Keo-Meier, a clinical psychologist in Houston who works with transgender patients.

"A young person sitting on what feels like a secret to them, not disclosing their authentic selves because they're scared or ashamed or gotten overt or covert messages that who they are is not okay — that will have an impact on them," Olson agrees. But like so much else in the field, that impact is unclear for now.

That's making the work harder for health care providers, especially as more and more transgender people seek treatment, says Olson. "The demand for clinical care is outpacing the scientific knowledge by – by a lot."

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For Kids With Tourette's, At-Home Training Could Help

Wed, 07/22/2015 - 8:26am

If you've ever had hiccups in a quiet room, you know how embarrassing and completely uncontrollable they can feel. What if, instead of the hiccups, your body jerked involuntarily or you blurted out words without meaning to? That's a rough idea of what living with Tourette syndrome can be like.

Designers of a new computer program called TicHelper hope that they will be able to help children recognize and control these impulses themselves.

People with Tourette's perform repetitive movements or vocalizations called tics. A simple tic might be something like head jerking, eye blinking, or throat clearing, and a complex tic might involve patterns of movement or saying multiple words or phrases.

We don't know exactly what causes Tourette's, says Douglas Woods, a psychologist at Texas A&M University. Woods, who is also co-chair of the Tourette Association of America Medical Advisory Board, is one of the minds behind TicHelper.

Tourette's affects more boys than girls, and symptoms usually start between ages 3-7.

A view of TicHelper.com

via TicHelper.com

"Sometimes kids will grow out of [Tourette's]," Woods says. But if the wait-and-see approach isn't working, and the tics are interfering with daily life, there are a few treatment options.

One option is medication. Woods says there are a few different antipsychotic drugs that are used to manage Tourette syndrome, but they have side effects and don't always work. An alternative to pharmaceutical treatment is behavioral therapy.

A form of behavioral therapy called comprehensive behavioral intervention for tics, or CBIT for short, is commonly used. CBIT training teaches people with Tourette's to recognize the onset of a tic and to perform a different behavior when they feel one coming on.

"The idea is that when someone has a tic, they tend to have an urge," says clinical psychologist Eric Storch, a professor at the University of South Florida and Clinical Director of Pediatrics at Rogers Memorial Hospital in Tampa. "It's like when you're about to yawn. You know just before it happens that a yawn's coming. [CBIT] teaches a person to be aware."

And it gives them the tools to manage tics. Storch describes a patient whose tic was rubbing two fingers together, to the point of rubbing off skin. With CBIT, the boy was able to recognize the onset of a tic and instead unobtrusively press down on his kneecap until the urge went away.

A typical CBIT training program involves eight sessions with a therapist, spread over 10 weeks. Results, Woods says, can be maintained up to six months.

Both psychologists say that CBIT is at least as effective as medical treatments. The problem is that it requires specially trained therapists — and there aren't that many of them. Which is where TicHelper comes in.

"It's essentially a self-help, self-guided program that leads the patient through a CBIT treatment," Woods says. He and his colleagues received funding from the National Institute of Mental Health to develop TicHelper, which is now being tested. So far, the results look promising. "The kids that go through it, enjoy it," Woods says. They're able to do the skills,"

The program has four main sections: tic education, reducing tic triggers, tic awareness and tic blocking. Videos featuring a friendly actress guide patients thorough each section. The program personalizes treatment based on feedback from the patient. Woods says the testing will help the designers modify and improve it based on user feedback. Though TicHelper isn't available yet, interested patients or doctors can sign up to receive updates on its progress.

The website currently lists the cost of an 8-week program through TicHelper at $150, but Woods says that the price isn't set.

Storch, who is unaffiliated with TicHelper, is enthusiastic about the idea of at-home treatment for tics. "I really think it's an exciting development that has a lot of practicality," he says. "We know what behavioral treatments work well for tics, but the dissemination is really terrible."

Storch says the biggest advantage of TicHelper will be its accessibility. CBIT, he says, works well and is incredibly safe compared with pharmaceuticals. TicHelper would maximize the benefits of CBIT by making it more inexpensive and easier to get to than therapy.

Which is not to say that Storch or Woods would recommend TicHelper as the only form of tic management. Both psychologists suggest that this program might work best as part of a management plan. One option, Woods says, might be to start treatment with TicHelper at first diagnosis and proceed to more intensive care if in-home treatment isn't working.

Storch thinks that ideally the patient would work with the program, but touch base periodically with an experienced therapist or health care provider to check progress. But, he says, "we don't have enough providers." And some treatment, he says, is better than no treatment at all.

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How Vandalism And Fear Ended Abortion In Northwest Montana

Tue, 07/21/2015 - 6:01pm
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Susan Cahill, owner of All Families Healthcare, stands in front of the first building in Kalispell, Mont., where she offered abortion services. After vandalism closed her last clinic down, Missoula became the nearest place for women in the Flathead Valley to find abortion services.

Corin Cates-Carney/MTPR

There has never been a welcome mat for abortion service providers in the Flathead Valley, a vast area that stretches over 5,000 square miles in the northwest corner of Montana. Susan Cahill began providing abortions in 1976 in the first clinic to offer the service in the Flathead.

"But that had an arson fire, and then we rebuilt that," she says. "Then we had the anti-choice people try to arrest me for doing abortions when I wasn't a doctor."

Cahill performed abortions as a physician assistant for 38 years. Police testified in a recent trial that in March of 2014, Zachary Klundt took a hammer to the photos in Cahill's office, poured iodine on the floor and tossed files from cabinets. Klundt damaged the building's heating and plumbing and discharged a fire extinguisher. He said he broke into the clinic looking for prescription drugs.

Everything was destroyed in Cahill's clinic.

"I've worked since I was 17," she says. "Everything I've had, I've worked for."

The clinic was in Kalispell, population 20,000. It's the hub of the Flathead Valley, and the largest employer is Kalispell Regional Medical Center. In a town full of health care professionals, Cahill was the only one providing abortions.

"Because I was the only one, I got targeted," she says.

Cahill's clinic was a general family practice; her patients have had to find other health care. For abortion care, the options are more limited.

According to the Guttmacher Institute, in 2008 about a third of American women seeking access to abortion services traveled more than 25 miles to get them. Today, a woman in Kalispell has to drive 120 miles — each way — to Missoula to get an abortion. And some women are doing just that, says Melissa Barcroft, of Planned Parenthood of Montana, in Missoula.

"Anytime a provider stops providing services, the need doesn't go away," Barcroft says. "Patients still need that care."

The loss of Cahill's clinic has been frustrating, Barcroft says.

"I know from talking with our providers that we have seen a definite increase of patients from the Flathead area," she says.

Cahill says she worries most about poor women, or those from the town of Browning, on the Blackfeet Indian reservation.

"The disadvantaged are always the ones that lose," Cahill says. "Now you've got people who are on Medicaid, or who are from Browning, and are teenagers." It can be much harder for them to get to Missoula, she says. "I used to give gas money for people to go home. Now ... it is just a harder struggle for them."

Cahill says plenty of local physicians can perform abortions, but they're afraid.

Samantha Avery trained under Cahill at All Families Healthcare. At the time, Avery thought about going to medical school to pursue a career like Cahill's.

"I know that she wanted me to be the one to take over her clinic," Avery says. "End even before all of this, I told her, 'I just don't know if I could do that to my family — my future family. I can't be the Susan Cahill. I'm not that brave of a person.' "

Zachary Klundt and his sister in court.

Corin Cates-Carney/MTPR

Avery decided instead to work for the Public Health Department in Flathead County. She says it was hard for her to watch Cahill lose everything so quickly. The weight of the community's opposition to abortion is difficult to counter, she says — citing Zachary Klundt, who was convicted in the attack against the clinic, as just one example.

Klundt's mother was on the board of Hope Pregnancy Ministries, which advocates for alternatives to abortion. She resigned after the attack.

Michelle Reimer, the executive director of Hope Pregnancy Ministries, says that what happened to Cahill and her clinic was terrible, and totally against her group's mission.

Shots - Health News States Aim To Restrict Medically Induced Abortions

"There is not a place for it in a Christian organization," Reimer says. "There is always going to be the outlier, the one who represents us poorly, or who says the wrong thing, or — as we all would with a very volatile topic like abortion — expresses [himself or herself] passionately rather than logically. And I think we see that on both sides."

Reimer says at the core of her faith is compassion — and telling a woman that regardless of what she chooses, she is loved.

In June, Klundt was sentenced to 20 years, with 15 years of that suspended. He was also ordered to pay restitution. In the courtroom, Klundt read Cahill an apology.

"I cannot even believe I did that to another soul," he says. "But I did that to you. I know what it's like to live with fear, and for me to do that to you is awful. And I am truly so sorry."

He said his actions do not represent his faith.

For women in the Flathead Valley, Susan Cahill says, getting reproductive care is not any easier now that Klundt is sentenced. Her clinic is still gone.

This story is part of NPR's reporting partnership with Montana Public Radio and Kaiser Health News.

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Women's Brains Appear More Vulnerable To Alzheimer's Than Men's

Tue, 07/21/2015 - 4:21pm
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Women with mild cognitive impairment, which can be a precursor to Alzheimer's, tend to decline faster than men.

Lizzie Roberts/Getty Images/Ikon Images

There's new evidence suggesting that women's brains are especially vulnerable to Alzheimer's disease and other problems with memory and thinking.

Women with mild cognitive impairment, which can lead to Alzheimer's, tend to decline faster than men, researchers reported this week at the Alzheimer's Association International Conference in Washington, D.C.

Another study showed that women's brains tend to contain more amyloid, the substance that forms sticky plaques in Alzheimer's. And a third study found that women who have surgery with general anesthesia are more likely than men to develop long-term problems with thinking and memory.

The studies help explain why women make up two-thirds of all Americans with Alzheimer's. And the results challenge the notion that more women have Alzheimer's simply because they tend to outlive men, says Kristine Yaffe of the University of California, San Francisco.

"There's something else going on in terms of the biology [or] the environment for women," Yaffe says.

The research on women with mild cognitive impairment was part of a large ongoing study called the Alzheimer's Disease Neuroimaging Initiative. Researchers studied up to eight years of records on about 400 men and women in that study who had mild cognitive impairment, a condition that often leads to Alzheimer's.

"We found that women decline at almost twice the rate of men and we also found that women have faster acceleration of decline over time," says Katherine Amy Lin, part of a team at Duke University Medical Center. So many women who had subtle memory problems at the beginning of the study period had major deficits by the end.

Another study presented at the Alzheimer's meeting used PET scanning to measure levels of amyloid in about 1,000 people, including many with cognitive impairment or Alzheimer's disease. Amyloid is the substance that forms sticky plaques in the brains of Alzheimer's patients.

There was a clear difference between men and women, regardless of their age, says Michael Weiner of UCSF, the study's senior author. "Overall, women had more amyloid in their brain than men," he says, which suggests they are at higher risk of developing Alzheimer's.

What's still not clear, though, is why women's brain cells are more vulnerable than men's to Alzheimer's and other memory problems, Weiner says.

One possible explanation is that every cell in a woman's body carries two X chromosomes, instead of an X and a Y, Weiner says. "But there are other differences," he says, such as hormones, lifestyle, childbearing, diet, and exercise.

If scientists can figure out the mechanism that causes more Alzheimer's disease in women, Weiner says, they might be able to develop treatments that halt the process.

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2 Gene Studies Suggest First Migrants To Americas A Complex Mix

Tue, 07/21/2015 - 3:45pm
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The area around the confluence of the Silverthrone and Klinaklini glaciers in southwestern British Columbia provides a glimpse into how the terrain traveled by Native Americans in Pleistocene times may have appeared.

David J. Meltzer/Science

The first people to set foot in the Americas apparently came from Siberia during the last ice age.

That's the conventional wisdom.

But now there's evidence from two different studies published this week that the first Americans may have migrated from different places at different times — and earlier than people thought.

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The human race has walked or paddled or sailed until it covered the globe. Scientists can trace those migrations from the stuff these people left behind: tools, dwellings or burial grounds.

Geneticists can now trace these patterns of travel, too — by examining the genes of living people and comparing them to each other, as well as to genes extracted from ancient bones. Rasmus Nielsen of the University of California, Berkeley and a large, international team of scientists have done just that for native people of the Americas. And they think they've figured out how the very first people got here.

"They came in a single migration wave into the Americas," Nielsen says — "people who diverged from people originally in Siberia and East Asia about 23,000 years ago."

Now, that confirms the standard view that people first got here across a frozen "land bridge" between Siberia and Alaska, albeit a few thousand years earlier than many had assumed.

But there's long been a lingering puzzle: Some ancient skulls found in the Americas look rather like Europeans, or maybe Polynesians. Did another group come from somewhere else?

Code Switch The Map Of Native American Tribes You've Never Seen Before

Writing in this week's issue of the journal Science, Nielsen says no. Genetically, no Native Americans match up with Europeans or Polynesians, in terms of these markers of ancient migration. Instead, he says, there was just one major, founding wave of people moving into the continent; any diversification of Native American groups must have evolved on its own after the first bunch of people got here.

"Diversification of modern Native Americans happened in the Americas," Nielsen says — "not because people came from all over the world into the Americas."

But there's often a twist when you're teasing apart the threads of ancient history with genetic tweezers. David Reich, a geneticist at Harvard Medical School, says his research — published Tuesday in the journal Nature — suggests a more complicated story.

When Reich studied groups of indigenous people in South America, he found that some of them had a peculiar genetic fingerprint. He searched the world for other copies of that fingerprint and found it far away — in modern Australasia.

"What we found," says Reich, "was that Native American people from Amazonia — from present-day Brazil — are more closely related to some populations in Asia than are other Native Americans, for example from Mexico, or from western South America and many parts of North America."

The Amazonians' modern relatives — the Australasians — are native Australians, and people of New Guinea and the Andaman Islands.

U.S. Phoenix Students Restore School To Reclaim Native American Identity

Reich says what may have happened is this: Members of a now-extinct population of people in what's now Southeast Asia — Reich calls them Population Y — crossed the land bridge as well, either before or after the first wave of people made it to the Americas. This splinter group from Population Y kept going, and some members got all the way to Brazil. Meanwhile, those who stayed behind in Asia populated what is now Australasia. But the two groups still are linked genetically.

Says Reich: "We now have the possibility of there being two different streams of ancestry penetrating south of the ice sheets, so that's a very exciting new observation."

That observation adds yet another branch — or root — to the American family tree.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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With Pap Tests Less Common, Women May Miss Out On STD Tests

Tue, 07/21/2015 - 2:14pm

The chlamydia bacteria can cause pelvic inflammatory disease and fertility problems, but women often don't know they're infected.

David M. Phillips/Science Source

Changes in how women are screened for cervical cancer mean they're getting Pap tests less often. But that may also mean young women are not getting tested for chlamydia, the most common sexually transmitted disease.

As the number of teens and young women getting annual Pap tests declined, so did the number getting screened for chlamydia, according to a study published Monday in Annals of Family Medicine.

Chlamydia infects an estimated 2.86 million men and women annually, according to the Centers for Disease Control and Prevention. It's most common in young women from the age of 15 to 24, and if left untreated, can cause pelvic inflammatory disease and make it difficult for women to get pregnant. It can cause preterm delivery, and conjunctivitis and pneumonia in newborns.

It's also easily cured with antibiotics. But because people with chlamydia often don't have symptoms, most people are diagnosed via screening tests. The CDC recommends yearly chlamydia screening for all sexually active women younger than 25, as well as older women with risk factors.

The research team looked at patient data of some 3,000 teenagers and young women aged 15 to 21 years old who made visits to five family medicine clinics at the University of Michigan, and identified young who had no symptoms for either cervical cancer or chlamydia but were tested for either or both.

In 2009, the American College of Obstetricians and Gynecologists recommended of starting cervical cancer screening at age 21, irrespective of sexual activity. And in 2012, the American Cancer Society and the United States Preventative Services Task Force recommended against routine yearly testing, but the study doesn't look into the impacts of this newer change.

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They compared two groups: those who made visits before the 2009 guidelines change for Pap tests (from 2008 to 2009), and those who visited after the change (from 2011 to 2012). They looked at patients who came in for a Pap test or for chlamydia screening, and also those who received chlamydia screening while getting a Pap test. Before the change, about 30 percent of the women in that age group got tested for chlamydia. Afterwards, less than 1 percent did. The number of women getting Pap tests dropped, too, from about 24 percent to less than 1 percent.

Were patients just not going to the doctors as frequently as before?

Not true, says Allison Ursu, lead author of the study and women's health fellow at University of Michigan Medical School.

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"The number of visits per patient were roughly the same," Ursu says, "We had chances to screen them; we just weren't doing it."

It's not hard to link a shift in guidelines with a decrease in Pap tests getting done, since evidence shows that annual screening isn't necessary and can lead to needless treatment, Shots has reported. But what do Pap smears have to do with screening for chlamydia in the first place?

Until 2000 or so, chlamydia screening was mostly done with a sample taken from the cervix, often at the same time that a Pap smear was performed, according to Michael Policar, associate clinical professor of obstetrics and gynecology at the University of California, San Francisco. Policar is not part of the study.

Ursu believes that one reason women aren't getting screened for chlamydia is the lack of knowledge about noninvasive screening methods, including a urine sample or vaginal swab. Pelvic exams aren't necessary.

"Uncoupling is the way we should approach the patient, to separate cervical cancer screening from sexually transmitted infections screening," Ursu says. At the University of Michigan's family medicine department, her team has started using its electronic medical record system to alert patients when they're due for testing for chlamydia. She says patients find the reminder to be helpful.

The "uncoupling" of Pap smears and chlamydia screening is not a new concept.

"This concept has been stressed by the CDC and the U.S. Preventive Services Task Force in their guidelines for at least a decade, and most providers already have unlinked chlamydia screening from either the performance of a Pap smear or a screening pelvic exam at the time of a well woman visit," says Policar. "A rallying cry following the change in 2009 guidelines was 'pee not Pap.' "

Policar also stressed the importance of what doctors call opportunistic screening — something that Ursu's team is doing and that the paper mentions.

"The concept is that some people never come in for preventive visits, like checkups, so we should use problem visits (acne, headaches, a sprained ankle) as an opportunity to perform desirable screening tests, including chlamydia screening in young women," Policar told Shots via email. "Highly functional provider groups, like Kaiser, are achieving chlamydia screening rates in the mid to high 80 percent range, based on an excellent electronic medical record."

National screening rates for chlamydia as reported by the National Chlamydia Coalition found that in a state-by-state analysis, most rates did not change as dramatically as found in the study. Policar said that's probably due to the limitations in scope of the family practice clinic where data was collected.

At the end of the day, the take-home message is "Chlamydia is easily treated and curable," Ursu says. And appropriate screening can greatly reduce this infection among young people.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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IRS: 7.5 Million Americans Paid Penalty For Lack Of Health Coverage

Tue, 07/21/2015 - 11:19am

The IRS released preliminary figures that show about three-quarters of taxpayers indicated they had qualifying health insurance in 2014.

Carolyn Kaster/AP

About 7.5 million Americans paid an average penalty of $200 for not having health insurance in 2014 — the first year most Americans were required to have coverage under the Affordable Care Act, the Internal Revenue Service said Tuesday.

By contrast, taxpayers filing three-quarters of the 102 million returns received by the IRS so far this year checked a box indicating they had qualifying insurance coverage all year.

Counting another 7 million dependents who weren't required to report their coverage but also filed returns, the proportion with qualifying insurance rises to 81 percent, the IRS said.

The government had estimated in January that from 3 million to 6 million households would have to pay a penalty: 1 percent of their annual income or $95 per adult in 2014, whichever is greater.

Final figures for the tax year aren't available yet. The IRS has so far processed about 135 million of the estimated 150 million returns expected. IRS Commissioner John Koskinen said the agency was reporting preliminary figures because it has received "numerous requests" from members of Congress.

In addition to penalty totals, the IRS reported Tuesday on tax subsidies the health law provided for people who were buying coverage through the state or federal online exchanges and who qualified based on income. People had a choice of filing for credits in advance — money the government paid to their insurers — or when filing tax returns.

About 2.7 million taxpayers claimed approximately $9 billion in subsidies, reporting an average subsidy of $3,400. About 40 percent claimed less than $2,000, 40 percent claimed $2,000 to $5,000, and 20 percent claimed $5,000 or more.

Among taxpayers who claimed a subsidy, about 1.6 million, or half of taxpayers who claimed or received a subsidy, had to pay money back to the government because their actual income was higher than projected when they applied for the subsidy. The average amount repaid was about $800.

When looking at the individual mandate, the report said the vast majority of people automatically satisfied the individual mandate because they were insured last year. Another 12 million had exemptions, including people whose incomes were too low and Native Americans.

In all, the IRS said it has collected $1.5 billion from the individual mandate penalty included in the health law. About 40 percent of taxpayers who paid a penalty paid less than $100.

About 300,000 taxpayers who made an individual mandate penalty payment should have claimed an exemption but did not, the government said. The agency is sending letters to these taxpayers telling them they generally have three years to file an amended tax return.

More than 5 million taxpayers did not check the box on their tax form saying had coverage, claim a health care coverage exemption, or pay a penalty. "We are analyzing these cases to determine their status," the government said.

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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How Sporty Is Your Sport?

Tue, 07/21/2015 - 10:02am

When it comes to sports, there seems to be something for everyone.

There are team sports and activities you can do alone. There's exercise that requires equipment, or none at all.

But how much benefit you get from each one depends on a lot of factors, including how much you weigh, how long you play and the intensity of the activity.

People play sports for personal enjoyment and health, according to NPR's poll on sports and health in America. The poll, done in collaboration with the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health, finds that other reasons include losing weight and staying in shape.

So how athletic are some of the sports Americans play? Playing golf burns almost as many calories as baseball. But how does dancing compare with playing darts?

We looked at the caloric expenditures of a variety of sports to see how moderate levels of activity stacked up for the average American woman.

Join us on the video tour created by California animator Ben Arthur.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Expanding, Not Shrinking, Saves A Small Rural Hospital

Tue, 07/21/2015 - 5:01am
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One of the first signs drivers see on the way into Unionville, Mo. is this billboard advertising cardiology at Putnam County Memorial Hospital. Offering specialty services, like cardiology and psychiatry turned the hospital around, community leaders say.

Bram Sable-Smith/KBIA/Side Effects Public Media

Missouri cattle farmer Greg Fleshman became so concerned about keeping his local hospital open that in 2011 he joined its governing board.

"I mean they've saved my dad's life twice," Fleshman says. "He had a heart attack and a stroke and they life-flighted him out of here both times." Keeping the doors open at Putnam County Memorial Hospital in Unionville, Mo., seemed crucial to the community — but maybe an impossible task.

"Things were just falling apart, is really what it was," Fleshman says — "financially, and morale of the employees. And it just seemed to get worse and worse."

Putnam County Memorial was ailing from the same conditions squeezing the finances of many of the nation's rural hospitals. At least 55 have closed since 2010 across the U.S., with another 1 in 10 at risk of going under, by one talley. Only about 5,000 people live in Putnam County, and they tend to be older, poorer, sicker and less insured than the rest of the state.

Health care analysts says Medicare and Medicaid's relatively low reimbursements, combined with dwindling populations in rural regions, are forcing many hospitals like Putnam to operate with tighter profit margins than suburban institutions — and sometimes even at a loss.

Like a lot of institutions, Putnam County Memorial initially looked to cut costs by reducing staff and services. But eventually, as more and more patients went to bigger towns for treatment, the hospital came to the brink.

Fleshman vividly recalls those darkest days: "We had about $8,000 in the bank," he says, and faced a payroll of about $70,000 or $80,000. Two CEOs quit, and the board started calculating what it would cost to close down the facility.

"We didn't think we could get anybody to come in," Fleshman says.

We think that's the way forward for rural hospitals, rather than just sort of a bunker mentality — saying that we can't proceed.

Then a key phone call and strikingly different strategy turned everything around. A doctor in the area called Jerry Cummings, who was then running a medical consulting business with his wife Cindy in central Missouri. Instead of closing its doors, Putnam County Memorial should expand, the couple advised.

The hospital could convert an unused 10-bed unit into a psychiatric wing to bring in new revenue, suggested the Cummings, and offer other medical services that Putnam County residents were driving hours away to get.

The board was convinced, and hired the couple to run the hospital — Cindy Cummings as CEO, and Jerry as COO. The two packed up their home in Jefferson City, Mo., and moved three hours north to Putnam County.

One of the first moves Jerry Cummings made, after becoming Putnam County Memorial's COO in 2012, was to hire more doctors and renovate an unused unit to become a psychiatric wing.

Bram Sable-Smith/KBIA/Side Effects Public Media

"Immediately, within 30 days, I brought in three other brand new physicians" Jerry Cummings says. He and Cindy brought new specialties to the hospital: anesthesiology, gynecology and cardiology. They also rallied the county to pass a roughly $7 million dollar bond initiative to buy out the hospital's old debt and renovate.

And patients started coming back.

"Our revenues went from $4 million to $22 million — a huge increase," Jerry Cummings says. "Our average daily [patient] census, it was less than 1 patient per day. Our average daily census now is around 11 to 12 patients."

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And, according to a report published by the health panel of the Rural Policy Research Institute last November; more cash-strapped rural hospitals could thrive by taking the same tack.

"We think that's the way forward for rural hospitals, rather than just sort of a bunker mentality — saying that we can't proceed," says Tim McBride, a health care economist at Washington University in St. Louis, and one of the study's authors.

In some ways the Putnam County story is unique McBride says. But expanding certain services instead of contracting, might work to save other hospitals, too.

"We believe that rural hospitals often can provide very high quality services," he says.

The community in Unionville had to have that same faith, says Greg Fleshman, that they weren't just throwing good money after bad.

"I think, people had to decide, Fleshman says. " 'Are we going to have a hospital or not?' — and they wanted it here."

This piece comes from Side Effects Public Media, a public radio reporting collaborative that explores the impacts of place, policy and economics on health.

Copyright 2015 KBIA-FM. To see more, visit http://www.kbia.org.
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More Health Plan Choices At Work: What's The Catch?

Mon, 07/20/2015 - 2:44pm
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Steve Heller has worked for Minnesota's John Henry Foster company for 15 years. He says he likes the greater choice of health plans he now has because of the private exchange.

Mark Zdechlik/MPR

Until recently, John Henry Foster, an equipment distribution firm based in Eagan, Minn., offered its employees only a couple of health plans to choose from. That's common in companies across the United States.

"They just presented what we got," says Steve Heller, a forklift operator who has worked at John Henry Foster for 15 years.

But these days the company's employees have dozens of choices. And something else is new: Each worker now receives money from the company (from $350 to $1,000 a month, depending on whether Heller and his co-workers are buying insurance for a single person, a couple or a family) to buy a health plan.

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Employees are then directed to an online exchange — a private, secure website that offers the selection of plans for side-by-side comparison. Workers can choose high-deductible plans with relatively low monthly premiums or they can pay more each month to have more of their care and medications covered.

Just as before, the company determines the insurance companies listed, and the scope of the treatments and procedures covered by each plan.

Three years after the switch, Heller says he's happy with his insurance and the exchange. The company's managers are happy with it, too.

In 2012, the company was facing a big increase — 30 percent in its costs for employee medical benefits. "Unlike anything we had ever seen before," says Jan Hawkins, co-owner of John Henry Foster.

Jan Hawkins, one of the co-owners of the equipment distribution firm John Henry Foster, says going to a private exchange has given the company much more flexibility in budgeting for health care costs.

Mark Zdechlik/MPR

So, Hawkins says, company leaders decided to sign up for a private exchange run by Medica, a Minnesota insurer, because they could choose to spend only about 10 percent more on health benefits in the first year, instead of that 30 percent increase projected under the old plan.

Since then, the firm has increased the money it gives employees to spend on health insurance by roughly 10 percent each year.

"I think it definitely helps us from an operational budget standpoint," Hawkins says. "We've just seen only positives from this."

Despite the benefits to a company's bottom line, and more choices for employees, John Henry Foster is one of relatively few businesses using a private health insurance exchange. According to research by the Kaiser Family Foundation, last year only 3 percent of employers (excluding the federal government) insure their employees this way.

But it's a trend that some experts expect to pick up steam soon. "I would say a majority of the companies will switch to private exchanges," says Dr. Jim Bonnette, with the health care consulting firm The Advisory Board Co.

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Bonnette thinks that employees under this sort of system are likely to choose high-deductible plans and be much more motivated than in the past to search out the best value for care. That could finally force consumers to pay attention to the price of health care, he says, a goal that has eluded health policymakers for decades.

"We can't afford the trend — that is, the increase in cost per year — that we currently have," Bonnette says. "So how do you get people to think differently about how they receive care and what it costs?"

But shopping wisely for health care is almost impossible says Sara Collins from the Commonwealth Fund, a health policy research organization.

It's often difficult for consumers to find out how much a doctor visit or a particular procedure costs. And, Collins says, studies show that people with high-deductible plans often forgo care to save money; they'll even avoid free preventive care because they don't understand how their health insurance works.

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"The idea that people who have such low understanding of what is included or excluded in their deductible can actually go out and price-shop for their health services, I think, really stretches the imagination," she says.

Kim Wagner, a benefits consultant, says predictions of a big shift to private exchanges are overblown. Although some employers are adding more health plan choices for workers, she says, giving employees a set amount to buy insurance on an exchange could alienate workers and increase turnover.

The practice of giving employees a limited amount of money to purchase their own insurance has been around for a while, Wagner says, but "hasn't taken off, particularly in the large employer space, because truly it's a cost shift."

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Workers suddenly asked to shoulder more of the cost of their health care may be more likely to look for a job elsewhere — opting for companies that offer better benefits.

Nonetheless, firms that now use generous benefits as a selling point to lure top talent may soon be more motivated to set up these sorts of private insurance exchanges, too. Beginning in 2018, companies that offer health insurance packages the government deems too generous will start having to pay a 40 percent tax on those packages.

It's called the "Cadillac" tax (meant to reduce health spending by discouraging luxurious health plans), but it is not as exclusive as its name implies. Towers Watson, a consulting firm, predicts that 48 percent of employers will have to pay the tax in its first year.

This story is part of NPR's reporting partnership with Minnesota Public Radio and Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Copyright 2015 Minnesota Public Radio. To see more, visit http://www.mpr.org/.
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5 Things Your Baby Should Avoid In The NICU

Mon, 07/20/2015 - 2:04pm

Babies in the neonatal intensive care unit hospital don't always need the tests and treatments suggested.

iStockphoto

If you've got a baby in the neonatal intensive care unit, your first thought is probably not, "Does my child really need that antireflux medication?"

But antireflux meds in for newborns topped the list of five overused tests or treatments released Monday as part of the "Choosing Wisely" program. About one-third of health care spending in the United States is overuse and waste, costing about $2.7 trillion a year.

"With newborns, there's very little evidence that routine use will improve the symptoms," says DeWayne Pursley, chief neonatologist at Beth Israel Deaconess Medical Center and senior author on the paper, which was published in Pediatrics.

In other words, babies spit up. There's evidence that giving newborns antireflux medications doesn't reduce the risk of apnea or low blood oxygen, the two problems it's typically prescribed for in preemies. And it could cause long-term harm, Pursley says.

The other four tests and treatments to avoid doing routinely are:

  • Antibiotics for more than 48 hours in babies who don't have evidence of a bacterial infection.
  • Overnight breathing studies for assessing apnea in premature infants before they go home.
  • Daily chest X-rays for infants who are intubated, unless there's a specific problem that needs to be investigated.
  • Screening brain MRIs when babies reach their term equivalent age, or at discharge from the hospital.

That's not to say that no infant should ever get these, Pursley says. "But our gripe, if you will, is their routine use."

To come up with the list, an expert panel of 51 specialists in neonatal care compared through almost 3,000 tests and treatments recommended by practitioners.

It was hard to narrow the list down to just five low-value items, Pursley says; there were so many that the experts thought were of dubious worth.

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"I think the take-home message isn't that these are five tests and treatments that appear to have low value, but these represent five of probably many that when used routinely don't add value to the care of the baby," Pursley says.

A great example is brain MRIs for extremely preterm babies around the time they should have been born. They're promoted as helping to predict which children will have neurological and developmental problems and will need interventions, Pursley says. But the MRIs have only a 50/50 chance of getting it right.

"Some families will say, 'Gee, if I had known there would be this uncertainty I wouldn't have wanted to have the test,' " Pursley says. "There are other ways of looking at the brain in babies and probably getting just as good information."

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MRIs cost a lot of money, and it's another stressful test that a fragile baby shouldn't have to undergo if it's not helping.

So what are parents to do when they've got a child in the NICU and they're facing dozens of mysterious tests or treatments?

Parents can ask if they can do rounds with the medical team, Pursley says, which is an increasingly common practice in NICUs. That way they'll hear how the care team assesses the child's progress and how they do their planning. "It provides [parents] an opportunity to ask why certain tests and treatments are being done."

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