• What is Governor LePage talking about? I’m seriously asking.

    Healthcare Triage has just completed a month on opioids (History, Science, Abuse, and Treatment). I admit I’m a little more on edge about them than usual. We were in the midst of production when Governor LePage of Maine made news by vetoing a bi-partisan bill that would allow pharmacists to dispense naloxone without a prescription. When asked to explain his veto, he released a statement:

    In a statement explaining his rationale, the Republican governor argued, “Naloxone does not truly save lives; it merely extends them until the next overdose.”

    This was not an “out-of-context” remark. It wasn’t a “gotcha” moment. It was a prepared statement, which basically said that naloxone shouldn’t be available because it keeps addicts alive longer until they inevitably overdose.

    Naloxone isn’t addictive. It doesn’t give you a high. It can help prevent overdoses and it stops the opioids from doing what they usually do. The Maine state legislature overrode the governor’s veto.

    At a town hall recently, LePage doubled down on his beliefs, relating a story:

    “A junior at Deering High School had three Narcan shots in one week. And after the third one, he got up and went to class. He didn’t go to the hospital. He didn’t get checked out. He was so used to it. He just came out of it and went to class,” LePage said.

    He told the audience that he could support the use of Narcan if someone given the shot would be taken directly to rehab afterward. Instead, he thinks the current approach is ineffective.

    “It will kill our society. And we’re gonna lose a whole generation,” he said.

    I’m all for addicts getting help. But depriving them of naloxone doesn’t “save a generation”. I don’t understand the anecdote. It gets worse, though. It appears LePage might have made up the story. The school says it isn’t true. They say that the medication isn’t even available in the school nurse’s office.

    Further confronted, LePage stood by his story. He told reporters to talk to Portland Police Chief Michael Sauschuck for verification of the story.

    Saruschuck said that the anecdote isn’t true.

    There’s a massive opioid epidemic in the US. Addiction isn’t a moral failure, and those who are addicted aren’t lost causes. I’m baffled by all of this, but it’s made worse when it appears that efforts to improve the situation are being thwarted by people who can’t even be bothered to say things that are true.

    @aaronecarroll

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  • Sorry, There’s Nothing Magical About Breakfast

    The following originally appeared on The Upshot (copyright 2016, The New York Times Company).

    I don’t eat breakfast. It’s not that I dislike what’s offered. Given the choice of breakfast food or lunch food, I’d almost always choose eggs or waffles. It’s just that I’m not hungry at 7:30 a.m., when I leave for work.

    In fact, I’m rarely hungry until about lunch time. So, other than a morning cup of coffee, I don’t eat much before noon. This habit has forced me to be subjected to more lectures on how I’m hurting myself, my diet, my work and my health than almost any other. Only a fool would skip the most important meal of the day, right?

    As with many other nutritional pieces of advice, our belief in the power of breakfast is based on misinterpreted research and biased studies.

    It does not take much of an effort to find research that shows an association between skipping breakfast and poor health. A 2013 study published in the journal Circulation found that men who skipped breakfast had a significantly higher risk of coronary heart disease than men who ate breakfast. But, like almost all studies of breakfast, this is an association, not causation.

    More than most other domains, this topic is one that suffers from publication bias. In a paper published in The American Journal of Clinical Nutrition in 2013, researchers reviewed the literature on the effect of breakfast on obesity to look specifically at this issue. They first noted that nutrition researchers love to publish results showing a correlation between skipping breakfast and obesity. They love to do so again and again. At some point, there’s no reason to keep publishing on this.

    However, they also found major flaws in the reporting of findings. People were consistently biased in interpreting their results in favor of a relationship between skipping breakfast and obesity. They improperly used causal language to describe their results. They misleadingly cited others’ results. And they also improperly used causal language in citing others’ results. People believe, and want you to believe, that skipping breakfast is bad.

    Good reviews of all the observational research note the methodological flaws in this domain, as well as the problems of combining the results of publication-bias-influenced studies into a meta-analysis. The associations should be viewed with skepticism and confirmed with prospective trials.

    Few randomized controlled trials exist. Those that do, although methodologically weak like most nutrition studies, don’t support the necessity of breakfast.

    Further confusing the field is a 2014 study (with more financial conflicts of interest than I thought possible) that found that getting breakfast skippers to eat breakfast, and getting breakfast eaters to skip breakfast, made no difference with respect to weight loss. But a 1992 trial that did the same thing found that both groups lost weight. A balanced perspective would acknowledge that we have no idea what’s going on.

    Many of the studies are funded by the food industry, which has a clear bias. Kellogg funded a highly cited article that found that cereal for breakfast is associated with being thinner. The Quaker Oats Center of Excellence (part of PepsiCo) financed a trial that showed that eating oatmeal or frosted cornflakes reduces weight and cholesterol (if you eat it in a highly controlled setting each weekday for four weeks).

    Many studies focus on children and argue that kids who eat breakfast are also thinner, but this research suffers from the same flaws that the research in adults does.

    What about the argument that children who eat breakfast behave and perform better in school? Systematic reviews find that this is often the case. But you have to consider that much of the research is looking at the impact of school breakfast programs.

    One of the reasons that breakfast seems to improve children’s learning and progress is that, unfortunately, too many don’t get enough to eat. Hunger affects almost one in seven households in America, or about 15 million children. Many more children get school lunches than school breakfasts.

    It’s not hard to imagine that children who are hungry will do better if they are nourished. This isn’t the same, though, as testing whether children who are already well nourished and don’t want breakfast should be forced to eat it.

    It has been found that children who skip breakfast are more likely to be overweight than children who eat two breakfasts. But that seems to be because children who want more breakfasts are going hungry at home. No child who is hungry should be deprived of breakfast. That’s different than saying that eating breakfast helps you to lose weight.

    The bottom line is that the evidence for the importance of breakfast is something of a mess. If you’re hungry, eat it. But don’t feel bad if you’d rather skip it, and don’t listen to those who lecture you. Breakfast has no mystical powers.

    @aaronecarroll

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  • Stuff for Healthcare Systems (PHMD2350)

    What is this post about? Look here.

    @afrakt

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  • Living in the antibiotic-resistant future: Answers for @MattYglesias

    Matt Yglesias asked:

    Thanks for asking, Matt! I’m 63 and I will happily oldsplain tell you what you need to know about your future.

    First, some advice about how to think about the problem. One of the difficulties in predicting your future health is that the data come from earlier generations (like me). Unfortunately, your experience will differ from mine, in part because the health care system you will face will be different from the one that I’ve experienced. For several generations, we’ve largely unconsciously assumed that future health care will be better than current health care.

    But that’s no longer clear. Our current antibiotics are failing and they are not being replaced with new ones. I’m sure you know this, but Aaron has great explainers here and here, Kevin has one here, and I have a rant here. In my piece, I quote Arjun Srinivasan, an associate director at the CDC:

    For a long time, there have been newspaper stories and covers of magazines that talked about “The end of antibiotics, question mark?” Well, now I would say you can change the title to “The end of antibiotics, period.” We’re here. We’re in the post-antibiotic era… we are literally in a position of having a patient in a bed who has an infection, something that five years ago even we could have treated, but now we can’t.

    We are already at a point where antibiotic-resistant bugs kill more Americans than AIDS does. Because there is uncertainty about whether this problem will be solved, the risks implied by future widespread antibiotic resistance should condition your current health care decision making.

    Given that you report having random knee pain, this is relevant to you. I started experiencing pain in my hip in my early 30s. My family is disposed to osteoarthritis. But I also made a questionable set of athletic choices. I got hooked on endurance sports (cycling, distance running, triathlon) and martial arts (an acrobatic style of kung fu). I loved these sports, but I could have made smarter choices. I’m 6’2″ with the frame more like an offensive lineman than a marathoner (or Jet Li).

    I logged many running miles, chronically stressing the tissue separating my femurs from my pelvis. I also injured my left hip landing an aerial kick involving 270 degrees of rotation. As a result of these traumas, by my late 50s that hip was trashed by osteoarthritis. I could not walk for long distances or without a cane.

    Then I got a hip replacement. OMG was that wonderful. But here is what joint replacement surgery looks like.

    Joint replacement surgery.

    Joint replacement surgery.

    These operations are spectacularly invasive and they are impossible without effective antibiotics.

    Of course, if we can’t do surgeries, the disappearance of joint replacements will be just one horrible detail. Peter Lee, Scott Regenbogen, and Atul Gawande estimate that the typical American will have 9 surgeries during their life. This will change, and not for the better, without antibiotics. Everyday events will once again become occasions of terror. I was once bitten by my cat while trying to protect her from a dog. Cat bites are amazingly dangerous. Within 24 hours there was a swelling on my hand about the size of half a softball. No big deal, though. It was quickly fixed through surgical debridement and intravenous antibiotics. Otherwise, I would have lost my hand.

    But you mentioned knee pain, so let’s talk about joint health. The upshot is that you have to make health decisions now with the knowledge that you may not be able to replace your joints. You can live without a joint replacement, at the cost of constant pain, with the attendant risks of mental health and substance abuse problems. Moreover, even with a cane or walker your mobility is significantly restricted, and you will discover how many buildings still do not meet the requirements of the Americans with Disabilities Act.

    In light of these risks, you should think through how to minimize the chance that you will need a joint replacement. About 1.2 million of these procedures are performed a year and about 10% of men develop osteoarthritis, so your prior probability even without early knee pain was already significant. See your physician, find out what your risk of developing joint disease might be, and learn what you can do to prevent it. Keep your weight down and engage in regular exercise. But don’t take up a sport that stresses the joints of big men.

    Finally, keep covering the problem of antibiotic resistance at Vox. Antibiotic resistance is in the class of problems that includes global warming and nuclear holocaust. They are all rooted in the foundations of how things work rather than in the easily fixable details. Any solution faces difficult coordination problems. Keep writing because people don’t get it yet; but they need to if we are going to get through this.

    @Bill_Gardner

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  • Healthcare Triage Special: Opioid Addiction and Treatment

    Thanks, in part, to the generous support of the NIHCM, this month we are releasing four special episodes on Opioids. We hope you enjoy them. This week’s episode:

    Treatment –  The best way to deal with opioid addiction is to prevent it, but for a huge and growing number of Americans, it’s too late for that. This episode looks at some of the pharmacotherapy and cognitive therapy options for treating opioid addiction, and looks at how we’ve so far largely failed to treat addicts.

    For those of you who want to read more:

    @aaronecarroll

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  • AcademyHealth: Sterile, generic injectables shortages

    Drug shortages are a problem, particularly for generic injectables. Learn why in my new AcademyHealth post.

    @afrakt

     

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  • Can we plan for the next pandemic?

    From Ron Klain, the former Ebola czar, in the Washington Post:

    If it seems like the world is being threatened by new infectious diseases with increasing frequency—H1N1 in 2009-2010, MERS in 2012, Ebola in 2014, Zika in 2016, yellow fever on the horizon for 2017—that’s because it is. These are not random lightning strikes or a string of global bad luck. This growing threat is a result of human activity: human populations encroaching on, and having greater interaction with, habitats where animals spread these viruses; humans living more densely in cities where sickness spreads rapidly; humans traveling globally with increasing reach and speed; humans changing our climate and bringing disease-spreading insects to places where they have not lived previously. From now on, dangerous epidemics are going to be a regular fact of life. We can no longer accept surprise as an excuse for a response that is slow out of the gate. …

    Here at home, we owe the American people an infectious-disease response effort as prompt, well-funded and effective as the Federal Emergency Management Agency (FEMA) at its best. We should create a Public Health Emergency Management Agency (PhEMA). And, whether it is housed in a new agency or put under the CDC or elsewhere in the Department of Health and Human Services, we should create a public health emergency fund that the president can draw down in the face of a dangerous epidemic—without waiting for Congress to act. The Zika-spreading mosquitoes are not going to wait to learn what a conference committee has decided on the Hill. Summer is coming, and Zika will be tagging along with it.

    Klain’s op-ed makes a terse, compelling case for urgency when it comes to pandemic preparation. He expands on that case over at Pulse Check, Dan Diamond’s podcast at Politico. It’s mind-boggling to Klain—and to me—that pandemic response has become a partisan issue. If Zika can’t bring us together, what the hell can?

    As Congress dithers, the World Bank has picked up on Klain’s suggestion. It’s trying something new and very smart to finance outbreak response. From the Financial Times:

    Outbreaks of diseases such as ebola will trigger a $500m fund to help countries and health agencies fight infection after the World Bank launched the first insurance market for pandemic risk.

    The aim of the Pandemic Emergency Financing Facility, unveiled at a G7 finance ministers meeting in Japan, is to make funds instantly available for curbing the spread of particular infectious diseases, thereby saving lives and money over the longer-term.

    The primary financing mechanism for the fund is an ingenious public-private partnership. Leveraging member-states’ contributions, the World Bank will either buy pandemic insurance or sell catastrophe bonds on the private market. (Catastrophe bonds are like normal bonds, except that, if a catastrophe occurs, investors are entitled to a lower return.) In the event of a qualifying pandemic, money from bond sales and insurance pay-outs will be available to disburse. For outbreaks that don’t meet the conditions specified in the World Bank’s insurance or bond contracts, some additional funding from member-states’ contributions will be on-hand.

    In other words, the World Bank is thinking creatively about how to plan for the next pandemic—even as the U.S. Congress does nothing to address the one that’s unfolding before our very eyes.

    @nicholas_bagley

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  • Telemedicine

    Via Taylan Bozkurt:

    telemed

    @afrakt

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  • 6 Things That Happened in Health Policy This Week

    6 Things That Happened in Health Policy This Week was created by Zoe Lyon and Garret Johnson. Find them on twitter @zoemarklyon and @garretjohnson22.

    This newsletter is produced each week by a mix of research assistants from the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health. In each edition we feature a variety of news articles, reports, and studies focused on U.S. health policy and health services research.

    Research on Aging: Medicare Advantage Enrollment Associated with Significantly Reduced Odds of Dying in the Hospital

    • Using 2008 and 2010 waves of data from the Health and Retirement Study (N=1030 people who completed the 2008 interview but had died by the time of the 2010 exit interview), the authors examined whether continuous enrollment in Medicare Advantage was associated with a decrease in odds of dying in a hospital compared to continuous enrollment in Medicare fee-for-service.
      • The strength of this study is that it captures data not available in Medicare claims which may impact site of death, such as the presence of advance directives, self-reported health, “social capital” (presence of a spouse and number of people in household) and death expected by proxy.
      • Hospice benefits are “carved out,” of Medicare Advantage; the moment that an MA enrollee switches to hospice, his/her palliative care is covered by the Medicare FFS hospice benefit program. As such, MA plans have a strong incentive to enroll patients in hospice care rather than continue to pursue curative treatment in a hospital.
    • Major limitations:
      • Observational
      • Cannot determine a patient’s state/city (these variables are masked in HRS data); it may be that areas of high MA enrollment also have higher hospice supply and this contributes to some of the difference.
      • There is actually no MA variable in the HRS data; the authors used a self-reported variable about HMO enrollment as a proxy for MA enrollment status.
    • Findings:
      • Compared to those continuously enrolled in Medicare FFS, those continuously enrolled in MA were 43% less likely to die in a hospital (OR 0.57; P≤0.05).
      • The authors used the subset of patients (N=213) who died from cancer, a disease with a more predictable prognosis and higher rates of hospice enrollment in general, to perform the same analysis.
        • The effect was even larger; continuous MA enrollees were 79% less likely to die in the hospital than continuous FFS enrollees (OR 0.21; P≤0.05).
      • Implication: MA may be associated with reduced odds of dying in a hospital due to incentives built into the program (i.e. capitated payments and hospice “carve-out”). Because most patients do not wish to die in a hospital, this may be a virtuous, if unintended, consequence of the MA program.

    KHN: Supreme Court sends health law birth control case back to lower courts

    • On Monday, the Supreme Court sent a series of cases surrounding the issue of religious rights vs. no-cost contraception back down to federal appeals courts.
    • Over the past few years, the government has made numerous changes to the requirement that under the ACA most employer health plans must provide no-cost contraception for women in order to accommodate religiously affiliated employers.
    • However, dozens of religious nonprofit employers sued on the grounds that even alerting the government to their objections (and hence triggering a series of steps so that the government can provide coverage) is a violation of their religious freedom.
    • The Court’s opinion erased all of the lower appeals rulings (all but one of which sided with the government), which at first appeared to jeopardize coverage for contraceptives for tens of thousands of employees of the organizations filing suit.
    • The Court did clarify, however, by saying that the notice of objections from employers enough for the government to “facilitate…full contraceptive coverage going forward”.
    • People on both sides of the argument are considering this a victory:
      • A lawyer for the group representing the suing organizations said “The government can find ways to give out contraception without hassling nuns”.
      • The ACLU, on the other hand, said “the opinion states clearly the need for women to receive full and equal coverage”.
      • Justices Sonia Sotomayor and Ruth Bader Ginsburg stressed that the decision should not be read as approving coverage strategies that make it harder for women to the get the benefits.
    • It isn’t yet clear what the decision the lower courts might reach, but the justices seem to want both sides to outline potential compromises.

    CQ Roll Call & Becker’s Hospital Review: Federal Judge Rejects FTC Effort to Stop Hospital Merger

    • A federal judge denied the FTC’s request for a preliminary injunction to stop the merger of Penn State Hersey Medical Center and PinnacleHealth System, largely on the grounds that the commission misrepresented the affected market area.
      • Justice John E. Jones III, U.S. District Court for the Middle District of Pennsylvania (George W. Bush appointee) said that the FTC had drawn too narrow of a geographic market: “Given the realities of living in Central Pennsylvania, which is largely rural and requires driving distances for specific goods or services, it is our view that these [other] 19 hospitals  . . .  provide a realistic alternative.”
    • The judge also said that the merged entity would benefit patients, and that recent policy efforts have encouraged hospitals to find efficiencies and cut costs in this way. Some legal experts are calling this the “Obamacare made me do it,” defense, and fear that it may take hold nationwide as a strategy to boost mergers past federal review.
      • Justice Jones: “This decision further recognizes a growing need for all those involved to adapt to an evolving landscape of healthcare that includes, among other changes, the institution of the Affordable Care Act, fluctuations in Medicare and Medicaid reimbursement, and the adoption of risk-based contracting. Our determination reflects the healthcare world as it is, and not as the FTC wishes it to be.”
      • The FTC vehemently disagrees. FTC Chairwoman Edith Ramirez: “Despite parties’ frequent claims to the contrary, risk-based contracting does not preclude the exercise of market power.”
    • The FTC has already begun the process of appealing the decision in federal appeals court, asking for an emergency motion to stay the merger.

    Health Affairs: Variation in health outcomes: The role of spending on social services, public health, and health care 2000-09

    • A new study in Health Affairs looks at the association between variation in state-level health outcomes and how states allocate spending between healthcare and social services.
    • Used data from the Behavioral Risk Factor Surveillance System, the CDC, and the National Center for Health Statistics for all 50 states to calculate state-level health outcomes (including but not limited to BMI, prevalence of asthma, and state-level mortality rates for AMI, lung cancer, and type 2 diabetes) and spending on social services and public health relative to healthcare spending to estimate any association between the two variables.
    • Findings:
      • States with a higher ratio of social to health spending had significantly better health outcomes for:
        • Adult obesity
        • Asthma
        • Mortality rates for AMI, lung cancer, type II diabetes
        • Mentally unhealthy days
        • Days with activity limitations
      • Implications: spending more on social services and public health rather than just on healthcare “may be key to understanding variations in health outcomes across the states,” but as the authors note from these findings we “cannot infer causality”.

    WSJ: Insurers’ Losses Deepened on ACA Plans in 2015

    • McKinsey & Co released a report showing that the insurance industry’s cumulative margin on ACA exchange plans was between -9% and -11% in 2015; only a quarter of plans made a profit.
    • These losses are roughly double the losses in 2014 (-4.8%), which McKinsey attributes to rising medical loss ratios.
    • Despite the losses, McKinsey reported some optimism:
    • “The analysis suggests that the health law’s subsidies, which help lower-income people purchase health plans, should prevent a ‘death spiral,’ in which an insurance market gets caught in a cycle of increasing rates and shrinking customer pools. The consultants also say that some insurers are finding profits in certain types of plan designs, notably those with limited networks of health-care providers, and health maintenance organization-style plans that tightly manage the health care people can get.”
    • Erica Coe, co-leader of McKinsey center for U.S. Health System Reform: “It may require a very different business model.”

    WSJ/The AP: House passes $622 million bill to fight Zika

    • Despite a White House veto threat and a warning from CDC director Tom Frieden that it wouldn’t be enough to respond to the growing threat of Zika, House Republicans pushed through a $622 million bill on Wednesday to battle the mosquito-borne virus.
    • Three months ago, President Obama requested $1.9 billion to fight Zika.
    • The passage of this bill sets up challenging negotiations with the Senate, which is moving ahead this week with a $1.1 billion plan.
    • President Obama said that the money should be added to the budget deficit rather than be offset with cuts to other programs; the House bill, however, limits the use of the money to the current budget year (which ends Sept. 30) and also cuts funds to fight Ebola.
    • Tom Cole (R-OK) said “Everything that needs to be done has been done”.
    • The White House says that the plan is inadequate but on Wednesday, White House press secretary Josh Earnest said “I don’t have a veto threat to issue”.
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  • Healthcare Triage News: The Facts About SIDS and Swaddling

    My physician-gaming-group-friends are being swamped by concerned parents because of a new study in Pediatrics that has led to many news articles declaring that swaddling – wrapping an infant tightly in a cloth or blanket – may increase the risk of Sudden Infant Death Syndrome, or SIDS.

    But a careful read of the study should help everyone to take a deep breath and calm down. This is Healthcare Triage News.

    For those of you who want to read more:

    @aaronecarroll

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