Health and Disability

A new injectable drug reduces flare-ups in patients with severeasthma that is not controlled by steroid inhalers alone, two new trials show.

The drug, benralizumab, is a biologic that works by killing white blood cells called eosinophils. These are present in large numbers in such patients, and they have been linked to severe asthma.

If approved by the U.S. Food and Drug Administration, benralizumab would join two similar drugs -- mepolizumab(Nucala) and reslizumab (Cinqair) -- in fighting hard-to-control asthma, the researchers said.

"We can offer patients who frequently require courses of oral corticosteroids and have a certain level of eosinophils [an allergy-related cell easily measured in the blood] a very effective treatment," said study author Dr. J. Mark FitzGerald. He is a professor of respiratory health at the University of British Columbia in Vancouver.

"With the right patient with the right characteristics, we can significantly modify the level of asthma severity," added FitzGerald, who had a hand in both trials.

During the first three months after stroke, the risk for depression was eight times higher than in a reference population of people without stroke, according to an article published online by JAMA Psychiatry.

More than 10 million people had a stroke in 2013 and more than 30 million people worldwide live with a stroke diagnosis.

Merete Osler, M.D., D.M.Sc., Ph.D., of Copenhagen University, Denmark, and coauthors used data linked from seven Danish nationwide registers to examine how risk and risk factors for depression differ between patients with stroke and a reference population without stroke, as well as how depression influences death.

Among 135,417 patients with stroke, 34,346 (25.4 percent) had a diagnosis of depression within two years after stroke and more than half of the cases of depression (n=17,690) appeared in the first three months after stroke.

In a reference population of 145,499 people without stroke, 11,330 (7.8 percent) had a depression diagnosis within two years after entering the study and less than a quarter of the cases (n=2,449) appeared within the first three months, according to the results.

The risk of depression in patients during the first three months after stroke was eight times higher than in the reference population without stroke, the authors report.

Major risk factors for depression for patients after stroke and in the reference population were older age, female sex, living alone, basic educational attainment, diabetes, a high level of somatic comorbidity, history of depression and stroke severity (in patients with stroke), according to the results.

In both groups - patients with stroke and the reference population without stroke - depressed individuals, especially those with new onset, had increased risk of death from all causes.

In the case of this latest study, the team found that food intake during infection may influence the immune system's ability to fight pathogens, depending on whether the infection is bacterial or viral and what type of foods are consumed.

"We were surprised at how profound the effects of feeding were, both positive and negative," says Medzhitov. "Our findings show that it has a strong protective effect with certain infections, but not with others."

Through the Part B Drug Payment Model, CMMI recently proposed to alter the way that doctors are paid for medications that they supply and administer to Medicare beneficiaries. The goal of the proposal is to address payment incentives that may lead some providers to prescribe higher cost medications rather than lower cost, equally effective alternatives. This proposal is part of a broader movement away from simple fee-for-service structures, which pay for care based on the volume of services provided, and towards a health care system that rewards efficient, high quality care.

The coalition letter expresses support for these broad transformations and highlights the importance of ensuring that beneficiaries needs are met throughout the transition to value-based payment models. E

The result of seven months of collaboration and discussion among the members of the Advisory Group for Consumer Priorities, which I co-chaired, recently culminated in a new multi-stakeholder, consensus-based framework,“Addressing Consumer Priorities in Value-Based Care: Guiding Principles and Key Questions.”  As one of the members tasked with representing consumers and consumer advocates, I am pleased that the recommendations made by the Advisory Group were fully endorsed by the diverse membership of the entire Task Force and are present in the final white paper.

The resulting document should raise eyebrows: this is a big deal. The Task Force is comprised 42 member organizations and individuals, which includes representation from six of the nation’s top 15 health systems and four of the top 25 health insurers, as well as leading national organizations representing employers, patients and their families, and the policy community.

This white paper should open the door for consumers and consumer advocates to have an increasingly meaningful seat at the table for discussions about value-based, people-centered care. In assessing their own consumer engagement efforts, plans, providers and payers agreed to examine the following six principles:

1. Include patients/consumers as partners in decision-making at all levels of care. For example, are patients/consumers included as integral partners in all aspects of health care decision-making at every level, from system-level reform design to point-of-care decisions?
2. Deliver person-centered care. For example, are patients/consumers and those who support them at the center of the care team?
3. Design alternative payment models (APMs) that benefit consumers. For example, do APMs achieve cost-savings only through improvements in health and health care and ensure beneficiary rights and protections?
4. Drive continuous quality improvement. For example, do the health care transformation policies and practices drive continuous quality improvement?
5. Accelerate use of person-centered health information technology. For example, do alternative payment and care delivery models accelerate the effective use of person-centered health information technology?
6. Promote health equity for all. For example, does the health care delivery system and payment reform model promote health equity and seek to reduce disparities in access to care and in health outcomes for all?

A federally funded project that researchers say has potential to promote aging in place began by asking low-income seniors with disabilities how their lives at home could be better, according to a study released Wednesday.

At the end of the program, 75 percent of participants were able to perform more daily activities than they could before and symptoms of depression also improved, theresearchers said in the journal Health Affairs. Called Community Aging in Place, Advancing Better Living for Elders, or CAPABLE for short, the program was funded by the Center for Medicare & Medicaid Innovation.

The seniors who took part were each paired with a team for five months that included an occupational therapist, who made six visits; a registered nurse, who made four; and a handyman, who worked a full-day at the participant’s home installing assistive devices and doing repairs, according to the study.

The nurses and therapists helped participants identify three achievable goals for each member of the team and identify what barriers had to be overcome. For example, the therapist might survey a house for safety issues such as unsafe flooring, poorly lit entrances and railings in disrepair. The therapist then worked with the elderly person to identify assistive devices, repairs or modifications that could help achieve the participant’s goals. Next, the therapist created a work order for the handyman that prioritized those goals within a $1,300 budget for each dwelling.

Spending on assistive devices and home repairs ranged from $72 to $1,398 for each participant, the researchers said.

For months after the program ended, she said, participants called to tell her they were still setting goals and working on accomplishing them. She saw that as her low-income patients aged, their environments became the biggest barriers to good health. She had patients who had to crawl to the front door to let her in because their homes weren’t built to accommodate a wheelchair.

In 2003 and 2004, I traveled to communities in Texas, Mississippi, Illinois, Idaho and Massachusetts to meet individuals and families scraping by without health insurance. They told me stories of jobs that did not provide health insurance, untreated health problems that led to lay-offs, declining employability, medical debt, evictions and loss of homes, and sometimes even death. The results of that project were published in 2005 as “Uninsured in America: Life and Death in the Land of Opportunity” by University of California Press.

In 2015, I returned to these communities to learn how the people I had originally interviewed were faring in the wake of the Affordable Care Act as well as the broad social and economic changes of the past decade. Altogether, I looked for 145 people and was able to re-interview 82. While some of the people were now insured and far healthier than they had been a decade earlier (see “Faces of the Newly Insured”), at least 10 people were dead and 36 people had disappeared without a trace from the homes and communities in which they’d been living when I first met them.

I have no doubt that if Shanice had turned 18 in the era of the Affordable Care Act, her experiences would have been quite different. She either would have been able to stay on her parents’ health insurance or she would have been eligible for Medicaid (Illinois has expanded Medicaid under the ACA). Not only would she have avoided medical debt and ensuing bankruptcy, but she may even have been able to access treatment that could have averted the expensive surgery to begin with.

The ACA would not, however, have saved her from the consequences of housing challenges.

At a community health center in Decatur, nurse administrators Karen Schneller and Tanya Andricks explain that it is impossible to provide follow-up care for patients who can’t be reached – whose phones are turned off and mail is returned “addressee unknown.” Even if they are able to access care in the next place they land, people like Shanice find different facilities and providers prefer different medication and treatment protocols. This results in a range of problems resulting from stopping and starting diagnostic and medication regimes with each move.

Dental and medical care have almost always been delivered separately and disjointedly. That division of care could now change. Provisions in the Affordable Care Act (ACA) offer new opportunities to bring medical and dental care delivery closer to one another in two ways.

First, the ACA includes pediatric oral health benefits among its list of essential health benefits, giving insurance plans the opportunity to embed pediatric dental benefits within the medical plan. Second, the ACA strives to improve quality of care while containing costs via health care delivery reform in patient-centered medical homes and accountable care organizations (ACOs).

The ACA’s construct of health care places the patient at the center of care delivery of all kinds, including behavioral, mental, dental, and vision care. Early ACOs provide useful lessons about this move toward patient-centered care, but financial and practical barriers often stymie a more coordinated effort to join dental and medical care.

Dental care in hospital emergency departments (EDs) provides an excellent opening to improve, integrate, and coordinate care via ACOs or other kinds of clinically integrated networks. The majority of ED visits for dental care involve only symptomatic management, with prescriptions for antibiotics and analgesics. While timely for the patient, such care bypasses definitive treatment, fails to address the source of infection, and increases costs associated with that tooth’s eventual treatment.

Most ED dental visits are financed by Medicaid or self-paying patients. In 2012 these visits accounted for nearly 2 percent of all ED visits, consumed $1.6 billion—roughly 3 percent of all ED expenditures—and averaged $749 per visit. It is estimated that 79 percent of ED dental visits could be avoided if preventive care were more routine, translating to as much as $4 million savings to a single state Medicaid program. Realizing such savings helps achieve the triple aim goals of the ACA.

Today, the Department of Veterans Affairs ranks hearing loss as the number one disability among vets. At least 60 percent of those returning from Iraq and Afghanistan—some 600,000 vets—suffer permanent hearing loss or tinnitus, a chronic ringing in the ears. It’s also the fastest-growing of all postwar disabilities, more than doubling over the past decade, and among the most costly in terms of lost productivity. Lose your hearing and you’re more likely to lose your job, suffer from high stress, or experience social anxiety, depression, and early-onset dementia. And though it can be treated, there is no cure.

Soldiers are suffering from hearing loss for a simple reason: War is loud, and getting louder. The F-35 fighter jet, which was declared operational in 2015, is among the most deafening flying machines ever created—four times louder than the F-16. It’s so loud that aircraft carriers need to be specially outfitted with extra sound-dampeners to protect the ears of sailors, even below deck. In Vermont, where the F-35 is scheduled to be deployed in 2019, an initial Air Force evaluation found that the jet’s decibel level during takeoff and landing would render 1,366 homes in the area “unsuitable for residential living.”

More firepower also means more noise. The crack of the military’s standard-issue pistol, the M9, is nearly as loud as the F-35. And the Mach 7 boom of the Navy’s new rail guns and other “kinetic weapons systems” are eight times louder than traditional artillery systems.

Conclusions: elderly patients are therefore rarely asked for their opinion prior to intensive care admission. Our results indicate that respect of the decision-making autonomy of elderly subjects in the admission process to an intensive care unit should be reinforced.