Health and Disability

The metabolite of a drug that is helping patients battle multiple sclerosis appears to significantly slow the onset of Parkinson’s disease, researchers say.

The oral drug, dimethylfumarate, or DMF, and its metabolite, monomethylfumarate, or MMF, both increase activity of Nrf2, a protein that helps protect the body from oxidative stress and inflammation, hallmarks of both diseases, said Dr. Bobby Thomas, neuroscientist in the Department of Pharmacology and Toxicology at the Medical College of Georgia at Augusta University.

But the new study provides the first evidence that the metabolite, which is essentially the active portion of the parent drug, more directly targets Nrf2, potentially reducing known side effects of the parent drug that include flushing, diarrhea, nausea, vomiting, abdominal pain and the brain infection encephalopathy, said Thomas, corresponding author of the study in The Journal of Neuroscience.

Particularly, the gastrointestinal side effects can exacerbate some problems patients with Parkinson’s already experience, said Dr. John Morgan, neurologist, neuroscientist and Parkinson’s disease specialist in the MCG Department of Neurology. In addition to destroying neurons in the brain that produce dopamine, a neurotransmitter that enables movement and learning, Parkinson’s causes nerve cell death in the gastrointestinal tract and related problems such as severe constipation.

The Affordable Care Act’s coverage expansions have benefited hospitals financially, helping to produce an overall decline nationwide in uncompensated care from $34.9 billion to $28.9 billion in 2014, according to anew analysis by the Kaiser Family Foundation. Nearly all of the decline occurred in Medicaid expansion states, where uncompensated care costs were $10.8 billion in 2014 – down $5.7 billion, or 35 percent, from 2013, the year before ACA coverage expansions took full effect.

“Acopia”/”Acopic”. [sic] Whenever I see this term in patients’ notes I take the doctor aside for some gentle “re-education”. The thing I am proudest of writing is my 2008 essay in the JRSM Acopia and Social admission are not diagnoses.  As Bytheway and Johnson stated, “ageism can range from well-meaning patronage to unambiguous vilification”. Giving some colleagues the benefit of the doubt, at best the “A” word means, “I have no training in dealing with frailty and no understanding that functional impairment usually comes with treatable diagnoses”, at worst, “older people are a just a bit crumbly, its their age, what did you expect?” or,“I can’t be bothered to try making a diagnosis”.

The cost of riding without a helmet:

Overall, older and clinically complex patients were nearly twice as likely to develop severe hypoglycemia as non-complex patients. Intensive treatment increased that risk by an additional 77 percent over two years, the researchers said.

"This means that 3 out of 100 older or clinically complex patients with [type 2] diabetes who never had hypoglycemia before, whose [blood sugar] is within recommended targets and who are not on insulin will experience a severe hypoglycemic episode at some point over two years," McCoy said in a Mayo news release.

"This does not even capture the more mild episodes of low blood sugar that patients can treat at home, without having to go to the doctor, emergency department or hospital," she added.

"These findings are concerning for many reasons," McCoy said. "Overtreatment results in greater patient burden, higher risk of medication side effects, and more severe hypoglycemia, which can lead to serious injury and even death. It adds more unnecessary costs for patients and the health care system."

McCoy stressed the need for providing individualized treatments for people with type 2 diabetes.

Exaggerated stats, but horrible nonetheless......

The IG report says “serious” problems with enrollment data are making it impossible to determine exactly how many veterans are actively seeking health care from the VA, and how many were. For example, “data limitations” prevent investigators from determining how many now-deceased veterans applied for health care benefits or when. 

But the findings would appear to confirm reports that first surfaced last year that many veterans died while awaiting care, as their applications got stuck in a system that the VA has struggled to overhaul. Some applications, the IG report says, go back nearly two decades.

The report addresses serious issues with the record-keeping itself. 

More than half the applications listed as pending as of last year do not have application dates, and investigators "could not reliably determine how many records were associated with actual applications for enrollment" in VA health care, the report said.

The report also says VA workers incorrectly marked thousands of unprocessed health-care applications as completed and may have deleted 10,000 or more electronic "transactions" over the past five years.

Linda Halliday, the VA's acting inspector general, said the agency's Health Eligibility Center "has not effectively managed its business processes to ensure the consistent creation and maintenance of essential data" and recommended a multi-year plan to improve accuracy and usefulness of agency records.

Halliday's report came in response to a whistleblower who said more than 200,000 veterans with pending applications for VA health care were likely deceased.

The inspector general's report substantiated that claim and others, but said there was no way to tell for sure when or why the person died. Similarly, deficiencies in the VA's information security -- including a lack of audit trails and system backups -- limited investigators' ability to review some issues fully and rule out data manipulation, Halliday said.

Over the last decade, insurers have increasingly used step therapy, or “fail-first,” policies as a strategy to contain pharmaceutical costs.

Step Therapy Can Delay Access To The Most Efficacious Therapies

This can increase the duration of illness and raise the total cost of health care in the long-run. Delays in receiving health care, whether caused by step therapy edits or other factors, have been shown to be significantly detrimental to patient health outcomes.

For example, breast cancer patients with a treatment delay of three months or more had a 12 percent lower five-year survival rate compared with breast cancer patients with only a zero to three month delay. Similarly, patients with rheumatoid arthritis who delayed disease-modifying treatment for approximately four months experienced significantly more radiologic joint damage after two years compared with patients who began treatment within two weeks of diagnosis.

Step Therapy Trades Prescription Spending For Time And Hospital Costs To Patients And Providers

One study reported that 28 percent of patients who had encountered a step therapy edit spent three or more hours trying to obtain second-line drugs from their physicians’ offices. Increased rates of discontinuation, along with delays in accessing treatment, can contribute to less efficient use of health care resources and increased costs over time. For example, the introduction of step therapy for schizophrenia medications initially saved Georgia’s Medicaid program $20 per member per month, but the state subsequently spent $32 per member per month on outpatient services because patients utilized ineffective medications.

Overall, the combination of prior authorization and step therapy is associated with higher inpatient spending, while formulary restrictions have been positively correlated with higher drug costs, more office visits, and higher likelihood of hospitalization among patients with certain diseases. Furthermore, drugs that require laboratory tests and monitoring can increase non-pharmacy costs that may have been avoidable with alternative therapies.

Complicated Step Therapy Rules Create Barriers To Health Care

The time and administrative burden associated with step therapy is an obstacle to access that can lead to unnecessary breaks in treatment. Indeed, depending on therapeutic class, 7 percent to 22 percent of patients did not submit any prescription claim to their insurance provider following a step edit, instead forgoing treatment.

This lack of follow-up may be due to insufficient levels of effective pharmacist involvement in the resolution of rejections, or due to the reality that more than 77 million U.S. adults have basic or below basic health literacy skills. This widespread low level of health literacy makes it challenging for patients to decipher complex policies and take appropriate action. Ultimately, the hassle patients face attempting to obtain coverage in restrictive health plans may result in lower medication utilization and adherence, with a related increase in total health care spending.

‘Fail-First’ Policies, As Their Name Suggests, Increase The Risk Of Dangerous Side Effects

For certain patients–like those who need immunologic and biologic agents—these concerns are particularly salient. Researchers found that 18 insurance plans— representing approximately 97 million insured lives—required 45 percent of beneficiaries to “step through” one or two drugs bearing an FDA “black box warning” of serious adverse events before progressing to a drug without such warning. As a result, patients may needlessly face severe health risks in disease areas that have benefited from recent advances in immunologic and biologic therapy, such as cancer and inflammatory diseases.

The researchers examined 164,256 records of obese people aged 65 or older who were admitted to nursing homes over a two-year period. They also examined the nursing homes' total number of deficiency citations and quality-of-care deficiencies to determine the quality of care that the homes provided.

The researchers reported that about 22 percent of older adults admitted to nursing homes were obese. Nearly 4 percent were considered morbidly obese. Nursing homes that admitted a higher number of obese residents were more likely to have a higher number of deficiencies.

The researchers discovered that nursing homes that admitted more morbidly obese residents were also more likely to have more severe deficiencies in care. The researchers said that their study raises concerns about creating equal opportunities for obese elders to gain access to nursing homes that provide the highest quality of care.