Lately, Doctor Pundit has been reporting some tidbits from the arena of medical research. Here are a few more to make the wires for 9/1.

• Is it really possible? For now you’ll just have to ask the mice taking it. Metformin, the country’s most widely used antidiabetic agent, could lead to the prevention of lung, breast, and prostate malignancies. | LINK
• Speaking of cancers, are certain heritable forms of breast cancer prevented by a certain surgical technique? | LINK
• Again, on the topic of cancer: an anti-tumor drug may be altered to serve as the basis for a novel agent to prevent the formation of senile plaques seen in the central nervous system in virtually all Alzheimer patients. | LINK
• Finally, on the lighter side of things — the all-star line-up for the “Stand Up to Cancer” telethon is almost finalized. | LINK

The huge drive to immunize the masses against threat of H1N1 in the 2009/10 influenza season (which the WHO has officially declared concluded) has created more than a watershed moment in 21st century public health response to a potential biological catastrophe, it has also touched off a political debate that’s just getting started. And it all has to do with authoritarian mandate of the vaccine for healthcare workers.

Contrary to popular thought, many healthcare workers do not receive the vaccine; in fact, approximately 40 percent of said workers actively refused [PDF link] the vaccine last year — during infection’s peak. This notion does not sit well with a couple of policy organizations — one academic and one medical. Both groups say mandatory influenza vaccine should be a condition of employment. The groups stress increased availability of the vaccine, a steadier supply of healthy workers to administer care in times of a crisis, and an overall decrease in the incidence of influenza-related deaths in already compromised inpatients with other medical problems.

Already, the state of New York is hard at work in developing regulatory actions for its public healthcare workers. | LINK

Just how effective are vaccines at keeping mass pandemics of infectious disease abated? Well, it may not be so easy to estimate.

[T]he number of annual flu-related deaths in the United States has ranged from a low of about 3,300 to a high of about 49,000. This is a revision of the static estimate of 36,000 annual deaths that has been reported consistently for years by the U.S. Centers for Disease Control and Prevention.

The CDC has revised its projections on the preventive care of the seasonal influenza vaccine, moving from statistical dead targets to ranges of mortality among influenza outbreak figures. Its projections cover most of the past 30 years (up to 2007, and not inclusive of last year’s H1N1 pandemic). | PDF  LINK to latest issue of CDC’s Morbidity & Mortality Weekly

Besides making news on the antidiabetic treatment front recently with Avandia, the FDA has also been tackling the push by some advocacy groups to tighten or restrict the use of some opioid medications — most notably drugs like oxycodone. The FDA voting panel rejected concerns of its various advisory panels on the subject to enforce the restrictions  (it usually follows its advisory recommendations).

Had the agency gone ahead with the recommendation to restrict usage, providers giving the drug would have been subjected to special training based upon the new rules for prescribing. At this time, only registration with the DEA is needed for physicians to give most opioids. Perhaps due to political pressures from providers and systems involved in chronic pain treatment, the FDA did not want to go down that road at a time when reform will probably produce more bureaucratic weight on the agency than what it can normally endure. Here’s to a sound decision on that point. | LINK

The U.S. Preventive Services Task Force, an independent, non-partisan body made up of primary care physicians involved in developing preventive medical guidelines based upon evidence-based medicine, has always reveled in its staunch self-governance. That could change ever so slightly in the new age of health reform.

The academic research-oriented group will continue to make recommendations on best-preventive practices and supply ratings (“A”, “B”, etc.); but this time, under reform, insurers will be required to cover services that receive such a rating. The Obama administration hopes that this increase in access (which will require a small premium increase by insurers in the near term) will reap savings in the future — as costs for preventive testing, screening for certain chronic diseases, vaccinations, and well-child visits would be covered (without health plan co-pays and deductibles) if so rated by the USPSTF.

Besides having to consider methodology involved in formulating its ultimate recommendations, the group will also have to contend with the specter of political agenda setting if lobbying groups and disease advocacy organizations have their way under this bit of legislation — scheduled to go into effect in September. | LINK

Research into better treatments and possible cures of Alzheimer dementia is one of the bright spots in the potential for better healthcare delivery in the decade of the 2010s. There are many signs that bode well for the approach to this disorder at the dawn of the second decade of the 21st century.

New research into alternate pathways of disease development is starting to generate excitement among primary care physicians and geriatricians (such as myself) as potential arenas for new classes of drugs to combat Alzheimer’s. Better care delivery models in long term care of the elderly as part of new initiatives in the Affordable Care Act are already starting to impact chronic disease care management strategies.

Perhaps most important, there is new evidence to suggest that earlier detection of this cognitive disorder can enhance those developments, and more. At an annual meeting of top dementia researchers, guidelines were proposed to expand on the research from the ’00s to diagnose the disorder earlier — a strategy that benefits more than just those potentially afflicted with Alzheimer’s.

If the guidelines are adopted in the fall, as expected, some experts predict a two- to threefold increase in the number of people with Alzheimer’s disease. Many more people would be told they probably are on their way to getting it. The Alzheimer’s Association says 5.3 million Americans now have the disease.

Heavier use of newly discovered biomarkers for earlier detection of the pathology behind Alzheimer dementia will be a closely watched process by both physicians and health policy analysts alike. | LINK

Some headlines prior to the Independence Day holiday. Normal posting resumes here at Doctor Pundit on July 6. Have a happy and safe holiday weekend!

• Veterans Admin admits to the debacle surrounding dirty dental instruments placing hundreds of patients at risk of HIV transmission. [LINK]
• Minnesota nursing strike may be averted, but time will tell if threat to strike was more of a bluff. Hospitals and nurses pledged to work within the constraints of internal governance. [LINK]
• How’s healthcare reform going? Just fine, according to some. [LINK]
• How influential will states’ insurance commissions be when regulating insurers’ medical loss ratios in the age of reform?
  

  The medical-loss ratio measures how much of premiums insurers pay out for medical care versus administrative costs. The new law requires that insurers use at least 80% of the premiums from individuals and small businesses to pay for medical care and profit-taking, and 85% of premiums from larger employers. Health insurers are waiting for regulators to clarify how companies must account for the numbers—whether they can average the MLRs of their subsidiaries, for instance.

  [LINK]

• Study: Genes key to longevity. [LINK]

Needy HIV+ patients a victim of the economic recession? With the rise once again in jobless claims in this country and the possibility of a much-maligned scenario of a double-dip recession, government programs that formed the cornerstone of HIV and AIDS treatment for patients who could not afford traditional access to those treatments are now closing — creating a fallout in states in which waiting lists are the result.

What’s more surprising than this development is the lack of safety funding for depleted federal and state programs; the Obama administration has yet to guarantee any sort of budgetary proposal or stimulus mechanism for saving these programs. In the state of Georgia, waiting lists for accessibility to HIV treatments is up to almost 1300 persons.^[1] In Florida, almost three-hundred.

An increasingly sad state of affairs in this early drive toward reform. This segment of the indigent care population could succumb to the same restrictions on eligibility those who are mentally ill perennially seem to face from many government-run programs. Will it take a redux of the same levels of prevalence rates of HIV not seen in 20 years to jar the Obama administration to attention on this issue? | LINK

1. Pregnant women, children and adolescents, and patients with “extreme conditions” can be exempt from the waiting list. [↩]

A study commissioned by the Commonwealth Fund confirms for some the dire straits quality healthcare delivery finds itself in today in the United States on the cusp of a reform effort. While, superficially, results like this are designed to provoke an immediate response (like from those on par with the Michael Moores of the world) — I find that the greatest asset findings like this can generate is creation of tough questions when one is forced to take a look at key quality indicators that reform will impact over the next decade.

On quality, the U.S. stood out “particularly with symptoms of more fragmented, poorly coordinated care,” Schoen said. In 2008, for instance, 14% of American adults with a chronic condition reported receiving the wrong medicine or the wrong drug dose in the past two years.

When compared to, say, Sweden or any other European country — an interesting stat. But getting out of the apples-and-oranges mentality allows us to see nuggets like this in a more sobering light. When placed in the context of Obama’s reform plight, it signals a call for urgency in healthcare delivery. | LINK

What is known about the H1N1 epidemic that plagued the world in 2009 was its influence in global approach to this infection — for good or bad — and the costs to nations which chose to meet its threat head on. What wasn’t known at the time (but may be increasingly apparent if many European countries have their say) is that the trajectory of the influenza strain’s influence as a major media event may have been manufactured, by, of all entities, Pharma and its association with the World Health Organization. The concerns are outlined in an 18-page report criticizing costs deemed by many nations as unnecessary, as were “amplified” fears at the hands of the organization in galvanizing support for guidelines influenced by Pharma makers of the H1N1 vaccine.

Calling the WHO and its response to the H1N1 epidemic “exaggerated” and “lacking credibility”, many European nations are quite vexed that, among other things, guidelines issued by the WHO in response to what it termed as an epidemic came from consultants who received much in the way of fees from two leading Pharma manufacturers of the vaccine that would prevent the virus’s spread: Roche and GSK. The WHO has opened up its own international investigations into the matter — one of which involves the Institute Of Medicine on these shores.

The WHO asserts no potential for conflict of interest within its ranks, as this appears to be the central question in this entire matter. | LINK

Phil Longman is a healthcare thinker and speaker and has recently penned his thoughts in a WaPo book review concerning the overutilization of testing and the moral/ethical problems it creates in healthcare delivery. Longman seizes the current political fervor surrounding both sides of the reform debate to consider this issue as a major force behind the need for healthcare reform.

In the second edition of his Best Care Anywhere, Longman posits that an answer to the questions surrounding the reform of care delivery in this country comes from a rather unexpected source — one which many associate with stories of rather problematic healthcare delivery — the nation’s VA healthcare system.

Snip:

In study after study published in peer‐reviewed journals, the VA beats other health care providers on virtually every measure of quality. These include patient safety, adherence to the protocols of evidence medicine, integration of care, cost‐effectiveness, and patient satisfaction. The VA is also on the leading edge of medical research, due to its close affiliation with the nation’s leading medical schools, where many VA doctors have faculty positions. TheVA has its problems, but compared to those found elsewhere in the U.S. health care system, it offers “Best Care Anywhere.”

Longman posits that a public option (which essentially failed at inclusion in the reform bill) in the mold of the federal healthcare system is a model that goes a long way to approximating the centerpiece of President Obama’s historic 2009 push for reform.

Read the rest of this entry »

It is well known that at this point in the debate on healthcare reform, one major benefit for the healthcare consumer is the retaining of adult children under their parents’ plan until the age of twenty-five. Not only does coverage in this demographic become extended over previous plans, it also creates a comparative level of coverage in policyholders whose benefits lapsed prior to passage of the healthcare reform law — closing potentially troublesome gaps in coverage. Although it is somewhat unclear how much this provision will cost the taxpayer upon initiation later this year, it is here to stay. Apparently, this is music to the ears of young patients who either let policies lapse because of prohibitive costs or considered themselves not especially desirous of coverage due to their generally good health and young age (the so-called ‘invincible’ demo).

The potential for subsidized coverage has recently forced many in this age group to reconsider forgoing it — mainly because that coverage is increasingly within reach.

Many young adults will be covered through other provisions of the health act. About 7.1 million, more than half the total, will be eligible for Medicaid beginning in 2014 because their income is less than 133 percent of the federal poverty level, or about $14,404 for a single person and $29,327 for a family of four.

Provided they take the leap and participate in insurance exchanges, the healthy young stand to qualify for much in the way of taxpayer subsidized care — offsetting traditionally higher premiums without such legislation. After all, it’s either this, or pay a penalty. As reform begins to unfold over the decade of the 2010s, the social engineering involved in creating collective thought with regard to healthcare coverage as being the norm — and not the previously regarded far-flung option in this age demo — is a goal of Obama’s administration as it seeks to transform preventive healthcare delivery. | LINK

How’s this for the ultimate Medicare entitlement irony? Medicare Part D offers, among many other benefits, the option for qualified beneficiaries to enroll in medication therapy management (MTM) plans with their pharmacy. The goal is to create a better informed patient-as-consumer among  myriad Medicare D  beneficiaries who suffer from many chronic illnesses requiring substantial polypharmacy — and hence, costs, to maintain their current state of health, improve it, and hopefully prevent further comorbid decline. To qualify for such a benefit within Part D, the beneficiary must be enrolled in the Medicare Part D drug program, have at least three chronic health conditions, take eight or more medications covered by Part D and spend at least $3,000 yearly on the medications.

Sounds fair enough and tailor-made for many seniors in the program. But there’s one problem: expense. Increasing numbers of racial minorities — predominant among them, Latinos and African-Americans — cannot afford many of those Part D-covered medications. They are less likely to gain medical access for a host of reasons, and cultural encumbrances make that latter problem more profound. Researchers studying this issue cite the potential problems that may occur with widening the racial healthcare disparity in terms of access — whether it be for affordable pharmacy or acute medical care. If it is incumbent upon the Obama administration to enrich Medicare on many levels, the systematic exclusion of many patients not able to take part in any part of the entitlement may set out to increase future healthcare costs if access to these government programs remains prohibitive | LINK