John Colbert

September 25, 2018

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

John Colbert

September 25, 2018

Use Of Yoga, Meditation, And Chiropractors Among U.S. Adults: 2012-2017
A report from the National Center for Health Statistics (NCHS) in November 2018 examines changes over time in the percentage of adults who used yoga, meditation, and chiropractors in the past 12 months, as well as variation by sex, age, race, and Hispanic origin. Among adults aged 18 and over, increases were seen from 2012 to 2017 in the use of yoga, meditation, and chiropractors. Yoga was the most commonly used complementary health approach among U.S. adults in 2012 (9.5%) and 2017 (14.3%). In 2017, women were more likely to use yoga, meditation, and chiropractors in the past 12 months compared with men. Non-Hispanic white adults were more likely to use yoga, meditation, and chiropractors compared with Hispanic and non-Hispanic black adults. In 2012, seeing a chiropractor was as popular as yoga, followed by meditation, but in 2017, meditation became the 2nd most-used approach ahead of chiropractic.

Increasing Medication Adherence Could Improve Care And Save Health Care Costs
Non-adherence to medication represents a major problem that limits the effectiveness of treatment and adds to the burden of illness and cost of health care. About half of all patients do not take their medication as prescribed, according to a September 2018 report from the National Council for Behavioral Health’s Medical Director Institute. Estimates indicate that medication non-adherence costs the health care delivery system $100 billion to $300 billion annually due to more frequent use of high-cost services, additional prescriptions to offset non-adherence, and interventions to address relapses. The report discusses medication non-adherence in chronic conditions, mental health, and substance use disorders, and offers some possible solutions. If many of these solutions were to be adopted by 2025, a projection is made that the health system would save $2 billion a year from reduced hospital costs alone. Apart from improving communication between patients and providers, some more high-tech solutions include apps and robots.

HEALTH TECHNOLOGY CORNER

Robotic Arm May Help To Rehabilitate Chronic Stroke Victims’ Communication Deficits
Apropos of the article about silos in Health Silo Disruption and Eradication of this issue of TRENDS, treatment in one domain (motor function) may benefit performance in another untreated domain (communication) in individuals with acquired aphasia, the loss of ability to understand or express speech. Research published in Frontiers in Neurology on October 22, 2018 shows that robotic arm rehabilitation in chronic stroke patients with aphasia may promote speech and language function recovery. The rehabilitation in this study targeted the right arm since study participants each had suffered a left hemisphere stroke leading to a deficit in motor function on their right side. The research team observed small, but consistent improvement on measures assessing speech articulation and overall language processing in aphasia. It is believed some treatment approaches may encourage plasticity and reorganization that can span multiple domains. Although this initial finding should be interpreted cautiously, it remains exciting to consider the possibility that stroke rehabilitation in one domain would improve performance in another domain.

Obesity Provides Unexpected Enhancement Of Anticancer Medications
Obesity is associated with increased mortality and reduced longevity, but counter-intuitive findings occasionally suggest evidence of an obesity paradox. An article published in the journal Nature Medicine on November 16, 2018 indicates that overweight patients sometimes respond better than other patients to powerful drugs that harness the immune system to fight tumors. Called checkpoint inhibitors, the drugs block the activation of PD-1, a protein on the surface of immune sentinels called T cells. The body naturally triggers PD-1 to dampen immune responses, but tumors also can stimulate PD-1 to protect themselves. Lifting this molecular “brake” allows the T cells to attack the cancer cells. PD-1 inhibitors have caused untreatable tumors to vanish for years in patients with melanoma, lung cancer, and some other cancer types. Although there is heightened immune dysfunction and tumor progression, there also is greater anti-tumor efficacy and survival after checkpoint blockade that targets some pathways activated in obesity.

return to trends september 2018

HEALTH REFORM DEVELOPMENTS

John Colbert

September 25, 2018

Trends Archives

Efforts have been made over the past several decades to achieve meaningful health reform. The number “three” figures prominently in such attempts. One version focuses on: increasing access to health care, improving quality, and reducing costs. Pursuing any one of these aims often has the unwanted outcome of making it difficult to realize the other two. Another version based on the number three is known as the Triple Aim, which consists of improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care.

Worth noting is that it occasionally proves challenging at times to obtain a clear picture of what is transpiring when reports from different sources present conflicting information. As an illustration, the U.S. Census Bureau earlier this month indicated that the uninsured rate from 2016-2017 remained statistically unchanged, while private polling data suggest an increased uninsured rate of 1-2 percent. Meanwhile, the most recent attempt of a comprehensive nature to make improvements in the realm of health care is represented by the Patient Protection and Affordable Care Act (usually referred to as the ACA or Obamacare) that became law in 2010. Since then, several policy initiatives of a more incremental nature have been proposed. Recent examples are described on this page of each issue of TRENDS, along with updates as they occur. Some developments that continue to materialize are discussed below.

Medicaid Work Requirements
Many individuals who previously did not have health insurance were able to obtain coverage when the federal-state Medicaid program was expanded to include them. Some states currently are planning to add work requirements for able-bodied adults who receive coverage. Michigan recently submitted a waiver application that would require enrollees in the age bracket 19-62 either to work, attend job-training, or volunteer at least 80 hours per month to retain coverage. If approved, the proposal will become effective in 2020 and may affect as many as 540,000 beneficiaries. Because of 12 possible exemptions that would apply to particular groups, such as family caretakers and pregnant women, the actual number may prove to be lower. If the waiver application is approved, Michigan is in line to become the fifth state to be able to impose work requirements. Utah and Wisconsin are among some other states that also are seeking waiver approvals.

Exploring The Fate Of Short-Term, Limited-Duration Health Insurance Plans
The Trump Administration was successful in having a final rule issued on August 1, 2018 to help individuals struggling to afford health coverage find new, more affordable options. The rule allows for the sale and renewal of short-term, limited-duration plans that cover longer periods than the previous maximum period of less than three months. Such coverage now can cover an initial period of less than 12 months, and taking into account any extensions, a maximum duration of no longer than 36 months in total. A case filed in mid-September 2018 in Washington, DC is aimed at stopping the expansion of short-term health plans because opponents view them as not requiring provision of the same essential health benefits as ACA-compliant plans and possibly jeopardizing the ability of individuals with pre-existing conditions to find coverage. In contrast, proponents believe that short-term, limited-duration insurance will benefit: individuals who are between jobs, students taking time off from school, and middle-class families without access to subsidized ACA plans. Compared to the federal final rule, Oklahoma released guidance on September 7, 2018 to limit the sale of short-term, limited-duration plans to six months.

Medicare Savings Achieved By Accountable Care Organizations (ACOs)
An estimate from the Center for Medicare & Medicaid Services (CMS) indicates that Medicare ACOs underperformed during the first few years of implementation, generating a gross savings of $954 million. This estimate is contested by a report commissioned by the National Association of Accountable Care Organizations (NAACOS), which claims that the Medicare Shared Savings Program (MSSP) produced more than $1.84 billion in gross savings between 2013 and 2015. According to NAACOS, as of January 2018, there are 561 Medicare ACOs serving more than 12.3 million beneficiaries with hundreds more commercial and Medicaid ACOs serving millions of additional patients.

Return to September 2018 trends

FISCAL YEAR 2019 FUNDING PICTURE BRIGHTENS

John Colbert

September 25, 2018

Trends Archives

A principal function of Congress is to provide funds to support a broad array of government activities in time for the start of a new fiscal year each October 1. Except for 2018, that particular task has proven to be exceptionally challenging. During the past 15 years, two kinds of obstacles have stood in the path of appropriating money in a timely manner. The first is differences between Democrats and Republicans, while the second is a basic disagreement that proves difficult to reconcile between the Senate and the House of Representatives.

Some candidates in elections of yesteryear were fond of using a campaign theme song called “Sunny Days Are Here Again.” Unlike those earlier funding cycles, 2018 truly represents a most welcome departure from more cloudy times to a present sunny day. Especially gratifying is that this turn of events affects one of the largest of the 12 categories of funding, the Departments of Labor, Health and Human Services, Education, and Related Agencies (Labor-HHS). The House Appropriations Committee on September 13, 2018 filed a two-bill Appropriations “minibus” funding bill, which was approved by a joint House and Senate Conference Committee. The Conference Report includes the Department of Defense and the Labor- HHS Appropriations bills for fiscal year 2019. This package also includes a short-term “Continuing Resolution (CR),” which will provide continued funding to keep the federal government operating until all yearly funding bills can be signed into law. The CR merely extends current levels of funding for federal agencies until December 7, 2018.

Some appropriation highlights that await being finalized by having bills signed into law are:

Includes vital funding for the National Institutes of Health – $39 billion, an increase of $2 billion.
Funds programs to protect against health threats such as pandemics and bio-threats, providing $7.9 billion for the Centers for Disease Control and Prevention (CDC) and $2 billion to prepare for and prevent public health and social services emergencies with programs such as biomedical research, acquisition of medical supplies and vaccines, and hospital preparedness grants.
Saves taxpayers $50 million in future appropriations by creating the first Infectious Diseases Rapid Response Reserve Fund, where funds only become available for use in the event of a future public health emergency.
Helps to combat the opioid epidemic by providing $6.7 billion, a historic level of funding, for programs that fight, treat, and stop substance abuse and support access to mental health services. Includes $5.7 billion for the Substance Abuse and Mental Health Services Administration, a $584 million increase. Funds activities authorized under the 21st Century Cures Act and other addiction and recovery programs.
As described on page five of this issue of TRENDS, furnishes support for students who are studying for careers in the health professions.

return to trends september 2018

PRESIDENT’S CORNER—ASAHP MEMBER FOCUS

John Colbert

September 25, 2018

Trends Archives

By Susan N. Hanrahan, ASAHP President

In my message in the November 2017 issue, I indicated that I will be asking some of you to send a photo and answer a series of “fun” questions to be shared with our membership so that we can continue our collegiality through our newsletter. The 6th of many profiles this year is presented as follows:

Name and Title: Charles J Gulas, Dean, Walker College of Health Professions, Professor of Physical Therapy

Place of Birth: Cleveland Ohio

University: Maryville University of Saint Louis

How long have you been in your position? Started at Maryville as an adjunct in 1999, Director of Clinical Education, and Director of Physical Therapy Program, 2000 and 2001, Dean in 2004.

What’s the value of a university education? Teaches students to be critical thinkers, reflective learners, be creative and ignite passions.

What is the value of ASAHP? Updated information, and Networking, Networking and Networking!!

Your philosophy on education in seven words: Facilitating Thinking to Expand Creativity and Passion.

If I could teach in another field, which one and why? Botany/landscaping because I love plants, or Cyber- security because I am fascinated by how our information is tracked.

Before I retire I want to: Teach abroad.

In college, I was known for: Undergraduate days organizing protests.

What music is playing in my car/office? No music in office... in car Sirius On Broadway or 80’s hits

The last book I read for fun was: “small great things” by Jodi Picoult

My favorite trip was: Greek Islands

If I could travel anywhere it would be: Africa safari

Four people I’d take to coffee or have a glass of wine with: Gertrude Stein, Abraham Lincoln, Claude Monet, Ignatius de Loyola

The best advice I ever received was: Always Be Present.

My hobby is: Gardening, Travel

My passion is: Experiencing life with fascinating people.

My pet peeve is: Having to wait for coffee to be brewed at Starbuck’s.

A perfect day is: When I am challenged to learn something new.

Cats or dogs? Either are nice to visit.

E-book or hardback? Depends on the day, but loving my Kindle more.

Beach or mountains? Beach

I wish I could: Have more time to be outdoors.

Only my friends know: How much I love chocolate, and do need time to be alone.

My favorite saying is: No good deed goes unpunished!

Return to TRENDS September 2018

FULFILLING A QUEST FOR PATIENT-CENTERED CARE

John Colbert

September 25, 2018

Trends Archives

Much emphasis is placed today on the importance of putting patients first as exemplified by the common use of related terms, such as patient-centered care and shared decision-making. Application of these terms represents worthy objectives. Repeated often enough, however, such language may be equivalent to the reification of a metaphor, with the implication that objectives are being fulfilled satisfactorily, while the reality of the actual situation may suggest otherwise.

Patient-centered care is a term highlighted when the Patient Protection and Affordable Care Act (PPACA), more popularly known as Obamacare, became law in March 2010. A new care model in the form of Patient-Centered Medical Homes (PCMH) and establishment of a Patient-Centered Outcomes Research Institute (PCORI) were created by that landmark piece of legislation. Regarding the former, a declared outcome by the American Academy of Pediatrics in 2002 for the 21st century was that “every child deserves a medical home.” Although for more than a decade efforts to improve the health care experiences and outcomes of high-risk pediatric populations have centered on the redesign of health care settings to deliver PCMH care, results show that more work is needed to reach fruition.

According to an article published in the October 2018 issue of the journal Medical Care, just over one-third of children with special health care needs reported experiencing PCMH concordant care and there was high variation across components. Disparities in access to PCMH care also were significant from the perspective of children’s demographic characteristics, with minority children faring worse in access to this care compared with their white counterparts.

Although they do not always agree on bracketed years, demographers find utility in generating population categories based on age, producing the following kinds of groups by birth year: Post-War Cohort (1928-1945), Baby Boomers (1946-1964), Generation X (1965-1979), Millennials (1980-1994), and Generation Z (1995- 2015). Health professionals also may benefit to some degree as a result of this taxonomy by seeking and acquiring greater knowledge about and increased sensitivity toward members of these groups from the standpoint of being able to provide more appropriate, targeted kinds of care for them.

Regardless of age bracket, shared characteristics cut across each classification, such as religiosity, adherence to prescribed treatment, and patient resilience. Also, within each group, members can be differentiated on the basis of their individual outlook, how they experience pain, reliance on family support, and desire to return to a pre-health problem stage involving employment or leisure activities.

A particularly important attribute is affective behavior consisting of verbal and non-verbal displays of emotion, mood, and other feeling states that contribute to impression formation when patients and their health care givers interact with one another. Differences stemming from age, gender, and race/ethnicity may play a decisive role in determining just how effective that interaction will prove to be.

Return to September 2018 trends

SOCIAL SECURITY AND PAYING FOR HEALTH CARE

John Colbert

August 27, 2018

Trends Archives

As guaranteed pension plans continue to disappear in the lives of most workers, many retirees will rely heavily on Social Security monthly payments. Numerically, the ranks of the so-called “Baby Boomer” generation reaching the age of 65 increase by an average 10,000 individuals every day, a growth spurt that will continue over a 19-year period that began on January 1, 2011. The Social Security program assumes great importance in the lives of patients who rely on Medicare to address their health care wants and needs.

Participation in Medicare can entail high out-of-pocket costs for some beneficiaries that relate to the nature of their health problems. Approximately one in five Medicare beneficiaries has serious physical or cognitive limitations that require personal care services and supports. A March 2017 report from the National Center for Health Statistics (NCHS) examines health care access and utilization among adults with multiple chronic conditions (MCC). As the number of these conditions increases, the health care costs for those so diagnosed also will grow. The program is expensive and money is spent unevenly: 10% of enrollees represent 63% of expenditures. The 5% who die each year account for 30% of costs, often involving intensive care that prolongs life with no hope of recovery.

The adequacy of retirement income – from Social Security benefits and other sources – can be reduced quite substantially by personal health care expenditures. As reported in a study published in October 2017 by the Center for Retirement Research at Boston College, data for the period 2002-2014 were used to calculate post-out-of-pocket benefit ratios, defined as the share of either Social Security benefits or total income available for non-medical spending. The results show that average out-of-pocket spending (excluding long-term care) was $4,274 per year in 2014, with approximately two-thirds ($2,965) spent on premiums.

In 2014, the average retiree had only 65.7 percent of Social Security benefits remaining after this spending and only 82.2 percent of total income. Nearly one-fifth (18 percent) of retirees had less than 50 percent of their 2014 Social Security income remaining after out-of-pocket spending, with six percent of retirees falling below 50 percent of total income. A conclusion drawn from this analysis is that with less than two -thirds of Social Security benefits available for non-medical consumption, and limited income outside of Social Security for much of the aged population, many retirees likely feel that making ends meet is difficult. Meanwhile, Medicare spending per beneficiary is expected to resume its decades-long rise by the end of the present decade, which will exert even more pressure on retirees’ budgets.

A shortfall in Social Security financing poses a significant challenge for policymakers. The Medicare program also is on a short financial leash since its trust fund rapidly is running dry. Alternatives for shoring up these two sets of accounts are not pleasant to contemplate because they entail some mixture of either lowering annual benefit levels or imposing higher tax rates. Finding remedies for certain problems can be deferred for only so long. Eventually, Congress will be compelled to tackle them. No option exists in shifting a portion of the burden to the states. Many of them have crises in the form of significantly underfunded pension and health benefit systems for current and future retired public service employees.

return to trends july - august 2018

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

John Colbert

August 27, 2018

Trends Archives

Matching Patients And Their Records
Despite widespread adoption of electronic health records and increasing exchange of health care data, the benefits of interoperability and health information technology have been hampered by the inability to match patients and their records reliably. The Pew Charitable Trusts contracted with the RAND Corporation to investigate "patient-empowered" approaches to record matching — solutions that have some additional, voluntary role for patients beyond simply furnishing demographics to their health care providers — and to select a promising solution for further development and pilot testing. A report recommends adopting a three-stage approach that aims to: improve the quality of identity information; establish new smartphone app functionality to facilitate bidirectional exchange of identity information and health care data between patients and providers; and create advanced functionality to improve value further. The report also suggests that because the solution contains multiple components involving diverse stakeholders, a governance mechanism likely will be needed to provide leadership, track pilot tests, and evaluation, along with convening key parties to build consensus where consensus is needed. The report can be obtained at https://www.rand.org/pubs/research_reports/RR2275.html.

Reasonable Patient Care Under Uncertainty
An article published on August 2, 2018 in the journal Health Economics discusses how limited ability to predict illness and treatment response may affect the welfare achieved in patient care. The discussion covers both decentralized clinical decision-making and care that adheres to clinical practice guidelines. The author explains why predictive ability has been limited, calling attention to questionable methodological practices in the research that supports evidence‐based medicine. Research is summarized on identification whose objective is to yield credible prediction of patient outcomes. Recognizing that uncertainty will continue to afflict medical decision making, basic decision theory is applied to suggest reasonable decision criteria with well‐understood welfare properties. The article can be obtained at https://onlinelibrary.wiley.com/doi/epdf/10.1002/hec.3803.

Patient-Centered Medical Homes And Accountable Care Organizations
Patient-centered medical homes (PCMHs) and accountable care organizations (ACOs) often were considered to be competing models for reforming health care delivery. It increasingly has become apparent, however, that one helps the other, according to the main finding from the new Patient- Centered Primary Care Collaborative (PCPCC) 2018 evidence report, “Advanced Primary Care: A Key Contributor to Successful ACOs,” the first study of its kind to look at how the role of advanced primary care, such as the PCMH, may contribute to the success or failure of ACOs. While these two leading models are transforming health care delivery and payment, little research has been done on how these models interact to promote lower costs and better quality for populations. Using qualitative and quantitative methods, researchers at the Robert Graham Center and IBM Watson Health found that: The attributes of successful ACO’s are necessary to transform the practice of primary care, successful ACO’s are more likely to be built on the basis of high- quality primary care, Medicare ACOs with a higher proportion of PCMH primary care physicians were more likely to generate savings, and Medicare ACOs with a higher proportion of PCMH primary care physicians demonstrated higher quality scores, including on a significant number of process and outcome measures. The report was published with support from the Milbank Memorial Fund for the fifth time. The document can be obtained at https://www.milbank.org/wp-content/uploads/2018/08/advanced_primary_care_report_080118.pdf.

return to trends july - august 2018

PRESIDENT’S CORNER—ASAHP MEMBER FOCUS

John Colbert

August 27, 2018

Trends Archives

By Susan N. Hanrahan, ASAHP President

In my message in the November 2017 issue, I indicated that I will be asking some of you to send a photo and answer a series of “fun” questions to be shared with our membership so that we can continue our collegiality through our newsletter. The 6th of many profiles this year is presented as follows:

Name and Title: Barbara Jacobsmeyer, EVP – President, Inpatient Hospitals at Encompass Health

Place of Birth: St. Louis, MO

Industry: Encompass Health, formerly called HealthSouth

How long have you been in your position? 11 years with the company and 1 1⁄2 years in current role

What’s the value of a university education? Well-rounded educational experience

What is the value of ASAHP? Focus on allied health professionals and common challenges and opportunities in the field to work on as a group. Great that it now includes the employer side so we can work together on these opportunities.

Before I retire I want to: Leave a legacy of mentoring other successful women executives. My favorite trip was: Mediterranean cruise

The best advice I ever received was: “People don’t care how much you know until they know how much you care.”

My hobby is: Running and playing golf.

My passion is: Education on heart disease and stroke My pet peeve is: Smacking gum.

A perfect day is: When I wake up.

Cats or dogs? Dogs – 2

E-book or hardback? E-book

Beach or mountains? Beach

I wish I could: Sing.

Only my friends know I: Can’t sing.

My favorite saying is: Hope is not a strategy.

Return to TRENDS July - August 2018

AFFORDABLE CARE ACT DEVELOPMENTS

John Colbert

August 27, 2018

Trends Archives

International comparisons developed by entities such as the Organization for Economic Co-Operation and Development (OECD), which consists of 36 member nations, rank the United States as highest in health care spending, but doing considerably less well in achieving positive health outcomes for patients. Concerns about the cost of health care have resonated for decades on Capitol Hill, with the result that both legislative and regulatory initiatives either of an incremental or a broad sweeping nature (e.g., the Affordable Care Act) have been implemented in an effort to curtail health care spending. Nonetheless, the challenge continues to exist. A factor contributing to the cost dilemma stems from the regulatory environment as discussed below.

Cost And Consequences Of Complying With Hospital Regulatory Requirements
On July 31 of this year, the Senate Committee on Health, Education, Labor & Pensions (HELP) held a hearing to discuss reducing administrative spending in health care. The event was the third in a series of hearings focused on curbing health care costs. Witnesses included the president and CEO of a state hospital and nursing home association, the president and CEO of America’s Health Insurance Plans (AHIP), an economics professor from Harvard University, and an advisor to the American Action Forum. HELP Committee Chairman Lamar Alexander (R-TN) made reference to a 2017 report from the American Hospital Association (AHA), noting that hospitals and health care providers must comply with 629 different regulatory requirements from four federal agencies. Along with these agency require- ments, providers must follow other state and federal regulations. The AHA report indicates that compliance with non-clinical regulatory requirements collectively costs providers almost $39 billion a year. A typical community hospital, for example, must employ 23 full-time workers just to comply with Medicare regulations.

Individual Insurance Performance In 2018
An analysis from the Kaiser Family Foundation shows that despite significant challenges, the individual market remains stable and insurers generally are profitable. Insurer financial results from 2018 – after the Administration’s decision to cease cost-sharing subsidy payments, but before the repeal of the individual mandate penalty in the tax overhaul goes into effect – showed no sign of a market collapse. Premium and claims data support the notion that 2017 premium increases were necessary as a one-time market correction to adjust for a sicker-than-expected risk pool, and premium increases in 2018 were in large part compensating for policy uncertainty and the termination of cost-sharing subsidy payments. Without these policy changes, it is likely that insurers generally would have required only modest premium increases in 2018. Low loss ratios and higher margins indicate that some insurers over- corrected in 2018, raising premiums more than was necessary to cover claims and administrative costs and earn a reasonable profit. Even though repeal of the individual mandate penalty and expansion of loosely regulated insurance options will tend to drive premiums up in 2019, increases will be mitigated by this over-correction, and in some cases, premiums even will decline. Some insurers have exited the market in recent years, but in 2019, some insurers are reentering markets they previously had departed.

Final Rule Issued On Short-Term, Limited-Duration Insurance Coverage
The Departments of Health and Human Services, Labor, and the Treasury on August 1, 2018 issued a final rule to help individuals struggling to afford health coverage find new, more affordable options. The rule allows for the sale and renewal of short-term, limited-duration plans that cover longer periods than the previous maximum period of less than three months. Such coverage now can cover an initial period of less than 12 months, and taking into account any extensions, a maximum duration of no longer than 36 months in total. This action has an objective of helping increase choices for beneficiaries faced with escalating premiums and dwindling options in the individual insurance market. Short-term, limited-duration insurance, which is not obliged to comply with federal market requirements governing individual health insurance coverage, is aimed at benefiting consumers who are involved in a transition between different coverage options, such as an individual who is between jobs or a student taking time off from school, as well as for middle-class families without access to subsidized ACA plans.

return to trends july - august 2018

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

John Colbert

August 27, 2018

Trends Archives

Causes Of Death In The United States
Data from the National Center for Health Statistics are based on information from all death certificates filed in the 50 states and the District of Columbia in 2016. Causes of death classified by the International Classification of Diseases, Tenth Revision are ranked according to the number of deaths assigned to rankable causes. Statistics are based on the underlying cause of death. In 2016, the 10 leading causes of death were, in rank order: Diseases of heart; Malignant neoplasms; Accidents (unintentional injuries); Chronic lower respiratory diseases; Cerebrovascular diseases; Alzheimer’s disease; Diabetes mellitus; Influenza and pneumonia; Nephritis, nephrotic syndrome, and nephrosis; and Intentional self-harm (suicide). They accounted for 74% of all deaths occurring in the United States. It is of special interest to reflect on the extent to which these conditions stem from human behavior and lifestyle choices rather than from infections or any other external causative agents.

Application Of A Tool To Identify Undiagnosed Hypertension — United States, 2016
Approximately 11 million U.S. adults with a usual source of health care have undiagnosed hypertension, placing them at increased risk for cardiovascular events. Using data from the National Health and Nutrition Examination Survey (NHANES), CDC developed the Million Hearts Hypertension Prevalence Estimator Tool, which allows health care delivery organizations to predict their patient population’s hypertension prevalence based on demographic and comorbidity characteristics. Organizations can use this tool to compare predicted prevalence with their observed prevalence to identify potential underdiagnosed hypertension. This study applied the tool using medical billing data alone and in combination with clinical data collected among 8.92 million patients from 25 organizations participating in the American Medical Group Association (AMGA) national learning collaborative to calculate and compare predicted and observed adult hypertension prevalence.

HEALTH TECHNOLOGY CORNER

Tumbling Microbots For Future Health Treatments
Microbots are tiny automated machines programmed to perform specific tasks. They are so tiny—as small as a cell—that they can be injected into the body to do tasks, such as clearing out plaque from arteries, performing tissue biopsies, or delivering targeted treatment to tumors. Because of their size and precision, these microbots could provide less-invasive treatments than a typical surgery or deliver medication in a much more targeted way than a pill. According to an article in the July/August 2018 issue of the journal American Scientist, researchers have been working on developing these tiny robots for three decades, but recent advancements in engineering have led to a surge in research. Animal testing has shown positive results. Microbots have been propelled by hydrogen microbubbles in live mice to treat gastric bacterial infections. For application in humans, challenges involve enabling microbots to move through wet areas and traverse through air pockets in the stomach, intestines, and lungs. Early studies show potential for a tumbling motion to make it possible to navigate such difficult terrains.

Using Shark Skin Patterns To Halt The Spread Of Infections
Efforts to combat the spread of infections, especially in health care settings, mostly involve the use of antibacterial cleaning agents and antibiotic drugs. Another possible strategy is the use of coatings that are antibacterial (inactivating bacteria) or antifouling (preventing the build-up of bacteria) on surfaces such as doorknobs. As reported on May 23, 2018 in the journal ACS Applied Material Interfaces, such a coating was developed with a structure inspired by shark skin. Bacterial attachment is reduced by 70% on the micropatterned, photocatalytic coating, compared with smooth films of the same composition. Most of the bacteria that do settle on the coating are inactivated when the coating is exposed to ultraviolet light. Because the coatings are imprinted onto a flexible substrate, it should be possible to use them in practical applications.

return to trends july - august 2018

21ST CENTURY CURES ACT, CANCER MOONSHOT, AND PRECISION MEDICINE

John Colbert

August 27, 2018

Trends Archives

Francis S. Collins, Director of the National Institutes of Health, presented testimony on July 25, 2018 at a hearing of the House Energy and Commerce Committee, Health Subcommittee on implementation of the 21st Century Cures Act. Among specific areas of scientific opportunity supported by the Act, he high- lighted two components of its Innovation Fund: the Cancer Moonshot, and the bold new Precision Medicine Initiative, called All of Us. The Cancer Moonshot initiative aggressively is pursuing an ambitious goal to accelerate advances in cancer prevention, diagnosis, treatment, and care. Such advances include immunotherapy, in which a person's own immune system is taught to recognize and attack cancer cells. After years of research supported by NIH, immunotherapy is leading to dramatic cures of some cancers, such as leukemia, lymphoma, and melanoma. Moreover, each year as many as 135,000 American women who have undergone surgery for the most common form of early stage breast cancer face a difficult decision, whether or not also to undergo chemotherapy to improve their odds. TAILORx, a large NIH-funded clinical trial, shows that about 70% of such women actually do not benefit from chemotherapy and a genomic test of tumor tissue can identify them quite reliably, producing a significant cost savings perhaps up to $1 billion a year.

The centerpiece of the Precision Medicine Initiative, the All of Us Research Program, will enroll one million or more individuals. On May 6 of this year when enrollment was launched in seven sites across the nation, 10,000 participants were reached. As of the Congressional hearing on July 25, more than 86,000 volunteers had signed up to contribute their health data in many ways over several years. Some are enrolled through health provider organizations, of which 10 are part of the NIH enterprise, including community health centers and the Department of Veterans Affairs. Other participants enroll as direct volunteers, who sign up over the Internet. Almost half are from historically underrepresented racial and ethnic groups, which will enhance research into health disparities. With each new person enrolled, every biological sample preserved, every electronic health record collected, every survey filled out, these data will hold increased promise for advancing human health.

return to trends july - august 2018

GENDER BIAS IN HOW PROFESSIONALS ARE SPOKEN ABOUT

John Colbert

August 27, 2018

Trends Archives

A manuscript appearing in the July 10, 2018 issue of the journal Proceedings of the National Academy of Sciences of the USA (PNAS) reports evidence for a gender bias in how individuals speak about profession- als. When discussing professionals or their work, it is common to refer to them by surname alone (e.g., “Darwin developed the theory of evolution”). Evidence indicates that individuals are more likely to refer to male than female professionals in this way. This gender bias emerges in archival data across domains. For example, students reviewing professors online and pundits discussing politicians on the radio are more likely to use a surname when speaking about a man (vs. a woman).

Gender inequality persists in many professions, particularly in high-status fields, such as science, technol- ogy, engineering, and mathematics (STEM). Potentially contributing to this unequal state is gender bias in implicit and explicit forms. This particular PNAS article offers evidence of a form of gender bias that manifests in the way that individuals refer to professionals when speaking about them and identifies the consequences of this bias. Men and women were, on average across studies, more than twice as likely to describe a male (vs. female) professional by surname in domains, such as science, literature, and politics. This simple difference in reference affects judgments of eminence, with participants judging those professionals described by surname as more eminent and 14% more deserving of honors, such as a National Science Foundation Career Award. This gender bias may contribute to the gender gap in perceived eminence as well as in actual recognition and partially may explain the persistent state of women’s underrepresentation in high-status fields, including STEM.

return to trends july - august 2018

TECHNOLOGY’S IMPACT ON THE HEALTH WORKFORCE

John Colbert

August 27, 2018

Trends Archives

Developments in the health technology arena continue to unfold at a robust pace. An aspect that may not attract as much attention as it deserves is how the health workforce will be affected. An example stems from 2007 when direct-to-consumer (DTC) genotyping for genomic risk assessment of common, genetically complex conditions began to become available. According to an article published in the May 2018 issue of the journal Health Affairs, among the marketplace options that are accessible, the firm 23andMe makes it possible to buy a kit and use the plastic tube contained in it to deposit two ml. of saliva and mail it to the company where a search will be conducted of the DNA for specific genetic variants known as single nucleotide polymorphisms (SNPs) associated with particular health conditions.

The purchaser later will receive a report containing some findings that may engender considerable stress because the test reveals the presence of the APOE4 variant, which is associated with the onset of Alzheimer’s disease. Association is not causation, yet a result of that kind can be highly worrisome for the individual who produced the saliva. Once a sense of panic is triggered, an expected response would be to seek professional advice regarding what to do next.

Primary care physicians represent a logical source of assistance, but current shortages of them exist and future projections indicate that the situation offers no signs of improvement. Even when they are available, it is likely that some of them may feel unprepared to work with patients at high risk for genetic conditions and also lack confidence in interpreting test results. Another professional group that may be in a favorable position to offer sound advice consists of genetic counselors.

As of May 2017 there were only 4,242 certified genetic counselors in North America. Becoming one typically involves completing a master’s program, obtaining clinical experience, and passing an exam from the American Board of Genetic Counseling. According to a 2018 report by a genetic counselors working group, that number is not projected to expand sufficiently even to meet traditional needs, such as genetic screening for a person who has a family history of cancer or who wants to become pregnant. ASAHP member institutions may be in a position to create new programs to add to the current supply. If so, they would need to determine: how much it will cost to do so, if there are enough faculty, and if enough students eventually will apply for admission.

CRISPR (clustered, regulatory, interspaced, short, palindromic repeats) is a gene editing tool that is being investigated for use in genetic modification of living organisms. If it reaches a stage where parents would be able to use it to engineer their offspring to be more intelligent, athletic, or imbued with other desirable attributes, genetic experts will be needed to provide sound advice. A challenge involving heritable genome interventions is to ensure that only the precise genome locations are the intended targets. Inappropriate, permanent gene modifying efforts may produce harmful results not only for the immediate offspring of a pair of parents, but also can influence successive generations.

Return to TRENDS July - August 2018

PRESIDENT'S CORNER — ASAHP MEMBER FOCUS

John Colbert

August 17, 2018

Trends Archives

By Susan N. Hanrahan, ASAHP President

In my message in the November 2017 issue, I indicated that I will be asking some of you to send a photo and answer a series of “fun” questions to be shared with our membership so that we can continue our collegiality through our newsletter. The fifth of many profiles is presented as follows:

Name and Title: Kim L. Halula, PhD, Associate Dean, College of Health Sciences

Place of Birth: Johnson Air Force Base, Japan

University: Marquette University

How long have you been in your position? At Marquette University for 37 years and Associate Dean of the College of Health Sciences for 18 years.

What’s the value of a university education? I like Albert Einstein’s idea that “the value of a college education is not the learning of many facts but the training of the mind to think.”

What is the value of ASAHP? ASAHP provides the opportunity to network with, learn from and participate on a national level with others who are concerned with critical issues that are currently affecting allied health education.

Your philosophy on education in seven words: Educating students holistically for lives of purpose.

If I could teach in another field, which one and why? Speech Language Pathology where I have been the Interim Chair of that department. So, being able to actively contribute in the classroom would be extremely rewarding.

Before I retire I want to: Continue mentoring our future college leaders.

In college, I was known for: Studying and being too serious.

What music is playing in my car/office? 70’s

The last book I read for fun was: The Whistler by John Grisham

My favorite trip was: Too many to choose from but Iceland, Italy, China, Hungary and Chile rank high on the “favorite list”.

If I could travel anywhere it would be: Easter Island

Four people I’d take to coffee or have a glass of wine with : Jesus, my parents and Dolly Parton

The best advice I ever received was: “Don’t ask someone to do a task you would not do yourself!”

My hobby is: Traveling

My passion is: Helping others be the best they can be.

My pet peeve is: Gossip

A perfect day is: Spent enjoying life with my husband.

Cats or dogs? Cats

E-book or hardback? Hardback Beach or mountains?

Mountains I wish I could: Spend more time with our grandchildren.

Only my friends know I: Hate to follow a recipe!

My favorite saying is: God grant me the serenity to accept the things I cannot change; courage to change the things I can; and, the wisdom to know the difference.

Return to trends june 2018

WORDS AND THEIR PLACEMENT REALLY MATTER

John Colbert

August 17, 2018

Trends Archives

Apart from gestures and semiotic influences, such as wearing a white coat and having a stethoscope, communication between a health professional and a patient relies heavily on language in the form of words—whether spoken or written. As stated in Lewis Carroll’s Alice’s Adventures in Wonderland and Through the Looking-Glass, "The question is," said Alice, "whether you can make words mean so many different things.” Along with person-to-person interaction, the widespread use of the electronic medical record and text messages provide ample opportunity for communication miscues to occur. Not only do words count heavily in deciding how to interpret what is being conveyed, the order of those words also can play a substantial determinative role.

Two decades ago, the federal Agency for Healthcare Research and Quality (called AHRQ) was known as the Agency for Health Care Policy and Research (AHCPR). The acronym was pronounced akper. Until an alert staff person spotted the problem immediately prior to launching the new name, this entity barely missed being labeled the Agency for Health Care Research and Policy (AHCRP) and the acronym would be pronounced ahcrap. To cite another example, consider the word only and how its placement affects the meaning of the following sentences:

The doctor only gave her the pill today.
The doctor gave only her the pill today.
The doctor gave her only the pill today.
The doctor gave her the only pill today.
The doctor gave her the pill only today.
The doctor gave her the pill today only.
Only the doctor gave her the pill today.

Several journals have wrestled with the issue of whether the individual or a health condition that identifies a person should be placed first. For example, should it be An individual with a disability or should it be A disabled individual (noting that critics prefer to use the term differently-abled)? The preferred order usually is individual first, condition second. Yet, there are some naysayers who believe that using this sequence of words accentuates stigmatization rather than attenuates it.

Metathesis is a term describing how sounds and letters are transposed. The word ask was pronounced aks in New England early in the 19th century, which usage then died out there and migrated to states in the south where it can be heard to the present day. Stigmatized in some places as substandard English, that critique can be considered invalid. For example, in Middle English, the word bird formerly was pronounced brid during the 1400s. Usage obviously can change over time. So, it may help to keep in mind that language is a metaphorical gun and words basically serve to pull the trigger. Proper aiming represents a way of ensuring that the outcome between health professionals and patients will be a satisfactory interaction as opposed to becoming an unfortunate and ill-advised collision.

Return to Trends June 2018

ARTIFICIAL INTELLIGENCE, ROBOTS, AND THE HEALTH CARE INDUSTRY

John Colbert

August 17, 2018

Trends Archives

The aging of the U.S. population and the extent to which multiple morbidities characterize a large segment of that sub-group provides assurance that the health care industry will continue to be robust for decades to come. What is unknown is the degree to which developments in artificial intelligence and robotics will have an impact on the health workforce and on the patients who obtain health care services. If efforts continue to develop driverless automobiles and trucks, it seems obvious that employment of humans to operate these vehicles will undergo a gradual disappearance in the taxi industry, to cite just one example. As jobs disappear in one line of work, it is uncertain how many new kinds of jobs will be created and whether individuals who are so displaced will find jobs in other aspects of the economy.

That question has relevance for the health field. As noted in the May/June 2018 issue of The Hastings Center Report, although medicine is particularly recalcitrant to change, applications of artificial intelligence (AI) in health care have professionals in fields like radiology worried about the future of their careers and have the public tittering about the prospect of soulless machines making life‐and‐death decisions. Medicine thus appears to be at an inflection point—a kind of Groundhog Day on which either AI will bring a springtime of improved diagnostic and predictive practices or the shadow of public and professional fear will lead to six more metaphorical weeks of winter in medical AI. The article points out that for decades, psychologists and decision scientists have argued that simple algorithms for specific diagnostic and prediction tasks often outperform clinicians. Despite robust evidence of this effect, professionals routinely overestimate their ability to carry out such tasks and underestimate the value of actuarial methods for making health care decisions. In the hospital setting, routine tasks that involve making beds, delivering food to patients, and perhaps even measuring blood pressure could be done by robots that do not complain, take sick days, or dislike working on weekends. Efforts to enhance the bottom line will be one of the key factors that help to dictate how many human functions in health care will be replaced by machines as the future unfolds.

Return to trends june 2018

THE WALKING CORPSE SYNDROME

John Colbert

August 17, 2018

Trends Archives

Page one of this issue of TRENDS is on the topic of communication as expressed by the use of words. An error made in speaking can be referred to as a slip of the tongue. When transferring information electronically using health records, a different kind of error might be called a digital slip of the finger. The May 2018 issue of the Journal of the American Geriatrics Society provides an account of how a physician upon concluding a visit by a patient typed discharge instructions, orders for a laboratory test, and follow‐up information into the electronic health record (EHR), at the moment her husband asked a question. While in the middle of selecting a diagnosis from a dropdown list to justify the test, the physician hit the “Accept” button when turning to answer the husband’s question. After doing so, he refocused on the wrap‐up and referred her to the laboratory for a blood draw. She then checked out and received the printed summary of the visit. Unfortunately, he inadvertently had selected the diagnosis “Walking Corpse Syndrome” (a rare mental illness in which patients have a delusion that they have died) from the dropdown list.

Once home, she and her spouse were astounded to read the diagnosis of “Walking Corpse Syndrome” on the visit summary. They called the office, panicked and obviously upset. The physician explained that it was an error caused by pressing the “Accept” button, sensing that she felt he somehow had been hiding a diagnosis from her for some time. Several apologies later, he learned that to avoid a similar experience in the future, he must inform patients when he needs to concentrate on the computer for critical data entry moments. He also began to dictate notes with the patients listening so that they are engaged in that part of the interaction with the computer.

Return to trends june 2018

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

John Colbert

August 17, 2018

Trends Archives

Academic Medical Centers And High-Need, High-Cost Patients: A Call To Action
In an article published on June 12, 2018 in the journal Academic Medicine, the authors issue a call to action for academic medical centers (AMCs) to accelerate the path to improving care for the country's sickest and most expensive patients. They point to six key features of care programs that have achieved proven results, including targeting interventions to those patients who are most likely to benefit and partnering with social services providers to address patients' nonclinical needs. Health care delivery systems increasingly are focused on improving care for patients with the highest needs and highest costs, in part because of the cost savings and financial returns that are possible through new value-based payment models. These models include the country's academic medical centers (AMCs), many of which have been at the forefront of efforts to meet the range of physical, behavioral, and social needs of a particularly vulnerable population. The article can be obtained at https://journals.lww.com/academicmedicine/Abstract/publishahead/ Academic_Medical_Centers_and_High_Need,_High_Cost.97882.aspx.

Youth Risk Behavior Survey Results And Trends Report
CDC’s Youth Risk Behavior Surveillance System (YRBSS) monitors priority health behaviors and experiences among high school students across the country. The Youth Risk Behavior Survey (YRBS) results help in understanding the factors that contribute to the leading causes of illness, death, and disability among youth and young adults. The YRBS Data Summary and Trends Report uses YRBS data to focus on four priority areas closely linked to HIV and STD risk including sexual behavior, high-risk substance use, violence victimization, and mental health over the past decade. Results from the 2017 YRBS show that fewer U.S. high school students are having sex and using select illicit drugs; however, far too many students remain at risk for HIV, STDs, and teen pregnancy. While the percentage of students who reported using select illicit drugs (defined as cocaine, heroin, methamphetamines, inhalants, hallucinogens, or ecstasy) was down from 23% in 2007 to 14% in 2017, the survey also found that nearly 1 in 7 U.S. high school students reported misusing prescription opioids – a behavior that can lead to future injection drug use and increased risk for HIV. Research shows experiences of violence and poor mental health can compound risks for STDs, including HIV. Nearly 1 in 5 students were bullied at school. More than 1 in 10 female students and 1 in 28 male students report having been physically forced to have sex. The proportion of students who persistently felt sad or hopeless increased from 29% in 2007 to 32% in 2017. The report can be obtained at https://www.cdc.gov/healthyyouth/data/yrbs/pdf/trendsreport.pdf.

New America’s Survey On Higher Education
Varying Degrees 2018: New America’s Second Annual Survey on Higher Education surveyed 1,600 Americans ages 18 and older to better understand their perceptions of higher education, economic mobility, and government funding. Respondents believe that well-paying jobs require education after high school, education after high school creates opportunities, and that public colleges and universities are worth the cost. They feel mixed about private and for-profit colleges and universities and whether higher education is a public benefit. They are in favor of having the government do more to make education affordable. They want change in higher education and they support workforce-based programs such as apprenticeships. The report can be obtained at https://na-production.s3.amazonaws.com/documents/Varying-Degrees.pdf.

Return to trends june 2018

HEALTH TECHNOLOGY CORNER

John Colbert

August 17, 2018

Trends Archives

Using Twitter To Find An Individual Who Becomes Lost Because Of Dementia
The results of a study published on April 18, 2018 in the open access journal npj Digital Medicine is based on an evaluation of the effectiveness of using Twitter to search for individuals who become lost due to dementia. Online messages on Twitter, i.e., tweets, were collected through an Application Programming Interface and the contents analyzed. Personal characteristics, features of tweets, and types of Twitter users were collected to investigate their associations with whether a person can be found within a month. Logistic regression was used to identify the features that were useful in finding the missing individuals. Results showed that the young age of persons with dementia who became lost, having tweets posted by police departments, and having tweets with photos can increase the chance of being found. The findings indicate that social media are reshaping the human communication pathway.

Dynamic Modeling To Predict The Behaviors Of Gut Microbes
It has been challenging to understand how the microbiome is formed, how it changes over time, and how it is affected by disturbances like antibiotics used to treat illnesses. The results of an investigation that was published on June 21, 2018 in the journal Molecular Systems Biology provides a platform for predicting how microbial gut communities work and represents a first step toward understanding how to manipulate the properties of the gut ecosystem. Doing so, for example, could allow scientists to design a probiotic that persists in the gut or tailor a diet to influence human health positively The data also can be used to start to answer questions about how pathogens cause damage when they invade communities, and how to prevent it. The model developed will allow scientists to begin to ask questions about the composition and dynamics of thousands of microbial communities.

Return to trends june 2018

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

John Colbert

August 17, 2018

Trends Archives

Genetic Test Availability And Spending
Genetic testing and spending on that testing have grown rapidly since the mapping of the human genome in 2003, but it is not widely known how many tests there are, how they are used, and how paid for. A manuscript in the May 2018 issue of the journal Health Affairs sheds light on genetic testing by providing an overview of the testing landscape. The authors found that there were approximately 75,000 genetic tests on the market, with about 10 new tests entering the market daily. Nearly 14,000 tests have arrived on the market since March 2014. Prenatal tests accounted for the highest percentage of spending on genetic tests and spending on hereditary cancer tests accounted for the second-highest. These results provide insights for parties interested in assessing genetic testing markets, test usage, and health policy implications, including current debates over the most appropriate regulatory and payer coverage mechanisms.

Trends And Circumstances Involving State Suicide Rates—United States
According to the CDC’s June 8, 2016 Morbidity and Mortality Weekly Report, during 1999–2016, suicide rates increased significantly in 44 states, with 25 states experiencing increases greater than 30%. Rates increased significantly among males and females in 34 and 43 states, respectively. Fifty-four percent of decedents in 27 states in 2015 did not have a known mental health condition. Among decedents with available information, several circumstances were significantly more likely among those without known mental health conditions than among those with mental health conditions, including relationship problems/ loss (45.1% versus 39.6%), life stressors (50.5% versus 47.2%), and recent/impending crises (32.9% versus 26.0%), but these circumstances were common across groups. An implication is that states can use a comprehensive evidence-based public health approach to prevent suicide risk before it occurs, identify and support persons at risk, prevent reattempts, and help friends and family members after suicide occurs.

Return to trends june 2018

HEALTH TECHNOLOGY CORNER

More Articles from TRENDS September 2018

FULFILLING A QUEST FOR PATIENT-CENTERED CARE

PRESIDENT’S CORNER—ASAHP MEMBER FOCUS

FISCAL YEAR 2019 FUNDING PICTURE BRIGHTENS

HEALTH REFORM DEVELOPMENTS

DEVELOPMENTS IN HIGHER EDUCATION

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

HURRICANE METHUSELAH MOVES STEADILY TOWARD U.S. SHORES

HOW LAWS, REGULATIONS, SELF-REGULATORY PRACTICES, AND FINANCIAL SUBSIDIES AFFECT U.S. HEALTH CARE

More Articles from TRENDS September 2018

FULFILLING A QUEST FOR PATIENT-CENTERED CARE

PRESIDENT’S CORNER—ASAHP MEMBER FOCUS

FISCAL YEAR 2019 FUNDING PICTURE BRIGHTENS

HEALTH REFORM DEVELOPMENTS

DEVELOPMENTS IN HIGHER EDUCATION