Bad Math Behind the Social Security Cuts

In a post on The Health Care Blog, Stephen Soumerai, ScD, Professor of Population Medicine and Director of the Drug Policy Research Group, discusses how high out-of-pocket health care costs for seniors can be tragic because people will opt to go without essential medical care. The “inflation adjustment” recently proposed by the federal government is supposed to decrease the Social Security beneficiary’s income by a few hundred dollars a year. But, in reality, the reduction will amount to $1,600 in cases where the beneficiary is older, poorer, and sicker – punishing those who already have difficulty paying for life’s necessities.

Studies conducted through the Department of Population Medicine have shown that a 50% reduction in drug benefits in New Hampshire for low income, chronically ill seniors backfired. Another study demonstrated that about 30% of disabled Medicare recipients in poor health skip or split pills to make them last longer because they cannot afford prescription drugs which has been shown, by other researchers, to increase hospitalization of heart disease patients by 21%.

Dr. Soumerai further cites financial estimates regarding average retirement savings and estimated average cost of retirees’ out-of-pocket medical expenses from several data sources to make the point that this Social Security cost-of-living adjustment is both flawed and morally unacceptable.


Inhaled steroids influence effect of gene on lung function

The goal of the study was to assess whether the association of genetic polymorphisms with bronchodilator response is different between patients with asthma who are treated with inhaled corticosteroids versus those on placebo. 
Ann Wu, MD, MPH, Assistant Professor with the Center for Child Health Care Studies, and researchers from other institutions conducted a genome-wide association analysis in 581 children from the Childhood Asthma Management Program (CAMP).   They examined the top 12 single nucleotide polymorphisms that looked promising in the childhood clinical trial and replicated them in a clinical trial of adults called the Leukotriene Modifier or Corticosteroid or Corticosteroid-Salmetereol Trial (LOCCS). 
The research team identified a region on chromosome 19 that appears to influence the effect of inhaled corticosteroids on asthma.  A particular gene on chromosome 19, the zinc finger protein gene, ZNF432, whose function is unknown, may actually play an important role in this relationship.
Based on these findings, inhaled corticosteroids appear to modulate the association of bronchodilator response with variant(s) in the ZNF432 gene among adults and children with asthma.
Dr. Wu discusses her article in a post on her blog, “ Asthma Blog from the view of an asthma researcher, doctor, and mom.”

Study Confirms Lower Risk of Intestinal Blockage from Second-Generation Rotavirus Vaccination

The level of risk from RotaTeq appears to be only about one-tenth of the risk from Rotashield, an earlier vaccine that was withdrawn from the market in 1999. The risk was found to be concentrated between the third and seventh day after vaccination. The study appears in New England Journal of Medicine on-line.
The study was funded by the FDA through its Mini-Sentinel Post-licensure Rapid Immunization Safety Monitoring (PRISM) project. RotaTeq was licensed in 2006, several years after the withdrawal of Rotashield, which carried a risk of intussusception of approximately 1-1.5 excess cases per 10,000 vaccine recipients. Studies in other countries had identified an increased risk of intussusception from second-generation rotavirus vaccines, including RotaTeq. The Harvard Pilgrim Institute researchers analyzed data for 1.3 million doses of RotaTeq given to infants in the U.S. from 2006 to 2011. The study found that RotaTeq vaccination led to about 1.5 excess cases of intussusception per 100,000 first-dose recipients, or about 1/10 of the risk found for the earlier vaccine. As a result of the study, the FDA approved a change to the RotaTeq product label, and the CDC revised its vaccine information statements for parents, guardians and providers about the risk of intussusception.
“The study team found a small increase in the risk of intussusception following vaccination with the first dose of RotaTeq," said Katherine Yih, PhD, MPH. “However, the benefits of the vaccine in reducing diarrheal disease and averting hospitalizations for severe diarrhea continue to outweigh the risks." she said. “This study demonstrates the value of FDA's Mini-Sentinel project, which has developed the capability to use electronic health data to assess important problems, while ensuring the confidentiality of patients' information,” Yih added.



Study Examines Physicians’ Awareness of Late and Long-term Effects of Chemotherapy

Lead author Larissa Nekhlyudov, MD, MPH,  of the HPHC Institute, and her colleagues from other institutions conducted a national survey of over 2200 oncologists and primary care physicians and asked them to select the long-term effects (LEs) they had either observed or had seen reported for five chemotherapy agents used to treat breast and colon cancer. 

Differences between clinicians in awareness of specific LEs was described and predictors of physicians’ awareness of LEs associated with the chemotherapy agents was determined using multivariate logistic regression models.

The five long-term effects of specific interest included cardiac dysfunction, premature menopause, secondary malignancies, pulmonary fibrosis, and peripheral neuropathy.

For chemotherapy agent doxorubicin, 55% of PCPs and 95% of oncologists stated they had observed or seen reported cardiac dysfunction as an associated LE.  For agent cyclophosphamide, 15% of PCPs and 71% of oncologists identified premature menopause as an LE, and 17% and 62% identified secondary malignancies, respectively.  Peripheral neuropathy was identified as an associated LE for paclitaxel by 27% of PCPs and 97% of oncologists and for oxaliplatin, by 22% of PCPs and 97% of oncologists. 

The study points out that there is a need for ongoing education about LEs of cancer treatment among all physicians who care for cancer survivors. Since PCPs don’t usually encounter chemotherapy agents and LEs in their clinical practices, oncologists need to communicate information about them.

Article underscores potential of early obesity prevention

Matthew W. Gillman, MD, SM, of the HPHC Institute and David S. Ludwig, MD, PhD, of Boston Children’s Hospital examined studies spanning a first generation of birth-weight research to recent, more sophisticated, epidemiologic work.  The authors highlighted the most promising obesity prevention approaches for pregnancy and infancy to date, but also cautioned that definitive conclusions await intervention trials, many of which are now occurring.   
Potential intervention strategies identified by the authors include  smoking cessation before pregnancy, reduction of excessive gestational weight gain, treatment of gestational diabetes, avoiding unnecessary cesarean delivery, establishing infants’ healthful sleep habits, and introduction of solid foods no earlier than 4-6 months. The authors hypothesize that obesity prevention efforts focusing on multiple risk factors will be the most effective.
“Mothers appear especially willing to modify their behavior to benefit their children during the prenatal and postpartum periods,” said Dr. Gillman.  “This willingness, coupled with knowledge that these periods are critical for setting children on lifelong trajectories of healthful biology and behavior, highlight the importance of anti-obesity efforts during early human development.” 
To read the article, click here.


Increasing Community Access to Wellness Resources

Emily Oken MD, MPH,  Dennis Ross-Degnan ScD, and Jennifer Thompson, along with other team members, developed a Community Wellness Map – an interactive, web-based tool to help residents be more active, eat better, and live a healthier lifestyle.  The map provides wellness resources for five towns served by Cambridge Health Alliance (CHA): Cambridge, Somerville, Malden, Everett and Revere. It features a comprehensive list of physical activity, nutrition, and weight management programs, and includes important program details, such as cost, contact information, and eligibility criteria. 

The development of this tool was part of a larger effort to improve diabetes prevention for CHA patients and individuals living in the neighboring areas.  Other institutions involved in the production of the interactive map were The Harvard Center for Geographical Analysis and the Dana Farber Cancer Institute Health Communication Core.

This project demonstrates it is possible to create mapped community program guides and suggests that such programs have the potential to improve population health management.

The Community Wellness Map is available online for all users. The Welcome Page provides instructions on how to use the program guide and also provides tips for healthy living, including suggestions for activities that can be done within publicly accessible outdoor and indoor public spaces. To access the Community Wellness Map, click here.

HPHC’s CMO Discusses New “Bundled Payment” Model

With the goal of aligning provider and insurer incentives to deliver more patient value, an academic team from Harvard Business School convened a group of orthopedic surgeons from the Boston Shoulder Institute and Harvard Pilgrim Health Care to create a new “bundled payment” (BP) model.  DPM faculty member and HPHC Chief Medical Officer, Michael Sherman, MD, MBA, MS played a critical role on the team and co-authored the piece.
Unlike the traditional fee-for-service reimbursement model that rewards volume of treatments rather than medical outcomes, a new bundled-payment model is designed to reward providers who deliver better outcomes at a lower cost. Clinicians would be paid a fixed fee for providing all of the services required to deliver a complete cycle of patient care for a specific clinical condition.
For this project, the working team chose rotator-cuff damage as the clinical condition to be bundled.  Because rotator-cuff repair is a high-volume procedure with a specific cycle of care that can result in great variability in outcomes among clinicians, this surgery offered an opportunity to improve outcomes and standardize treatment around best practices.
The blog goes on to describe how the research team worked together-- in a real spirit of collaboration -- to define the bundle, select the population for a pilot project, specify outcomes, estimate costs, and ultimately set prices.
For additional information and to follow the blog, click here.

Study Demonstrates that Statins are Associated with Decreased Asthma-related ED visits

Researchers from Harvard Pilgrim Health Care Institute and other institutions found that asthma patients who are started on statins experience fewer asthma-related emergency department visits and decreased oral corticosteroid use. The study will be published Nov. 1 in American Journal of Respiratory and Critical Care Medicine. 

The research was based on a large population-based cohort of subjects with asthma drawn from the data of five health plans, including Harvard Pilgrim Health Care.  Statin users were matched with non-statin users using characteristics such as age, baseline asthma therapy, site of enrollment, season of enrollment and propensity score.  Statin exposure and asthma exacerbations were assessed over a 24-month observation period. The results found significantly decreased odds of asthma-related ED visits and use of oral corticosteroids for statin users compared to non-statin users. 

 “This study used a large sample to test the effect of statins on asthma symptoms,” said senior author Ann Wu, MD, MPH, of Harvard Pilgrim Health Care Institute at Harvard Medical School.  “While other studies on statins and asthma have had mixed results, most were limited by small sample sizes and short treatment periods. These results may be encouraging for the more than 300 million people around the world with asthma, but additional randomized controlled trials are needed to confirm these findings.”




Strategies for Sharpening a Blunt Instrument

According to authors Frank Wharam, MB, BCh, BAO, MPH, Dennis Ross-Degnan, ScD, and colleagues, an increasingly HDHP-oriented health system could have unintended consequences but proactive strategies could prevent worsening of health outcomes and disparities.  To prevent negative effects of increased HDHP enrollment, policymakers and employers could adopt common sense strategies such as:
  • Educating consumers about the best venues for buying health insurance, e.g., through an employer versus a state health insurance exchange. 
  • Offering low-cost-sharing plans to vulnerable individuals, which might be most feasible at large employers.
  • Facilitating contributions to non-taxed Health Savings Accounts for low-income workers.
  • Increasing consumer education about coverage details of HDHPs
  • Encouraging shared patient-physician decision-making at or before the point of care, and providing patients with decision-support tools.
In addition, research is urgently needed on HDHPs’ long-term effects on major health outcomes and vulnerable populations.  Such research could facilitate creation of more sophisticated "personalized health insurance" designs tailored to improve health in specific populations.
To read the complete “Perspective” click here.

Exercise May be as Effective as Drugs in Decreasing Death for Common Diseases

Lead author Huseyin Naci, MHS, a DPM research fellow in Pharmaceutical Policy Research, and his colleague from Stanford University School of Medicine conducted a meta-analysis of over 300 randomized controlled trials that compared the effectiveness of exercise and drug interventions and involved over 330,000 individuals.

In this systematic review, the researchers compared the effectiveness of exercise versus drugs on mortality across four conditions: rehabilitation of stroke, treatment of heart failure, prevention of diabetes, and secondary prevention of coronary heart disease (i.e., treating patients with existing disease before it causes significant illness).

Results showed no statistically-significant differences between exercise and drug interventions for secondary prevention of heart disease and prevention of diabetes.

Physical activity interventions were more effective than drug treatment among stroke patients; for heart failure, diuretic drugs were more effective than exercise and all other types of drug treatment.

The authors note that there is a scarcity of data on the mortality benefits of exercise as compared to that of drugs, and this may have had an impact on their results. However, they believe available evidence suggests that exercise and many drug interventions may frequently be similar in terms of their mortality benefits in the health conditions studied.