New GAO Reports and Testimonies
Source: Government Accountability Office
1. Homeland Security: An Overall Strategy Is Needed to Strengthen Disease Surveillance in Livestock and Poultry. GAO-13-424, May 21.
Highlights – http://www.gao.gov/assets/660/654750.pdf
Podcast – http://www.gao.gov/multimedia/podcasts/654743
2. Funding for 10 States’ Programs Supported by Four Environmental Protection Agency Categorical Grants. GAO-13-504R, May 6.
1. Immigration Enforcement: Preliminary Observations on DHS’s Overstay Enforcement Efforts, by Rebecca Gambler, director, homeland security and justice, before the Subcommittee on Border and Maritime Security, House Committee on Homeland Security. GAO-13-602T, May 21.
Highlights – http://www.gao.gov/assets/660/654753.pdf
2. Telecommunications Networks: Addressing Potential Security Risks of Foreign-Manufactured Equipment, by Mark L. Goldstein, director, physical infrastructure issues, before the Subcommittee on Communications and Technology, House Committee on Energy and Commerce. GAO-13-652T, May 21.
Highlights – http://www.gao.gov/assets/660/654764.pdf
3. Fiscal Year 2014 Budget Request: U.S. Government Accountability Office, by Gene L. Dodaro, Comptroller General of the United States, before the Subcommittee on Legislative Branch, Senate Committee on Appropriations. GAO-13-617T, May 21.
Highlights – http://www.gao.gov/assets/660/654758.pdf
Childhood and adolescent melanoma is rare but has been increasing. To gain insight into possible reasons underlying this observation, we analyzed trends in melanoma incidence diagnosed between the ages of 0 and 19 years among US whites by gender, stage, age at diagnosis, and primary site. We also investigated incidence trends by UV-B exposure levels.
By using Surveillance, Epidemiology, and End Results (SEER) program data (1973–2009), we calculated age-adjusted incidence rates (IRs), annual percent changes, and 95% confidence intervals for each category of interest. Incidence trends were also evaluated by using joinpoint and local regression models. SEER registries were categorized with respect to low or high UV-B radiation exposure.
From 1973 through 2009, 1230 children of white race were diagnosed with malignant melanoma. Overall, pediatric melanoma increased by an average of 2% per year (95% confidence interval, 1.4%–2.7%). Girls, 15- to 19-year-olds, and individuals with low UV-B exposure had significantly higher IRs than boys, younger children, and those living in SEER registries categorized as high UV-B. Over the study period, boys experienced increased IRs for melanoma on the face and trunk, and females on the lower limbs and hip. The only decreased incidence trend we observed was among 15- to 19-year-olds in the high UV-B exposure group from 1985 through 2009. Local regression curves indicated similar patterns.
These results may help elucidate possible risk factors for adolescent melanoma, but additional individual-level studies will be necessary to determine the reasons for increasing incidence trends.
Source: Morbidity and Mortality Weekly Report (CDC)
Mental disorders among children are described as "serious deviations from expected cognitive, social, and emotional development" (US Department of Health and Human Services Health Resources and Services Administration, Maternal and Child Health Bureau. Mental health: A report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, and National Institutes of Health, National Institute of Mental Health; 1999). These disorders are an important public health issue in the United States because of their prevalence, early onset, and impact on the child, family, and community, with an estimated total annual cost of $247 billion. A total of 13%–20% of children living in the United States experience a mental disorder in a given year, and surveillance during 1994–2011 has shown the prevalence of these conditions to be increasing. Suicide, which can result from the interaction of mental disorders and other factors, was the second leading cause of death among children aged 12–17 years in 2010. Surveillance efforts are critical for documenting the impact of mental disorders and for informing policy, prevention, and resource allocation. This report summarizes information about ongoing federal surveillance systems that can provide estimates of the prevalence of mental disorders and indicators of mental health among children living in the United States, presents estimates of childhood mental disorders and indicators from these systems during 2005–2011, explains limitations, and identifies gaps in information while presenting strategies to bridge those gaps.
Attention-deficit/hyperactivity disorder (6.8%) was the most prevalent parent-reported current diagnosis among children aged 3–17 years, followed by behavioral or conduct problems (3.5%), anxiety (3.0%), depression (2.1%), autism spectrum disorders (1.1%), and Tourette syndrome (0.2% among children aged 6–17 years). An estimated 4.7% of adolescents aged 12–17 years reported an illicit drug use disorder in the past year, 4.2% had an alcohol abuse disorder in the past year, and 2.8% had cigarette dependence in the past month. The overall suicide rate for persons aged 10–19 years was 4.5 suicides per 100,000 persons in 2010. Approximately 8% of adolescents aged 12–17 years reported ≥14 mentally unhealthy days in the past month.
Future surveillance of mental disorders among children should include standard case definitions of mental disorders to ensure comparability and reliability of estimates across surveillance systems, better document the prevalence of mental disorders among preschool-age children, and include additional conditions such as specific anxiety disorders and bipolar disorder. Standard surveillance case definitions are needed to reliably categorize and count mental disorders among surveillance systems, which will provide a more complete picture of the prevalence of mental disorders among children. More comprehensive surveillance is needed to develop a public health approach that will both help prevent mental disorders and promote mental health among children.
Tentative Eligibility Determinations; Presumptive Eligibility for Psychosis and Other Mental Illness
Source: U.S. Department of Veterans Affairs (via Federal Register)
This document amends the Department of Veterans Affairs (VA) regulation authorizing tentative eligibility determinations to comply with amended statutory authority concerning minimum active-duty service requirements. This document also codifies in regulation statutory presumptions of medical care eligibility for veterans of certain wars and conflicts who developed psychosis within specified time periods and for Persian Gulf War veterans who developed a mental illness other than psychosis within 2 years after service and within 2 years after the end of the Persian Gulf War period.
New GAO Report and Press Release
Source: Government Accountability Office
1. GAO Fills Vacancy on Health Information Technology Policy Committee May 20.
Source: RAND Corporation
From press release:
Hospital emergency departments play a growing role in the U.S. health care system, accounting for a rising proportion of hospital admissions and serving increasingly as an advanced diagnostic center for primary care physicians, according to a new RAND Corporation study.
While often targeted as the most expensive place to get medical care, emergency rooms remain an important safety net for Americans who cannot get care elsewhere and may play a role in slowing the growth of health care costs, according to the study.
Emergency departments are now responsible for about half of all hospital admissions in the United States, accounting for nearly all of the growth in hospital admissions experienced between 2003 and 2009.
Despite evidence that people with chronic conditions such as asthma and heart failure are visiting emergency departments more frequently, the number of hospital admissions for these conditions has remained flat. Researchers say that suggests that emergency rooms may help to prevent some avoidable hospital admissions.
"Use of hospital emergency departments is growing faster than the use of other parts of the American medical system," said Dr. Art Kellermann, the study’s senior author and a senior researcher at RAND, a nonprofit research organization. "While more can be done to reduce the number of unnecessary visits to emergency rooms, our research suggests emergency rooms can play a key role in limiting growth of preventable hospital admissions."
Sequestering Meals on Wheels Could Cost the Nation $489 Million per Year
Source: Center for Effective Government
Sequestering Meals on Wheels funds could cost taxpayers far more than it saves. While across-the-board spending cuts that began March 1, called sequestration, are expected to reduce spending on Meals on Wheels programs this year by an estimated $10 million, these savings will be dwarfed by at least $489 million per year in increased spending on Medicaid, both this year and in each subsequent year that sequestration remains in place.
Outside of Washington, waiting lists for Meals on Wheels enrollees have received media attention, but the expected savings have remained largely unquestioned. In reality, cutting Meals on Wheels will very likely increase the federal deficit by increasing the overall cost burden and shifting it to Medicaid, local charities, and other programs.
Overall, Meals on Wheels saves the federal taxpayers money by helping participants live at home instead of living in comparatively expensive nursing homes. The average cost to Medicaid of nursing home care per patient is approximately $57,878 annually.
By contrast, the cost to Medicaid of home care is much lower, approximately $15,371 annually, or $42,507 less than nursing home care. Nationally, according to a survey by the Administration on Aging, as many as "92% [of enrollees] say Meals on Wheels means they can continue to live in their own home."
Based on these estimates, our analysis suggests that sequestering Meals on Wheels funds will actually cost the U.S. taxpayer $479 million dollars over the seven months it will be implemented during this federal fiscal year, which ends September 30 (see the appendix for details of this estimate). Moreover, because sequestration-related cuts are expected to increase in FY 2014 and beyond, if sequestration is not reversed, Medicaid-related costs will increase even more in those years.
Microbes in Pool Filter Backwash as Evidence of the Need for Improved Swimmer Hygiene — Metro-Atlanta, Georgia, 2012
Microbes in Pool Filter Backwash as Evidence of the Need for Improved Swimmer Hygiene — Metro-Atlanta, Georgia, 2012
Source: Morbidity and Mortality Weekly Report (CDC)
Filters physically remove contaminants, including microbes, from water in treated recreational water venues, such as pools. Because contaminants accumulate in filters, filter concentrates typically have a higher density of contamination than pool water. During the 2012 summer swimming season, filter concentrate samples were collected at metro-Atlanta public pools. Quantitative polymerase chain reaction (qPCR) assays were conducted to detect microbial nucleic acid. Pseudomonas aeruginosa was detected in 95 (59%) of 161 samples; detection indicates contamination from the environment (e.g., dirt), swimmers, or fomites (e.g., kickboards). P. aeruginosa detection underscores the need for vigilant pool cleaning, scrubbing, and water quality maintenance (e.g., disinfectant level and pH) to ensure that concentrations do not reach levels that negatively impact swimmer health. Escherichia coli, a fecal indicator, was detected in 93 (58%) samples; detection signifies that swimmers introduced fecal material into pool water. Fecal material can be introduced when it washes off of swimmers’ bodies or through a formed or diarrheal fecal incident in the water. The risk for pathogen transmission increases if swimmers introduce diarrheal feces. Although this study focused on microbial DNA in filters (not on illnesses), these findings indicate the need for swimmers to help prevent introduction of pathogens (e.g., taking a pre-swim shower and not swimming when ill with diarrhea), aquatics staff to maintain disinfectant level and pH according to public health standards to inactivate pathogens, and state and local environmental health specialists to enforce such standards.
Recent analysis indicates cell phone distracted driving crashes vastly under-reported
Source: National Safety Council
Today, the National Safety Council released findings from a recent analysis of national statistics on fatal motor vehicle crashes, in a report entitled, “Crashes Involving Cell Phones: Challenges of Collecting and Reporting Reliable Crash Data,” funded in part by Nationwide Mutual Insurance Company. The report reviewed 180 fatal crashes from 2009 to 2011, where evidence indicated driver cell phone use. Of these fatal crashes, in 2011 only 52% were coded in the national data as involving cell phone use.
Even when drivers admitted cell phone use during a fatal crash, the Council’s analysis found that in about one-half of these cases, the crash was not coded in Federal data (the National Highway Traffic Safety Administration’s Fatal Analysis Reporting System). In addition, there are an unknown number of cases in which cell phone use involvement in crashes is impossible to determine. One example would be a driver reading an email or text message on a phone who dies in a crash without any witnesses.
The report also brings up large differences in cell phone distraction fatal crashes reported by states. For instance, in 2011, Tennessee reported 93 fatal crashes that involved cell phone use, but New York, a state with a much larger population, reported only one. Texas reported 40, but its neighboring state Louisiana reported none.
Source: U.S. Postal Service
As a prelude to National Dog Bite Prevention Week, the Postal Service released its dog attack city rankings today and urged pet owners to help reduce the incidence of dog bites to letter carriers.
“If our letter carriers deem your loose dog to be a threat, you’ll be asked to pick up your mail at the Post Office until it’s safe to deliver,” said Ken Snavely, acting postmaster of Los Angeles, where 69 postal employees were attacked last year, placing the City of Angels as the most vicious for dog attacks. Nationwide, 5,879 postal employees were attacked.
Snavely noted that in situations where a dog roams the neighborhood, delivery to the owner’s neighbors could be curtailed as well. Additionally, when letter carriers come to a customer’s door, pet owners are asked to place dogs in a separate room and close the door, as many canines have been known to jump through screen and glass doors.
Dog attacks are a nationwide issue and not just a postal problem. Nearly 5,900 letter carriers were attacked last year, but that pales in comparison to the 4.7 million Americans annually bitten by dogs — more than half of whom are children — according to the Centers for Disease Control and Prevention (CDC). The U.S. Postal Service, the medical community, veterinarians and the insurance industry are working together to educate the public that dog bites are avoidable by declaring May 19-25 as National Dog Bite Prevention Week.
Bird-Friendly Building Design (PDF)
Source: American Bird Conservancy
A unique publication that provides planners, architects designers, bird advocates, local authorities, and the general public with a clear understanding of the nature and magnitude of the threat glass poses to birds and solutions to eliminate the threat. This edition includes a review of the science behind bird collisions, real-world examples of solutions in action, and an investigation into what information is still needed.
Declining Medicine Use and Costs: For Better or Worse? A Review of the Use of Medicines in the United States in 2012
Declining Medicine Use and Costs: For Better or Worse? A Review of the Use of Medicines in the United States in 2012 (PDF)
Source: IMS Institute for Health Informatics
From press release:
Total spending on U.S. medicines fell 3.5 percent on a real per capita basis in 2012 and the use of healthcare services overall declined for the second consecutive year, according to a new study released today by the IMS Institute for Healthcare Informatics.
The report – Declining Medicine Use and Costs: For Better or Worse? – finds that total dollars spent on medications in the U.S. reached $325.8 billion last year, or real per capita spending of $898, down $33 from 2011. Underlying drivers for the overall decline in healthcare service use included fewer patient visits to office-based physicians, fewer non-emergency admissions to hospitals and outpatient facilities, and a less severe flu season in the early part of 2012. Patent expiries in 2012 contributed $28.9 billion to the reduction in medicine spending. This was their largest-ever impact as millions of patients accessed lower-cost generic versions of additional medicines.
Patients with insurance paid higher deductibles, copays and co-insurance for their overall healthcare, but prescription drug copays for most patients declined. At the same time, new transformative medicines became available to treat a large number of diseases with small or strictly defined patient populations.
Genworth 2013 Annual Cost of Care Survey: Nursing Home Costs Up, At Home Care Prices Remain Relatively Flat
In its 10th year, the Genworth 2013 Cost of Care Survey shows a continued upward trajectory when it comes to the cost of obtaining long term care services. The cost of receiving care in a setting such as an assisted living facility or nursing home is dramatically increasing, while the cost to receive care at home through homemaker services or a home health aide is rising at a much more gradual pace.
"There are many factors that go into rising care costs, from the number of available skilled professionals to real estate prices," said Pat Foley, president of distribution and marketing for Genworth. "If you look at national private nursing home costs over the past 10 years that we’ve done this study, the median annual costs have gone up from $65,200 to $83,950, increasing at more than four percent a year. The better news is that costs for homemaker services and home health aides have remained relatively flat. Since 70% of Genworth’s first time long term care claimants choose in-home care, these costs have remained more manageable."
Nationally, the 2013 median hourly cost of homemaker services and home health aide services is $18 and $19 respectively. Homemaker costs have risen just 1.4 percent since 2012 and 0.8 annually over the past five years. Home health aide services have risen 2.3 percent since 2012 and 1.0 percent annually over the past five years.
The costs to receive care in an assisted living facility are rising much faster. The median annual cost for care in an assisted living facility is $41,400. This represents an increase of 4.6 percent since 2012 and a 4.3 percent annual increase over the past five years. The comparable cost for a private nursing home room rose 3.6 percent from 2012 to 2013, to $83,950, or 4.5 percent annualized over the past five years.
Interventions for the Prevention of Posttraumatic Stress Disorder (PTSD) in Adults After Exposure to Psychological Trauma
Source: Agency for Healthcare Research and Quality
To assess efficacy, comparative effectiveness, and harms of psychological, pharmacological, and emerging interventions to prevent posttraumatic stress disorder (PTSD) in adults.
PubMed®, the Cochrane Library, CINAHL, Embase, PILOTS, International Pharmaceutical Abstracts, PsycINFO®, Web of Science, reference lists of published literature (from January 1, 1980, to July 30, 2012). In addition, we searched various sources for grey literature.
Two investigators independently selected, extracted data from, and rated risk of bias of relevant studies. If data were sufficient, we conducted quantitative analyses using random-effects models to estimate pooled effects. We graded strength of evidence (SOE) based on established guidance.
We included 19 trials with a range of populations exposed to a variety of psychological traumas. Participants suffered from symptoms of PTSD but did not meet diagnostic criteria for PTSD. For most interventions studied, we did not find reliable evidence to support efficacy for the prevention of PTSD or for the reduction of PTSD-related symptom severity. Evidence was sufficient to justify conclusions about three treatments. First, debriefing does not reduce either the incidence or the severity of PTSD or related psychological symptoms in civilian victims of crime, assault, or accident trauma (low SOE). Second, our meta-analyses of three trials showed that, in subjects with acute stress disorder, brief trauma-focused cognitive behavioral therapy (CBT) was more effective than supportive counseling (SC) in reducing the severity of PTSD (moderate SOE). Pooled results did not reach statistical significance for incidence of PTSD, depression symptom severity (both low SOE), and anxiety symptom severity (moderate SOE), but numerically favored CBT over SC. Finally, collaborative care for a traumatic injury requiring hospitalization produces a greater decrease in PTSD symptom severity at 6, 9, and 12 months after injury than does usual care (low SOE). The efficacy of psychological interventions to prevent PTSD did not differ between men and women (low SOE). Evidence was insufficient to determine whether previous depression or a history of child abuse or baseline PTSD symptoms influence the effectiveness of interventions. Evidence was insufficient to determine the effect of timing, intensity, or dosing on the effectiveness or risk of harms of interventions or to justify conclusions about the comparative risk of harms. For emerging interventions such as yoga, dietary supplements, and complementary or alternative interventions, no studies met our eligibility criteria. Evidence was insufficient to determine whether any treatment approaches were more effective for victims of particular trauma types.
Evidence supporting the effectiveness of most interventions used to prevent PTSD is lacking. If available in a given setting, brief trauma-focused CBT might be the preferable choice for reducing PTSD symptom severity in persons with acute stress disorder and collaborative care might be preferred for trauma patients requiring surgical hospitalization; by contrast, debriefing appears to be an ineffective intervention to reduce symptoms and prevent PTSD.
Safety of antidepressants in adults aged under 65: protocol for a cohort study using a large primary care database.
Source: BMC Psychiatry
Antidepressants are among the most commonly prescribed drugs in primary care in England and their use is increasing. This is largely due to longer durations of treatment of depression. Observational studies have shown some differences in adverse outcomes associated with different antidepressant drugs but relatively little is known about their relative safety particularly with long term use. The primary aim of this study is to determine the relative and absolute risks of pre-defined adverse events comparing different classes of antidepressant drugs in adults aged under 65 years and diagnosed with depression.
The study will identify a cohort of patients with a first recorded diagnosis of depression between 1/1/2000 and 31/07/2011, and made between the ages of 20 to 64 years using a large primary care database (QResearch). Patients will be followed up until 1/08/2012. Details of all prescriptions for antidepressants in patients in the cohort will be extracted, including the date of each prescription, the type of antidepressant drug, the dose and total quantity prescribed. Prospectively recorded data will be used to ascertain information on adverse outcomes that occurred during follow-up and after entry into the cohort. These are: all-cause mortality, suicide, attempted suicide/self-harm, sudden death, antidepressant overdose/poisoning, myocardial infarction, stroke/transient ischaemic attack, cardiac arrhythmia, epilepsy/seizures, upper gastrointestinal bleeding, falls, fractures, adverse drug reactions and motor vehicle crashes. Cox proportional hazard models will be used to estimate the association of the outcomes with class of antidepressant drug adjusting for potential confounding variables. The analyses will also examine associations by duration and dose and with the most frequently prescribed individual antidepressant drugs. Self-controlled case series analyses will be used to estimate the relative incidence of the outcomes of interest for defined time periods of antidepressant use.
The results of this study will help to establish the relative safety and balance of risks for different antidepressant drugs in people aged under 65.
Source: Centers for Disease Control and Prevention
Fact sheets on insufficient sleep are available for all 50 states, the District of Columbia, and three U.S. territories (Puerto Rico, Guam, and the Virgin Islands). Each fact sheet includes a table with the prevalence of insufficient rest or sleep (≥ 14 days in past 30 days) among adults in the state or territory by sex, age, race/ethnicity, education, employment status, marital status, presence of children in the home, and body mass index (a measure of excess weight). The fact sheet also includes a map that presents the prevalence of insufficient sleep among adults of the state or territory by region.
Select a state or territory from the drop-down menu or from the map to open that state’s or territory’s fact sheet (in PDF format).
Screening for and Treatment of Suicide Risk Relevant to Primary Care: A Systematic Review for the U.S. Preventive Services Task Force
Source: Annals of Internet Medicine
In 2009, suicide accounted for 36 897 deaths in the United States.
To review the accuracy of screening instruments and the efficacy and safety of screening for and treatment of suicide risk in populations and settings relevant to primary care.
Citations from MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL (2002 to 17 July 2012); gray literature; and a surveillance search of MEDLINE for additional screening trials (July to December 2012).
Fair- or good-quality English-language studies that assessed the accuracy of screening instruments in primary care or similar populations and trials of suicide prevention interventions in primary or mental health care settings.
One investigator abstracted data; a second checked the abstraction. Two investigators rated study quality.
Evidence was insufficient to determine the benefits of screening in primary care populations; very limited evidence identified no serious harms. Minimal evidence suggested that screening tools can identify some adults at increased risk for suicide in primary care, but accuracy was lower in studies of older adults. Minimal evidence limited to high-risk populations suggested poor performance of screening instruments in adolescents. Trial evidence showed that psychotherapy reduced suicide attempts in high-risk adults but not adolescents. Most trials were insufficiently powered to detect effects on deaths.
Treatment evidence was derived from high-risk rather than screen-detected populations. Evidence relevant to adolescents, older adults, and racial or ethnic minorities was limited.
Primary care–feasible screening tools might help to identify some adults at increased risk for suicide but have limited ability to detect suicide risk in adolescents. Psychotherapy may reduce suicide attempts in some high-risk adults, but effective interventions for high-risk adolescents are not yet proven.
Primary Funding Source:
Agency for Healthcare Research and Quality
Safety Report on Eliminating Impaired Driving
Source: National Transportation Safety Board
On May 14, 2013, the 25th anniversary of our nation’s deadliest drunk-driving crash, which killed 24 children and three adults in Carrollton, Ky., the NTSB’s five-member board voted unanimously to issue bold recommendations to help the United States reach zero and eliminate alcohol-impaired driving.
Bold steps are needed: On average, every hour, one person dies in a crash involving a drunk driver and 20 more people are injured, including three with debilitating injuries. That adds up quickly to yearly totals of nearly 10,000 deaths, 27,000 lives forever altered and another 146,000 injured.
The safety report and recommendations culminate a year-long effort by the NTSB to thoroughly examine this problem and develop a set of targeted interventions. The recommendations include:
- Reduce state BAC limits from 0.08 to 0.05 or lower
- Increase use of high-visibility enforcement
- Develop and deploy in-vehicle detection technology
- Require ignition interlocks for all offenders
- Improve use of administrative license actions
- Target and address repeat offenders
- Reinforce use and effectiveness of DWI courts