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Health Reform and Changes in Health Insurance Coverage in 2014

August 13, 2014 Comments off

Health Reform and Changes in Health Insurance Coverage in 2014
Source: New England Journal of Medicine

In this analysis of nationally representative survey data from January 2012 through June 2014, we found a significant decline in the uninsured rate among nonelderly adults that coincided with the initial open-enrollment period under the ACA. These changes remained highly significant after adjustment for potential confounders such as employment, demographic characteristics, and income. As compared with the baseline trend, the uninsured rate declined by 5.2 percentage points by the second quarter of 2014, a 26% relative decline from the 2012–2013 period. Combined with 2014 Census estimates of 198 million adults 18 to 64 years of age,19 this corresponds to 10.3 million adults gaining coverage, although depending on the model and confidence intervals, our sensitivity analyses imply a wide range from 7.3 to 17.2 million adults.

The pattern of coverage gains was consistent with the effects of the ACA, with major gains for persons likely to be eligible for expanded Medicaid on the basis of their income and state of residence but smaller and nonsignificant changes for low-income adults in states without Medicaid expansion. Coverage gains were significant both in states with Medicaid expansion and in those without Medicaid expansion for persons with incomes between 139% and 400% of the federal poverty level, which is consistent with tax subsidies under the ACA for private insurance in this income range, regardless of state decisions regarding Medicaid expansion. Absolute gains were largest among young adults and Hispanics, two groups with high uninsured rates at baseline. State-level estimates of coverage gains were significantly associated with official HHS enrollment statistics, showing that each percentage point of the state population enrolling via the marketplaces was associated with a half-point decline in the uninsured rate. Nonetheless, the inherent lack of a control group precludes a causal interpretation for these findings, and other unmeasured factors may have contributed to these changes.

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Drug Safety in the Digital Age

July 2, 2014 Comments off

Drug Safety in the Digital Age
Source: New England Journal of Medicine

In this digital age, engaging with new media offers an unparalleled opportunity for medical and public health professionals to find information they need and to interactively reach out to patients and their support networks. One domain where these capabilities may have far-reaching effects that are currently undefined is drug safety. As the volume of health-related information on the Internet has grown, important questions have emerged. How are messages from regulators — for example, warnings against using a drug in a specific patient population — diffused digitally? And are the messages still accurate when they reach the general population?

Despite debates over its credibility, Wikipedia is reportedly the most frequently consulted online health care resource globally: Wikipedia pages typically appear among the top few Google search results and are among the references most likely to be checked by Internet users. We therefore evaluated Google searches and Wikipedia page views for each drug in our sample. We also examined the content of Wikipedia pages, looking specifically for references to safety warnings. To control for secular trends, we examined results from a 120-day window around the date of the announcement (from 60 days before the announcement to 60 days after it) and constructed a baseline period for comparison that ran from 60 days to 10 days before the period of interest began.

We identified safety warnings for 22 prescription drugs that are indicated for a range of clinical conditions, including primary hypertension, chronic myelogenous leukemia, and hepatitis C. Collectively, these drugs triggered 13 million searches on Google and 5 million Wikipedia page views annually during the study period. FDA safety warnings were associated with an 82% increase, on average, in Google searches for the drugs during the week after the announcement and a 175% increase in views of Wikipedia pages for the drugs on the day of the announcement, as compared with baseline trends.

Did users find accurate information on the drugs’ safety? We found that 41% of Wikipedia pages pertaining to the drugs with new safety warnings were updated within 2 weeks after the warning was issued with information provided in the FDA announcements. The Wikipedia pages for drugs that were intended for treatment of highly prevalent diseases (affecting more than 1 million people in the United States) were more likely to be updated quickly (58% were updated within 2 weeks) than were those for drugs designed to treat less-prevalent conditions (20% were updated within 2 weeks, P=0.03; see Fig. S2 in the Supplementary Appendix).

Overall, 23% of Wikipedia pages were updated more than 2 weeks after the FDA warning was issued (average, 42 days), and 36% of pages remained unchanged more than 1 year later (as of January 2014). For example, the FDA issued a safety communication on January 13, 2012, that brentuximab vedotin (Adcetris), used to treat Hodgkin’s lymphoma and systemic anaplastic large-cell lymphoma, had been linked to two cases of progressive multifocal leukoencephalopathy. As a result, the FDA placed a new black-box warning about this risk on the drug label, a move that was followed by a 50% increase in Google searches for the drug during the ensuing week and a 141% increase in views of the drug’s Wikipedia page. However, there was still no mention of the new black-box warning on Wikipedia 2 years later, a discrepancy that substantiates concerns raised by previous studies over the reliability of online drug information.

Distracted Driving and Risk of Road Crashes among Novice and Experienced Drivers

January 14, 2014 Comments off

Distracted Driving and Risk of Road Crashes among Novice and Experienced Drivers
Source: New England Journal of Medicine

Among novice drivers, dialing or reaching for a cell phone, texting, reaching for an object other than a cell phone, looking at a roadside object such as a vehicle in a previous crash, and eating were all associated with a significantly increased risk of a crash or near-crash. Among experienced drivers, only cell-phone dialing was associated with an increased risk.

How Medicaid affects adult health — Study: Health insurance helps lower-income Americans avoid depression, diabetes, major financial shocks

January 10, 2014 Comments off

How Medicaid affects adult health — Study: Health insurance helps lower-income Americans avoid depression, diabetes, major financial shocks
Source: New England Journal of Medicine (via MIT)

Enrollment in Medicaid helps lower-income Americans overcome depression, get proper treatment for diabetes, and avoid catastrophic medical bills, but does not appear to reduce the prevalence of diabetes, high blood pressure and high cholesterol, according to a new study with a unique approach to analyzing one of America’s major health-insurance programs.

The study, a randomized evaluation comparing health outcomes among more than 12,000 people in Oregon, employs the same research approach as a clinical trial, but applies it in a way that provides a window into the health outcomes of poor Americans who have been given the opportunity to get health insurance.

“What we found was that Medicaid significantly increased the probability of being diagnosed with diabetes, and being on diabetes medication,” says Amy Finkelstein, the Ford Professor of Economics at MIT and, along with Katherine Baicker of Harvard University’s School of Public Health, the principal investigator for the study. “We find decreases in rates of depression, and we continue to find reduced financial hardship. However, we were unable to detect a decline in the incidence of diabetes, high blood pressure, or high cholesterol.”

Health Care Spending — A Giant Slain or Sleeping?

December 26, 2013 Comments off

Health Care Spending — A Giant Slain or Sleeping?
Source: New England Journal of Medicine

The health care system is confronting a shocking surprise: slow growth in cost. According to U.S. government actuaries, real spending for health care increased a scant 0.8% per person in 2012, slightly less than the real gross domestic product (GDP) per capita. In contrast, since 1960, spending has increased an average of 2.3 percentage points more than GDP growth. The yearly gap between increases in health spending and GDP growth explains why national health expenditures jumped from 5% of the GDP in 1960 to 18% in 2011.

The recent moderation in spending is good news for payers of the health care bill, but analysts are divided about what to make of it. On the one hand, some believe that the Great Recession of 2007–2009 and the nation’s very slow recovery can explain ebbing increases in health care costs. Writing recently in the Journal, Fuchs described how — with rare exceptions — trends in health spending have always tracked with trends in the general economy. The implication is that health care costs will probably surge as the economy recovers.

On the other hand, some analysts (including one of us) believe that the slowdown exceeds what trends in the GDP would predict and that the past may no longer be prologue. They theorize that public and private efforts to control health spending, including features of the Affordable Care Act (ACA), may finally be working.

The purpose of this report is to explore this debate about national health expenditures and to understand its implications. We start by reviewing historic trends in health care spending and efforts to control them. We then probe further the rationales for seeing the recent slowdown as either temporary or likely to endure. We conclude by discussing possible consequences and policy responses should either the optimistic or the pessimistic scenario prevail.

Association of Nut Consumption with Total and Cause-Specific Mortality

November 21, 2013 Comments off

Association of Nut Consumption with Total and Cause-Specific Mortality
Source: New England Journal of Medicine

In two large prospective U.S. cohorts, we found a significant, dose-dependent inverse association between nut consumption and total mortality, after adjusting for potential confounders. As compared with participants who did not eat nuts, those who consumed nuts seven or more times per week had a 20% lower death rate. Inverse associations were observed for most major causes of death, including heart disease, cancer, and respiratory diseases. Results were similar for peanuts and tree nuts, and the inverse association persisted across all subgroups.

Note: Supported by grants from the National Institutes of Health (UM1 CA167552, P01 CA055075, P01 CA87969, R01 HL60712, R01 CA124908, P50 CA127003, and 1U54 CA155626-01) and the International Tree Nut Council Nutrition Research and Education Foundation.

Talking with Patients about Other Clinicians’ Errors

November 1, 2013 Comments off

Talking with Patients about Other Clinicians’ Errors
Source: New England Journal of Medicine

Although a consensus has been reached regarding the ethical duty to communicate openly with patients who have been harmed by medical errors, physicians struggle to fulfill this responsibility. One particular challenge is that although the literature assumes the physician providing the disclosure also committed the error, health care today is delivered by complex groups of clinicians across multiple care settings. In addition, safety experts emphasize the role that system breakdowns play in adverse events. Thus, many decisions about discussing errors with patients involve situations in which other clinicians were primarily responsible for the error.

Confronting the apparent error of a colleague raises challenging questions about whether an error occurred, how the error arose, which professionals carry what responsibilities, and how to talk with the patient about the event. Existing guidelines emphasize the overall importance of disclosing errors, but (with the exception of the case study of the American College of Physicians Ethics and Human Rights Committee)16 they offer little guidance on disclosing others’ mistakes; this lack of guidance heightens clinicians’ uncertainty about what to do. Consequently, patients may be told little about these events, and opportunities to build trust, ensure that learning occurs after errors, and avoid litigation may be lost.

We convened a working group of experts in patient safety, medical malpractice insurance and litigation, error disclosure, patient–provider communication, professionalism, bioethics, and health policy. After the meeting, a subgroup of attendees collaborated to refine these concepts and draft this manuscript. Below, we describe recommendations that extend existing guidelines for clinicians and institutions on communicating with patients about colleagues’ harmful errors.

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