Friday, September 11, 2015
The answer: way lower than the current guidelines.
For years doctors have been uncertain what the optimal goal should be for patients with high blood pressure. The aim of course is to bring it down, but how far and how aggressively remained a mystery. There are trade-offs — risks and side effects from drugs — and there were lingering questions about whether older patients needed somewhat higher blood pressure to push blood to the brain.
The study found that patients who were assigned to reach a systolic blood pressure goal below 120 — far lower than current guidelines of 140, or 150 for people over 60 — had their risk of heart attacks, heart failure and strokes reduced by a third and their risk of death reduced by nearly a quarter.
The study, called Sprint, randomly assigned more than 9,300 men and women ages 50 and over who were at high risk of heart disease or had kidney disease to of two systolic blood pressure targets: less than 120 millimeters of mercury, which is lower than any guideline ever suggested, or less than 140. (Systolic pressure is the higher of the two blood pressure numbers and represents pressure on blood vessels when the heart contracts.)
The study was expected to conclude in 2017, but considering the results of great importance to public health, the National Heart, Lung and Blood Institute announced them Friday morning, saying a paper with the data would be published within a few months.
"This study provides potentially lifesaving information," Dr. Gary H. Gibbons, director of the institute, said in a statement announcing the decision.
Nearly 79 million adults in this country — one of three — have high blood pressure, and half of those being treated for it still have systolic pressures over 140.
Wednesday, September 9, 2015
Most businesses know the cost of everything that goes into producing what they sell — essential information for setting prices. Medicine is different. Hospitals know what they are paid by insurers, but it bears little relationship to their costs.
No one on Dr. Lee's staff at the University of Utah Health Care could say what a minute in an M.R.I. machine or an hour in the operating room actually costs. They chuckled when she asked.
But now, thanks to a project Dr. Lee set in motion after that initial query several years ago, the hospital is getting answers, information that is not only saving money but also improving care.
The effort is attracting the attention of institutions from Harvard to the Mayo Clinic. The secretary of health and human services, Sylvia Mathews Burwell, visited last month to see the results. While costs at other academic medical centers in the area have increased an average of 2.9 percent a year over the past few years, the University of Utah's have declined by 0.5 percent a year. "We have bent the cost curve," Dr. Lee said.
Inpatient hospital costs account for nearly 30 percent of health care spending in the United States and are increasing by a little less than 2 percent a year, adjusted for inflation, according to the federal Agency for Healthcare Research and Quality.
The cost issue has taken on new urgency as the Affordable Care Act accelerates the move away from fee-for-service medicine and toward a system where hospitals will get one payment for the entire course of a treatment, like hospitalization for pneumonia. Medicare, too, is setting new goals for payments based on the value of care.
Under such a system, if a hospital does additional tests and procedures or if patients get infections or are readmitted, the hospital bears the cost. To make money, medical centers have to figure out what it actually costs to provide care and how to spend less while maintaining or improving outcomes.
The linchpin of this effort at the University of Utah Health Care is a computer program — still a work in progress — with 200 million rows of costs for items like drugs, medical devices, a doctor's time in the operating room and each member of the staff's time. The software also tracks such outcomes as days in the hospital and readmissions. A pulldown menu compares each doctor's costs and outcomes with others' in the department.
The hospital has been able to calculate, for instance, the cost per minute in the emergency room (82 cents), in the surgical intensive care unit ($1.43), and in the operating room for an orthopedic surgery case ($12).
With such information, as well as data on the cost of labor, supplies and labs, the hospital has pared excess expenses and revised numerous practices for more efficient and effective care.
Michael Porter, an economist and professor at Harvard Business School, called the accomplishments "epic progress."
We're paying too much for prescription drugs. The price for cancer drugs like Yervoy, Opdivo and Keytruda routinely exceeds $120,000 a year.
Despite representing about 1 percent of prescriptions in 2014, these types of high-cost drugs accounted for some 32 percent of all spending on pharmaceuticals.
Polls show that Americans are fed up with high drug costs. A commonly proposed solution has been to let the federal government, through Medicare, negotiate with drug companies. Currently, while Medicare tells hospitals and doctors what it will pay for services, by law it cannot negotiate with companies for lower drug prices. Some independent estimates suggest that negotiated drug prices could save the federal government $15 billion or more per year.
But this approach will not solve the problem of stratospheric drug prices, for several reasons. For many diseases, there exist only a couple of effective drugs, with little price competition. Also, Medicare would have little negotiating leverage since, unlike private insurers, it cannot maintain an approved drug list and exclude overly expensive drugs from coverage.
It is an irony that troubles health care providers and policymakers nationwide: Even as public awareness of mental illness increases, a shortage of psychiatrists worsens.
In vast swaths of America, patients face lengthy drives to reach the nearest psychiatrist, if they can even find one willing to see them. Some states are promoting wider use of long-distance telepsychiatry to fill the gaps in care. In Texas, which faces a severe shortage, lawmakers recently voted to pay the student loans of psychiatrists willing to work in underserved areas. A bill in Congress would forgive student loans for child psychiatrists.
Even with such efforts, problems are likely to persist. A recent survey by the Association of American Medical Colleges found that 59 percent of psychiatrists are 55 or older, the fourth oldest of 41 medical specialties, signaling that many may soon be retiring or reducing their workload.
Charles Ingoglia, a vice president of the National Council for Behavioral Health, helps coordinate a network of 2,300 not-for-profit clinics nationwide that provide mental health services.
"I'm not aware of any part of the country where it is easy for our members to find psychiatrists," he said.
Statistics help tell the story. According to the American Medical Association, the total number of physicians in the U.S. increased by 45 percent from 1995 to 2013, while the number of adult and child psychiatrists rose by only 12 percent, from 43,640 to 49,079. During that span, the U.S. population increased by about 37 percent; meanwhile, millions more Americans have become eligible for mental health coverage under the Affordable Care Act.
Federal health authorities have designated about 4,000 areas in the U.S. as having a shortage of mental health professionals — areas with more than 30,000 people per psychiatrist.
Monday, September 7, 2015
Hospital admissions because of bike injuries more than doubled between 1998 and 2013, doctors reported Tuesday in JAMA, the journal of the American Medical Association. And the rise was the biggest with bikers ages 45 and over.
"There are just more people riding and getting injured in that age group. It's definitely striking," says Dr. Benjamin Breyer, who led the study at the University of California, San Francisco.
Another study, published last month in the Morbidity and Mortality Weekly Report, found a similar trend with bicycle deaths: While the death rate among child cyclists has plummeted in the past four decades, the mortality rate among cyclists ages 35 to 54 has tripled.
Breyer isn't sure what's driving the surge in accidents among Generation Xers and baby boomers, but one reason could be what's known as the "Lance Armstrong effect."
"After Lance Armstrong had all of his success at the Tour de France, a lot more people were riding, and there were a lot more older riders that took up the bicycle for sport," he says.