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Tag: Nursing

  • Health workers fear it’s profits before protection as CDC revisits airborne transmission

    Health workers fear it’s profits before protection as CDC revisits airborne transmission

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    Four years after hospitals in New York City overflowed with covid-19 patients, emergency physician Sonya Stokes remains shaken by how unprepared and misguided the American health system was.

    Hospital leadership instructed health workers to forgo protective N95 masks in the early months of 2020, as covid cases mounted. “We were watching patients die,” Stokes said, “and being told we didn’t need a high level of protection from people who were not taking these risks.”

    Droves of front-line workers fell sick as they tried to save lives without proper face masks and other protective measures. More than 3,600 died in the first year. “Nurses were going home to their elderly parents, transmitting covid to their families,” Stokes recalled. “It was awful.”

    Across the country, hospital leadership cited advice from the Centers for Disease Control and Prevention on the limits of airborne transmission. The agency’s early statements backed employers’ insistence that N95 masks, or respirators, were needed only during certain medical procedures conducted at extremely close distances.

    Such policies were at odds with doctors’ observations, and they conflicted with advice from scientists who study airborne viral transmission. Their research suggested that people could get covid after inhaling SARS-CoV-2 viruses suspended in teeny-tiny droplets in the air as infected patients breathed.

    But this research was inconvenient at a time when N95s were in short supply and expensive.

    Now, Stokes and many others worry that the CDC is repeating past mistakes as it develops a crucial set of guidelines that hospitals, nursing homes, prisons, and other facilities that provide health care will apply to control the spread of infectious diseases. The guidelines update those established nearly two decades ago. They will be used to establish protocols and procedures for years to come.

    “This is the foundational document,” said Peg Seminario, an occupational health expert and a former director at the American Federation of Labor and Congress of Industrial Organizations, which represents some 12 million active and retired workers. “It becomes gospel for dealing with infectious pathogens.”

    Late last year, the committee advising the CDC on the guidelines pushed forward its final draft for the agency’s consideration. Unions, aerosol scientists, and workplace safety experts warned it left room for employers to make unsafe decisions on protection against airborne infections.

    “If we applied these draft guidelines at the start of this pandemic, there would have been even less protection than there is now — and it’s pretty bad now,” Seminario said.

    In an unusual move in January, the CDC acknowledged the outcry and returned the controversial draft to its committee so that it could clarify points on airborne transmission. The director of the CDC’s National Institute for Occupational Safety and Health asked the group to “make sure that a draft set of recommendations cannot be misread to suggest equivalency between facemasks and NIOSH Approved respirators, which is not scientifically correct.”

    The CDC also announced it would expand the range of experts informing their process. Critics had complained that most members of last year’s Healthcare Infection Control Practices Advisory Committee represent large hospital systems. And about a third of them had published editorials arguing against masks in various circumstances. For example, committee member Erica Shenoy, the infection control director at Massachusetts General Hospital, wrote in May 2020, “We know that wearing a mask outside health care facilities offers little, if any, protection from infection.”

    Although critics are glad to see last year’s draft reconsidered, they remain concerned. “The CDC needs to make sure that this guidance doesn’t give employers leeway to prioritize profits over protection,” said Jane Thomason, the lead industrial hygienist at the union National Nurses United.

    She’s part of a growing coalition of experts from unions, the American Public Health Association, and other organizations putting together an outside statement on elements that ought to be included in the CDC’s guidelines, such as the importance of air filtration and N95 masks.

    But that input may not be taken into consideration.

    The CDC has not publicly announced the names of experts it added this year. It also hasn’t said whether those experts will be able to vote on the committee’s next draft — or merely provide advice. The group has met this year, but members are barred from discussing the proceedings. The CDC did not respond to questions and interview requests from KFF Health News.

    A key point of contention in the draft guidance is that it recommends different approaches for airborne viruses that “spread predominantly over short distances” versus those that “spread efficiently over long distances.” In 2020, this logic allowed employers to withhold protective gear from many workers.

    For example, medical assistants at a large hospital system in California, Sutter Health, weren’t given N95 masks when they accompanied patients who appeared to have covid through clinics. After receiving a citation from California’s occupational safety and health agency, Sutter appealed by pointing to the CDC’s statements suggesting that the virus spreads mainly over short distances.

    A distinction based on distance reflects a lack of scientific understanding, explained Don Milton, a University of Maryland researcher who specializes in the aerobiology of respiratory viruses. In general, people may be infected by viruses contained in someone’s saliva, snot, or sweat — within droplets too heavy to go far. But people can also inhale viruses riding on teeny-tiny, lighter droplets that travel farther through the air. What matters is which route most often infects people, the concentration of virus-laden droplets, and the consequences of getting exposed to them, Milton said. “By focusing on distance, the CDC will obscure what is known and make bad decisions.”

    Front-line workers were acutely aware they were being exposed to high levels of the coronavirus in hospitals and nursing homes. Some have since filed lawsuits, alleging that employers caused illness, distress, and death by failing to provide personal protective equipment.

    One class-action suit brought by staff was against Soldiers’ Home, a state-owned veterans’ center in Holyoke, Massachusetts, where at least 76 veterans died from covid and 83 employees were sickened by the coronavirus in early 2020.

    “Even at the end of March, when the Home was averaging five deaths a day, the Soldiers’ Home Defendants were still discouraging employees from wearing PPE,” according to the complaint.

    It details the experiences of staff members, including a nursing assistant who said six veterans died in her arms. “She remembers that during this time in late March, she always smelled like death. When she went home, she would vomit continuously.”

    Researchers have repeatedly criticized the CDC for its reluctance to address airborne transmission during the pandemic. According to a new analysis, “The CDC has only used the words ‘COVID’ and ‘airborne’ together in one tweet, in October 2020, which mentioned the potential for airborne spread.’”

    It’s unclear why infection control specialists on the CDC’s committee take a less cautious position on airborne transmission than other experts, industrial hygienist Deborah Gold said. “I think these may be honest beliefs,” she suggested, “reinforced by the fact that respirators triple in price whenever they’re needed.”

    Critics fear that if the final guidelines don’t clearly state a need for N95 masks, hospitals won’t adequately stockpile them, paving the way for shortages in a future health emergency. And if the document isn’t revised to emphasize ventilation and air filtration, health facilities won’t invest in upgrades.

    “If the CDC doesn’t prioritize the safety of health providers, health systems will err on the side of doing less, especially in an economic downturn,” Stokes said. “The people in charge of these decisions should be the ones forced to take those risks.”




    Kaiser Health NewsThis article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.

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  • SNFists enhance end-of-life care quality for nursing home residents

    SNFists enhance end-of-life care quality for nursing home residents

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    Specialized nursing facility clinicians, or SNFists, may decrease the likelihood of nursing home residents experiencing stressful hospitalizations and improve the quality of life in their last days, according to researchers from Weill Cornell Medicine.

    The paper, published in JAMA Network Open on Mar. 15, examined how SNFists uniquely impacted the care of nursing home residents in their last 90 days, compared with those cared for by other clinicians. This large-scale study is the first of its kind.

    The literature has described certain features or outcomes that translate into what we think is poor quality at the end of life. One example is transferring residents to the hospital and admitting them for conditions like pneumonia or UTIs (urinary tract infections) that may have been managed in the nursing home, or going from nursing home to hospital to another nursing home.”

    Dr. Arnab Ghosh, assistant professor of medicine at Weill Cornell Medicine and a hospitalist at NewYork-Presbyterian/Weill Cornell Medical Center

    The physical act of transferring the residents to new environments increases their risk of delirium and discomfort, the researchers said. Transfers also interrupt communication and continuity of care, burdening patients and making them more uncomfortable.

    The study defined SNFists as healthcare professionals (physicians, nurse practitioners and physician assistants) who provided at least 80 percent of their patient visits in the nursing home setting. They noted this specialization gives SNFists deeper insight into the clinical conditions facing nursing home residents, which allows for better communication between the residents, their families and other staff members.

    The study of 2,091,954 nursing home residents aged 65 and older, during a period from January 2012 to December 2019, found that SNFists managed about 46 percent of this group. The researchers determined that care from an SNFist decreased risk up to 6 percent for hospitalizations due to any reason including pneumonia, urinary tract infection, dehydration or sepsis.

    The need for SNFists will only grow as the U.S. population ages and more people develop dementia-;two-thirds of all deaths related to Alzheimer’s disease occur in nursing homes. Other professions may also need to step up. “We need more research comparing the quality of care from different nursing home clinicians including medical doctors, nurse practitioners and physician assistants, but we clearly see fewer MDs working in nursing homes while NPs and PAs are increasing,” said Dr. Hye-Young Jung, associate professor of Population Health Sciences at Weill Cornell Medicine.

    The researchers suggest that medical schools and residency programs may need to offer more nursing home care experiences to increase the number of physicians in this field. They also emphasize the need for designating an official specialization, as with other areas of medicine like hospitalists, which would provide certification of the unique knowledge and skills needed in the nursing home setting.

    Source:

    Journal reference:

    Ghosh, A. K., et al. (2024). Clinicians Who Practice Primarily in Nursing Homes and the Quality of End-of-Life Care Among Residents. JAMA Network Open. doi.org/10.1001/jamanetworkopen.2024.2546.

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  • Why covid patients who could most benefit from paxlovid still aren’t getting it

    Why covid patients who could most benefit from paxlovid still aren’t getting it

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    Evangelical minister Eddie Hyatt believes in the healing power of prayer but “also the medical approach.” So on a February evening a week before scheduled prostate surgery, he had his sore throat checked out at an emergency room near his home in Grapevine, Texas.

    A doctor confirmed that Hyatt had covid-19 and sent him to CVS with a prescription for the antiviral drug Paxlovid, the generally recommended medicine to fight covid. Hyatt handed the pharmacist the script, but then, he said, “She kept avoiding me.”

    She finally looked up from her computer and said, “It’s $1,600.”

    The generally healthy 76-year-old went out to the car to consult his wife about their credit card limits. “I don’t think I’ve ever spent more than $20 on a prescription,” the astonished Hyatt recalled.

    That kind of sticker shock has stunned thousands of sick Americans since late December, as Pfizer shifted to commercial sales of Paxlovid. Before then, the federal government covered the cost of the drug.

    The price is one reason Paxlovid is not reaching those who need it most. And patients who qualify for free doses, which Pfizer offers under an agreement with the federal government, often don’t realize it or know how to get them.

    “If you want to create a barrier to people getting a treatment, making it cost a lot is the way to do it,” said William Schaffner, a professor at Vanderbilt University School of Medicine and spokesperson for the National Foundation for Infectious Diseases.

    Public and medical awareness of Paxlovid’s benefits is low, and putting people through an application process to get the drug when they’re sick is a non-starter, Schaffner said. Pfizer says it takes only five minutes online.

    It’s not an easy drug to use. Doctors are wary about prescribing it because of dangerous interactions with common drugs that treat cholesterol, blood clots, and other conditions. It must be taken within five days of the first symptoms. It leaves a foul taste in the mouth. In one study, 1 in 5 patients reported “rebound” covid symptoms a few days after finishing the medicine — though rebound can also occur without Paxlovid.

    A recent JAMA Network study found that sick people 85 and older were less likely than younger Medicare patients to get covid therapies like Paxlovid. The drug might have prevented up to 27,000 deaths in 2022 if it had been allocated based on which patients were at highest risk from covid. Nursing home patients, who account for around 1 in 6 U.S. covid deaths, were about two-thirds as likely as other older adults to get the drug.

    Shrunken confidence in government health programs is one reason the drug isn’t reaching those who need it. In senior living facilities, “a lack of clear information and misinformation” are “causing residents and their families to be reluctant to take the necessary steps to reduce covid risks,” said David Gifford, chief medical officer for an association representing 14,000 health care providers, many in senior care.

    The anti-vaxxers spreading falsehoods about vaccines have targeted Paxlovid as well. Some call themselves anti-paxxers.

    “Proactive and health-literate people get the drug. Those who are receiving information more passively have no idea whether it’s important or harmful,” said Michael Barnett, a primary care physician at Brigham and Women’s Hospital and an associate professor at Harvard, who led the JAMA Network study.

    In fact, the drug is still free for those who are uninsured or enrolled in Medicare, Medicaid, or other federal health programs, including those for veterans.

    That’s what rescued Hyatt, whose Department of Veterans Affairs health plan doesn’t normally cover outpatient drugs. While he searched on his phone for a solution, the pharmacist’s assistant suddenly appeared from the store. “It won’t cost you anything!” she said.

    As Hyatt’s case suggests, it helps to know to ask for free Paxlovid, although federal officials say they’ve educated clinicians and pharmacists — like the one who helped Hyatt — about the program.

    “There is still a heaven!” Hyatt replied. After he had been on Paxlovid for a few days his symptoms were gone and his surgery was rescheduled.

    About that $1,390 list price

    Pfizer sold the U.S. government 23.7 million five-day courses of Paxlovid, produced under an FDA emergency authorization, in 2021 and 2022, at a price of around $530 each.

    Under the new agreement, Pfizer commits to provide the drug for the beneficiaries of the government insurance programs. Meanwhile, Pfizer bills insurers for some portion of the $1,390 list price. Some patients say pharmacies have quoted them prices of $1,600 or more.

    How exactly Pfizer arrived at that price isn’t clear. Pfizer won’t say. A Harvard study last year estimated the cost of producing generic Paxlovid at about $15 per treatment course, including manufacturing expenses, a 10% profit markup, and 27% in taxes.

    Pfizer reported $12.5 billion in Paxlovid and covid vaccine sales in 2023, after a $57 billion peak in 2022. The company’s 2024 Super Bowl ad, which cost an estimated $14 million to place, focused on Pfizer’s cancer drug pipeline, newly reinforced with its $43 billion purchase of biotech company Seagen. Unlike some other recent oft-aired Pfizer ads (“If it’s covid, Paxlovid”), it didn’t mention covid products.

    Connecting with patients

    The other problem is getting the drug where it is needed. “We negotiated really hard with Pfizer to make sure that Paxlovid would be available to Americans the way they were accustomed to,” Department of Health and Human Services Secretary Xavier Becerra told reporters in February. “If you have private insurance, it should not cost you much money, certainly not more than $100.”

    Yet in nursing homes, getting Paxlovid is particularly cumbersome, said Chad Worz, CEO of the American Society of Consultant Pharmacists, specialists who provide medicines to care homes.

    If someone in long-term care tests positive for covid, the nurse tells the physician, who orders the drug from a pharmacist, who may report back that the patient is on several drugs that interact with Paxlovid, Worz said. Figuring out which drugs to stop temporarily requires further consultations while the time for efficacious use of Paxlovid dwindles, he said.

    His group tried to get the FDA to approve a shortcut similar to the standing orders that enable pharmacists to deliver anti-influenza medications when there are flu outbreaks in nursing homes, Worz said. “We were close,” he said, but “it just never came to fruition.” “The FDA is unable to comment,” spokesperson Chanapa Tantibanchachai said.

    Los Angeles County requires nursing homes to offer any covid-positive patient an antiviral, but the Centers for Medicare & Medicaid Services, which oversees nursing homes nationwide, has not issued similar guidance. “And this is a mistake,” said Karl Steinberg, chief medical officer for two nursing home chains with facilities in San Diego County, which also has no such mandate. A requirement would ensure the patient “isn’t going to fall through the cracks,” he said.

    While it hasn’t ordered doctors to prescribe Paxlovid, CMS on Jan. 4 issued detailed instructions to health insurers urging swift approval of Paxlovid prescriptions, given the five-day window for the drug’s efficacy. It also “encourages” plans to make sure pharmacists know about the free Paxlovid arrangement.

    Current covid strains appear less virulent than those that circulated earlier in the pandemic, and years of vaccination and covid infection have left fewer people at risk of grave outcomes. But risk remains, particularly among older seniors, who account for most covid deaths, which number more than 13,500 so far this year in the U.S.

    Steinberg, who sees patients in 15 residences, said he orders Paxlovid even for covid-positive patients without symptoms. None of the 30 to 40 patients whom he prescribed the drug in the past year needed hospitalization, he said; two stopped taking it because of nausea or the foul taste, a pertinent concern in older people whose appetites already have ebbed.

    Steinberg said he knew of two patients who died of covid in his companies’ facilities this year. Neither was on Paxlovid. He can’t be sure the drug would have made a difference, but he’s not taking any chances. The benefits, he said, outweigh the risks.




    Kaiser Health NewsThis article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.

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  • Metabolic syndrome increases mortality risk in women with high-risk HPV

    Metabolic syndrome increases mortality risk in women with high-risk HPV

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    Using large-scale U.S. data following patients for more than a decade, York University Faculty of Health researchers found that women with both metabolic syndrome and high-risk strains of human papillomavirus (HPV) are at a 2.6 times higher risk for mortality than women without either condition, suggesting a need to look at chronic disease comorbidity when it comes to HPV-related cancers.

    “While it has been known for some time that metabolic conditions can contribute to lingering HPV, this study extends previous work by examining the associations with mortality risk,” says School of Nursing Assistant Professor Catriona Buick, also an Oncology Nurse Clinician Scientist at Sunnybrook Health Sciences Centre.

    Buick, an expert in HPV, women’s health and cancer care, teamed up with School of Kinesiology and Health Science PhD student Parmis Mirzadeh, whose research looks at obesity and metabolic illness, to take a closer look at the association.

    Data for the study, published yesterday in PLOS ONE, was obtained by the United States National Health and Nutrition Examination Survey with a final sample of 5,101 individuals (3,274 women). The researchers found more than a quarter of the women with metabolic syndrome had high-risk HPV.

    Their study didn’t suggest increased mortality for HPV status alone, which the researchers say could be attributed to the fact that the data only allowed for a snapshot of whether a woman had HPV or not, and could not speak to the persistence.

    HPV is the most prevalent sextually transmitted infection and has been referred to as the common flu of STIs. In most cases, the body will clear HPV fairly quickly, but lingering cases of high-risk HPV can develop into precancerous changes in the cervix and in some cases over many years cervical cancer.”


    Catriona Buick, Assistant Professor and Oncology Nurse Clinician Scientist, Sunnybrook Health Sciences Centre

    While most of the 200 known strains do not present a serious problem, a handful are responsible for nearly all cases of cervical cancer, which represents 4.5 per cent of all cancers worldwide.

    Metabolic syndrome refers to a cluster of conditions that increase the risk of heart disease, stroke and type 2 diabetes, which can include excess fat around the waist, high fasting blood sugar levels and high blood pressure. While not looked at directly in this study, individuals with metabolic syndrome are about 65 per cent more likely to develop cardiovascular disease and are 25 per cent more likely to die from “any” cause. It is not clear how metabolic syndrome could affect HPV.

    “It likely has something to do with a weakened immune response and chronic inflammation, but the research looking at a direct physiological pathway still needs to be done,” said Mirzadeh.

    One in five Canadian adults have metabolic syndrome and those numbers are rising, and both Buick and Mirzadeh underline the importance of a healthy lifestyle, participating in routine cancer screening and getting vaccinated for HPV.

    Jurisdictions in Canada and around the world are moving away from Pap smears and towards HPV testing, which Buick says can alert health practitioners to potential issues earlier and don’t need to be done as frequently. While HPV vaccinations are very helpful, they only help protect against a handful of the most common of the 40 known cancer-causing HPV strains, says Buick.

    “Regardless of vaccination status, everyone with a cervix still needs to get screened.”

    Source:

    Journal reference:

    Mirzadeh, P., et al. (2024). Association between human papillomaviruses, metabolic syndrome, and all-cause death; analysis of the U.S. NHANES 2003–2004 to 2015–2016. PLOS ONE. doi.org/10.1371/journal.pone.0299479.

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  • Study links higher mortality among rural elderly to understaffed Norwegian municipalities

    Study links higher mortality among rural elderly to understaffed Norwegian municipalities

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    Elderly people living in rural areas in Norway have higher mortality rates if they are discharged to a municipality that has too many patients and not enough caregivers to provide services.

    Aging baby boomers are swelling the ranks of elderly across the Western world, with Norway no exception.

    We know Norway’s elderly population will increase, and it’s likely there will be far fewer healthcare professionals to take care of them. The last 20 years has seen the population of Norwegians over the age of 80 increase by 40,000; the percentage of people aged 67-79 has grown by 37.9 per cent over the last 10 years.

    Over the next 20 years, there will be 250,000 more Norwegians over the age of 80.

    The aging crisis has been predicted for a long time, but the country still doesn’t appear to be prepared.

    Research now shows that elderly people living in rural areas have higher mortality rates if they are discharged to a municipality under pressure.

    Elderly people over the age of 70 who live in a municipality with fewer than 10,000 inhabitants are particularly vulnerable.

    Over 350,000 elderly people involved in the study

    Gudrun Maria Waaler Bjørnelv is an associate professor of Health Economics at NTNU. Her work has her concerned that municipal authorities in Norway may not be prepared for an aging population.

    Working with a research team from NTNU, St. Olavs Hospital, Trondheim Municipal Authority and SINTEF, she has studied all Norwegians over the age of 70 who were admitted to emergency departments from 2012 to 2016.

    That amounted to just over 350,000 people.

    This group of elderly people had almost 900,000 emergency hospital admissions during this period. The researchers followed them for 30 days after the day they were admitted.

    Nursing and care services that were under pressure led to increased mortality in elderly who were under their care, and that elderly people in small municipalities had the highest mortality rate.

    A small municipality was defined as having fewer than 10,000 inhabitants. According to Statistics Norway, 70 per cent of Norwegian municipalities in 2016 had fewer than 10,000 inhabitants. In total, 17 per cent of the population lives in a small municipality.

    Increased mortality rates in pressured municipalities

    Previously, it was thought that small municipalities do better than large municipalities, because they have fewer patients in hospitals waiting to be discharged to the municipal services. Our findings, however, indicate that small municipalities are more vulnerable during periods when the demand for nursing and care services is higher than the municipality can supply,”


    Gudrun Maria Waaler Bjørnelv, Associate Professor of Health Economics at NTNU

    She points out that small municipalities may experience more pressure regarding demand for available nursing home places and health professionals.

    “This may make them more vulnerable to fluctuations and pressure on health services,” Bjørnelv said.

    To investigate how mortality rates among patients changed, the researchers relied on information regarding the amount of pressure individual municipalities were under.

    The process is as follows:

    As soon as a person is ready to be discharged from a hospital, the home municipality of the patient must either receive the patient in that municipality or pay a daily fee to the hospital until the patient is moved home to the municipality.

    Need to know more about municipalities under pressure

    “If there is a build-up of patients who are ready to be discharged from hospital to one municipality, this suggests that the municipal services such as home care and nursing homes are under pressure. It shows that they do not have the capacity to receive these patients,” says Bjørnelv.

    The study investigated how mortality rates changed if people were admitted to emergency departments during periods of increased pressure in the municipality. That would be during periods where many people from the same municipality as the acutely admitted patient were waiting to be discharged from hospital.

    “We need to take a closer look at the municipal services, and it needs to happen now,” says Bjørnelv. She believes that we must find out more about what happens when a municipality is under pressure.

    “Is there a greater tendency to move some people home after hospitalization rather than to a municipal short-term care facility if the municipality is under pressure? Is it better for elderly people from a pressured municipality to longer in the hospital – without the municipality having to pay a ‘fine’ to the hospital? What is best for the patient?” Bjørnelv said.

    Source:

    Norwegian University of Science and Technology

    Journal reference:

    Bjørnelv, G., et al. (2023). Mortality and subsequent healthcare use among older patients discharged to a municipality with excess demand for elderly care. Nordic Journal of Health Economics. doi.org/10.5617/njhe.10145.

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  • With medical debt burdening millions, a financial regulator steps in to help

    With medical debt burdening millions, a financial regulator steps in to help

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    When President Barack Obama signed legislation in 2010 to create the Consumer Financial Protection Bureau, he said the new agency had one priority: “looking out for people, not big banks, not lenders, not investment houses.”

    Since then, the CFPB has done its share of policing mortgage brokers, student loan companies, and banks. But as the U.S. health care system turns tens of millions of Americans into debtors, this financial watchdog is increasingly working to protect beleaguered patients, adding hospitals, nursing homes, and patient financing companies to the list of institutions that regulators are probing.

    In the past two years, the CFPB has penalized medical debt collectors, issued stern warnings to health care providers and lenders that target patients, and published reams of reports on how the health care system is undermining the financial security of Americans.

    In its most ambitious move to date, the agency is developing rules to bar medical debt from consumer credit reports, a sweeping change that could make it easier for Americans burdened by medical debt to rent a home, buy a car, even get a job. Those rules are expected to be unveiled later this year.

    “Everywhere we travel, we hear about individuals who are just trying to get by when it comes to medical bills,” said Rohit Chopra, the director of the CFPB whom President Joe Biden tapped to head the watchdog agency in 2021.

    “American families should not have their financial lives ruined by medical bills,” Chopra continued.

    The CFPB’s turn toward medical debt has stirred opposition from collection industry officials, who say the agency’s efforts are misguided. “There’s some concern with a financial regulator coming in and saying, ‘Oh, we’re going to sweep this problem under the rug so that people can’t see that there’s this medical debt out there,’” said Jack Brown III, a longtime collector and member of the industry trade group ACA International.

    Brown and others question whether the agency has gone too far on medical billing. ACA International has suggested collectors could go to court to fight any rules barring medical debt from credit reports.

    At the same time, the U.S. Supreme Court is considering a broader legal challenge to the agency’s funding that some conservative critics and financial industry officials hope will lead to the dissolution of the agency.

    But CFPB’s defenders say its move to address medical debt simply reflects the scale of a crisis that now touches some 100 million Americans and that a divided Congress seems unlikely to address soon.

    “The fact that the CFPB is involved in what seems like a health care issue is because our system is so dysfunctional that when people get sick and they can’t afford all their medical bills, even with insurance, it ends up affecting every aspect of their financial lives,” said Chi Chi Wu, a senior attorney at the National Consumer Law Center.

    CFPB researchers documented that unpaid medical bills were historically the most common form of debt on consumers’ credit reports, representing more than half of all debts on these reports. But the agency found that medical debt is typically a poor predictor of whether someone is likely to pay off other bills and loans.

    Medical debts on credit reports are also frequently riddled with errors, according to CFPB analyses of consumer complaints, which the agency found most often cite issues with bills that are the wrong amount, have already been paid, or should be billed to someone else.

    “There really is such high levels of inaccuracy,” Chopra said in an interview with KFF Health News. “We do not want to see the credit reporting system being weaponized to get people to pay bills they may not even owe.”

    The aggressive posture reflects Chopra, who cut his teeth helping to stand up the CFPB almost 15 years ago and made a name for himself going after the student loan industry.

    Targeting for-profit colleges and lenders, Chopra said he was troubled by an increasingly corporate higher-education system that was turning millions of students into debtors. Now, he said, he sees the health care system doing the same thing, shuttling patients into loans and credit cards and reporting them to credit bureaus. “If we were to rewind decades ago,” Chopra said, “we saw a lot less reliance on tools that banks used to get people to pay.”

    The push to remove medical bills from consumer credit reports culminates two years of intensive work by the CFPB on the medical debt issue.

    The agency warned nursing homes against forcing residents’ friends and family to assume responsibility for residents’ debts. An investigation by KFF Health News and NPR documented widespread use of lawsuits by nursing homes in communities to pursue friends and relatives of nursing home residents.

    The CFPB also has highlighted problems with how hospitals provide financial assistance to low-income patients. Regulators last year flagged the dangers of loans and credit cards that health care providers push on patients, often saddling them with more debt.

    And regulators have gone after medical debt collectors. In December, the CFPB shut down a Pennsylvania company for pursuing patients without ensuring the debts were accurate.

    A few months before that, the agency fined an Indiana company working with medical debt for violating collection laws. Regulators said the company had “risked harming consumers by pressuring or inducing them to pay debts they did not owe.”

    With their business in the crosshairs, debt collectors are warning that cracking down on credit reporting and other collection tools may prompt more hospitals and doctors to demand patients pay upfront for care.

    There are some indications this is happening already, as hospitals and clinics push patients to enroll in loans or credit cards to pay their medical bills.

    Scott Purcell, CEO of ACA International, said it would be wiser for the federal government to focus on making medical care more affordable. “Here we’re coming up with a solution that only takes money away from providers,” Purcell said. “If Congress was involved, there could be more robust solutions.”

    Chopra doesn’t dispute the need for bigger efforts to tackle health care costs.

    “Of course, there are broader things that we would probably want to fix about our health care system,” he said, “but this is having a direct financial impact on so many Americans.”

    The CFPB can’t do much about the price of a prescription or a hospital bill, Chopra continued. What the federal agency can do, he said, is protect patients if they can’t pay their bills.




    Kaiser Health NewsThis article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.

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  • Innovative in-vehicle sensing system helps detect cognitive decline in older drivers

    Innovative in-vehicle sensing system helps detect cognitive decline in older drivers

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    An estimated 4 to 8 million older adults with mild cognitive impairment are currently driving in the United States, and one-third of them will develop dementia within five years. Individuals with progressive dementias are eventually unable to drive safely, yet many remain unaware of their cognitive decline.

    Currently, screening and evaluation services for driving can only test a small number of individuals with cognitive concerns, missing many who need to know if they require treatment.

    Nursing, engineering and neuropsychology researchers at Florida Atlantic University are testing and evaluating a readily and rapidly available, unobtrusive in-vehicle sensing system they have developed. This technology could provide the first step toward future widespread, low-cost early warnings of cognitive change for this large number of older drivers in the U.S. and elsewhere.

    In their study, published in the journal BMC Geriatrics, they are systematically examining how this system could detect anomalous driving behavior indicative of cognitive impairment. Few studies have reported on the use of continuous, unobtrusive sensors and related monitoring devices for detecting subtle variability in the performance of highly complex everyday activities over time. This significant proportion of older drivers constitutes a previously unexplored opportunity to detect cognitive decline. 

    The neuropathologies of Alzheimer’s disease have been found in the brains of older drivers killed in motor vehicle accidents who did not even know they had the disease and had no apparent signs of it. The purpose of our study arose from the importance of identifying cognitive dysfunction as early and efficiently as possible. Sensor systems installed in older drivers’ vehicles may detect these changes and could generate early warnings of possible changes in cognition.”


    Ruth Tappen, Ed.D., principal investigator, senior author and the Christine E. Lynn Eminent Scholar and Professor, FAU Christine E. Lynn College of Nursing

    The study uses a naturalistic longitudinal design to obtain continuous information on driving behavior that is being compared with the results of extensive cognitive testing conducted every three months for three years. A driver facing camera, forward facing camera, and telematics unit are installed in the vehicle and data is downloaded every three months when the cognitive tests are administered.

    Researchers are gauging abnormal driving such as getting lost, ignoring traffic signals and signs, near-collision events, distraction and drowsiness, reaction time and braking patterns. They also are looking at travel patterns such as number of trips, miles driven, miles on the highway, miles during the night and daytime, and driving in severe weather.

    The in-vehicle sensor network developed by FAU researchers in the College of Engineering and Computer Science, uses open-source hardware and software components to reduce the time, risks and costs associated with developing in-vehicle sensing units. In-vehicle sensor systems are kept simple and compact by minimizing complex wiring, limiting the size of the sensing units, and limiting the number of sensors in a vehicle to support the unobtrusiveness of in-vehicle sensors. Each in-vehicle sensor system is comprised of two distributed sensing units: one for telematics data and the other for video data.

    Inertial measurement unit data is processed to determine hard braking, hard accelerations and hard turns and GPS data. It also includes a timestamp, latitude, longitude, altitude, course over ground and the number of communicating satellites.

    The video unit has built-in artificial intelligence functions that analyze video in real-time. The driver-facing camera is mounted in the left corner of the windshield and is directed to the driver’s face to analyze his/her behavior and facial expressions. The forward-facing camera is mounted under the rearview mirror and is used to record events external to the vehicle.

    Driver-facing indices include face detection, eye detection (open or closed), yawning, distraction, smoking and mobile phone use. Behavior indices include traffic sign detection (running a red light), object detection (pedestrian, cyclists, curbs, barriers or nearby vehicles), lane crossing, near-collision and pedestrian detection.

    “These travel-pattern-related driver behavior indices are known to be indicative of the changes in older drivers’ cognition and physical functions since they tend to incorporate deliberate avoidance strategies to compensate for age-related deficits,” said Tappen. “Driver behavior indices are evaluated for each driver and are summarized on a daily, weekly and monthly basis and are classified into four categories.”

    A total of 460 study participants will be recruited from Broward and Palm Beach counties in Southeast Florida and are classified into three diagnostic groups: mild cognitive impairment, early dementia and unimpaired (normal). The Louis and Anne Green Memory and Wellness Center operated by FAU’s College of Nursing serves as the testing site for a clinical battery including assessments of cognition, functioning in daily activities and mood (depression), and an additional set of tests including executive function and attention.

    “The innovation of our research project lies in the unobtrusive, rapidly and readily available in-vehicle sensing and monitoring system built upon modern open-source hardware and software using existing techniques to develop and customize the components and configure them for this new purpose,” said Tappen.

    The study is supported by a grant from the National Institute on Aging, National Institutes of Health (1R01AG068472) awarded to Tappen.

    Source:

    Florida Atlantic University

    Journal reference:

    Tappen, R., et al. (2023) Study protocol for “In-vehicle sensors to detect changes in cognition of older drivers”. BMC Geriatrics. doi.org/10.1186/s12877-023-04550-5.

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  • House of Lords committee opens call for evidence on prevention and consequences of preterm birth

    House of Lords committee opens call for evidence on prevention and consequences of preterm birth

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    The House of Lords Preterm Birth Committee has published its call for evidence as part of its inquiry looking into the prevention, and consequences, of preterm birth.

    The Committee is seeking evidence on a number of topics, including:

    • treatments and interventions that can assist in the prediction and prevention of preterm birth;
    • neonatal and longer-term care and support for babies born preterm;
    • existing clinical guidance relating to preterm birth, and how this is implemented;
    • the ethnic and socioeconomic inequalities seen in relation to preterm birth, and how these could be reduced;
    • priority areas for research to prevent preterm birth and improve care for mothers and babies.

    Members of the committee include; Lord Patel (obstetrician), Lord Winston (IVF pioneer), Baroness Watkins of Tavistock (Emeritus Professor of Nursing), and Baroness Cumberlege (former Under-Secretary of State for Health), and Baroness Wyld (Lords sponsor of the Neonatal Care (Leave and Pay) Act 2023.)

    Preterm birth affects around 8% of live births in England each year, and it can have serious and long-term consequences. It is the single biggest cause of neonatal mortality and morbidity in the UK.

    The Government has set an ambition to reduce the preterm birth rate to 6% of live births by 2025. Our inquiry will examine how preterm births can be prevented and their impact reduced, and whether Government policy is adequate to meet its target.

    We are keen to hear from parents with lived experience of preterm birth, health professionals, academics, charities, and professional organizations to ensure all views are considered.”

    Lord Patel, Chair, Preterm Birth Committee

    The complete list of questions, plus details of how to submit evidence by the deadline of Wednesday 27 March 2024, can be found on the committee’s website.

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  • Genetic variants influence blood pressure from early in life

    Genetic variants influence blood pressure from early in life

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    Certain genes associated with hypertension affect blood pressure from early in life, and they increase the risk of cardiovascular disease as you get older. However, you can do something about it.

    We are talking about really small differences, so small that they may fall within what is considered normal blood pressure. The problem is that they tend to last your whole life.” 


    Karsten Øvretveit, PhD Candidate at the Norwegian University of Science and Technology’s (NTNU) Department of Public Health and Nursing

    He is one of the researchers behind a new study that has looked at the relationship between gene variants and blood pressure in the population.

    The study shows that high blood pressure occurs in all age groups and that it is related to hereditary factors.

    “We found that genetic factors affect blood pressure from the first years of childhood and throughout your entire life,” says Øvretveit.

    Genetic data from large population studies

    High blood pressure is the main cause of heart attacks and strokes, and cardiovascular disease is the second most common cause of death in Norway, accounting for 23 per cent of all deaths in 2022.

    The direct medical cause of high blood pressure is unknown in many cases, but research shows that our genes play a signifcant role.

    “Lifestyle diseases are often caused by a combination of heredity and environment. Diseases are often the result of not only one, but very many genetic variants,” says Øvretveit.

    In order to find out how much a person is at risk of high blood pressure, researchers have used genetic data from large population studies. This has helped them develop a genetic risk score, which indicates how much your exact genetic makeup puts you at risk.

    Developing genetic risk scores

    Put very simply, a certain value is placed on each gene variant, which reflects the extent to which it can affect blood pressure. The variants are then “weighted”, i.e. some genes weigh more heavily than others, and the genetic risk score is then the sum of the genetic effects.

    “This is how people who are particularly at risk can be identified, and measures can be taken at an early stage before the condition is expressed.

    By keeping their blood pressure alow level, people with a high genetic risk score can achieve a lower risk of disease than people diagnosed with high blood pressure who we consider genetically protected,” says Øvretveit.

    To study the significance of the genetic risk, the researchers have used health data from participants in the HUNT Study from Trøndelag and from the British ‘Children of the 90s’ study. The latter includes health data from nearly 14,000 children from the time they were born until they were in their twenties. The Health Survey in Trøndelag (HUNT) is a large, Norwegian population-based health survey that includes health information and biological material from the inhabitants of Trøndelag. Since the first collection round in 1984, 250,000 people from Trondheim have participated.

    By comparing the blood pressure of the children who had the highest genetic risk with the children who were lowest on the scale, the researchers were able to see how the average blood pressure in the first group was higher from as early as the age of three. The difference lasted throughout their childhood and became more pronounced in adulthood.

    Difference increases with age

    “Although the differences in blood pressure are not very large, the time component is important. If your blood pressure is slightly elevated over many years, it will affect how prone you are to cardiovascular disease and kidney disease,” says Øvretveit.

    When the researchers compared the risk scores and health data of the HUNT Study participants, they saw that the differences in blood pressure between the participants with the highest and those with the lowest risk persisted throughout their whole lives.

    “We have been able to follow the same people from when they were around 37 until they were approximately 70 years old. We found that the differences persisted and resulted in various disease risks, where the differences in disease were quite large.”

    The researchers also found more positive results: if measures are taken, such as lifestyle changes and medications, the risk of disease can be significantly reduced.

    “By keeping their blood pressure at a low level, people with a high genetic risk score can achieve a lower risk of disease than people diagnosed with high blood pressure who we consider genetically protected. It seems that controlling your blood pressure matters more than genetics,” says Øvretveit.

    Large population studies provide good data

    As a basis for the study, Øvretveit and colleagues have used findings from the largest genetic study on blood pressure currently available, which includes data from over a million people. Øvretveit believes the study shows the possibilities that lie in genetic data from large population studies.

    “I don’t think you should start measuring blood pressure in every single child, but the type of data we have used in this study can be used in the future not only to prevent disease, but also to address the risk factors associated with a disease,” says Øvretveit.

    Is it a problem that Europeans are overrepresented in population studies?

    “Yes, it is, but we are now actively working on developing genetic risk scores that are adapted to other populations, and that can be used across many different populations,” says Øvretveit.

    To date, the researchers have identified around 1500 gene variants that have a clear connection with blood pressure, but the biological effect that many of these genes have on blood pressure is not known. In order to find a reliable method, the researchers had to identify high-risk combinations of gene variants and combinations that posed a lower risk through a process of trial and error. 

    “A common method for creating a risk score for genetic disease is to include only those gene variants that are known to have a strong connection with the disease,” says Øvretveit.

    But there are other methods such as including gene variants that produce effects we are more uncertain about. As a result, we get a lot more data in the calculation. 

    “Complex blood pressure traits may be affected by far more gene variants than we have identified so far. The methods we have developed allow this to be taken into account, but we also have to keep in mind that the individual effects of these variants are small,” says Øvretveit.

    The method that gave the most accurate risk score included over a million gene variants.

    “But there are far more that have a known connection with high blood pressure,” says Øvretveit.

    Source:

    Norwegian University of Science and Technology

    Journal reference:

    Øvretveit, K., et al. (2023). Polygenic risk scores associate with blood pressure traits across the lifespan. European Journal of Preventive Cardiology. doi.org/10.1093/eurjpc/zwad365.

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  • Study shows favorable response to app-based cancer pain management for children

    Study shows favorable response to app-based cancer pain management for children

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    A recent study led by Assistant Professor Lindsay Jibb of the Lawrence Bloomberg Faculty of Nursing and Scientist at The Hospital for Sick Children (SickKids) found that parents of young children with cancer, along with pediatric cancer clinicians are in favor of an app-based solution that Jibb and her team are creating, to help parents manage their child’s cancer pain at home.

    The study published in PLOS Digital Health showed that parents and clinicians not only found the pain management app to be helpful and safe, but also provided them with a sense of empowerment.

    “The burden of caring and pain management for these children falls on parents when they are at home, and kids can experience frequent and sometimes severe cancer pain,” says Jibb who holds the Signy Hildur Eaton Chair in Paediatric Nursing Research. “The goal of our mobile app is to ease this burden and help both parents and children receive better quality pain management.”

    As part of the qualitative study, participants were also invited to provide recommendations for the digital app. Many of these recommendations focused on accessibility and ease of use, but also the need for the app to be available in multiple languages, and with a gamification component to involve children where appropriate in their own care.

    Currently in a pilot stage, the app includes a library of pharmacological advice as well as advice for psychological and physical symptoms children may be experiencing. The algorithm-based instructions tell a parent how to help their child respond to certain types of pain, which can include actions such as belly breathing, stretching, or mindfulness sessions. The advice is targeted to the parent based on their child’s age and development stage. 

    In addition, a chat feature is being embedded into the app to further address the need for real-time support for parents something that groups such as the Ontario Parents Advocating for Children with Cancer (OPACC) Advisory Group have indicated is of considerable importance. The chat option will connect parents with a nurse in hospital, allowing them to ask questions and seek nurse-led clinical pain support for their child when needed.

    Digital and mobile apps are used for a variety of reasons, and it is surprising that they are not more routinely used in health care. As technology continues to advance, particularly with artificial intelligence, the capacity to connect people who are outside the hospital with real-time care and support will hopefully continue to expand.”


    Lindsay Jibb, Assistant Professor of the Lawrence Bloomberg Faculty of Nursing and Scientist at SickKids

    Participants pointed to some challenges the digital app could pose, such as the ability to measure pain thresholds and know when a doctor or clinician should intervene.

    “Pain is very subjective, and perhaps even more so for a child. As a result, some of the feedback we have received as part of this study is to ensure that multidimensional pain assessments, multi-modal pain management support, and pain tracking over time are dedicated features in the app,” says Jibb.

    This Jibb says, will address the need for a biopsychosocial approach to cancer pain management and ensure that each patient threshold is individualized to patients and their families.

    Jibb has currently received funding from the University of Toronto’s Connaught New Researcher Award to support the pilot rollout of this digital cancer pain management app to parents of children with cancer, in early 2024.

    Source:

    Journal reference:

    Jibb, L. A., et al. (2023). Parent and clinician perceptions and recommendations on a pediatric cancer pain management app: A qualitative co-design study. PLOS Digital Health. doi.org/10.1371/journal.pdig.0000169.

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