ScienceDaily (Aug. 3, 2011) — A signaling system in the brain previously shown to regulate sleep is also responsible for inducing lethargy during illness, according to research conducted at Oregon Health & Science University Doernbecher Children’s Hospital.
This research is particularly meaningful because it implies that a new class of drugs developed to treat sleep disorders can reverse the inactivity and exhaustion brought on by acute illness. Although the sleep drugs were initially designed to treat narcolepsy, they have the potential to restore energy and motivation in patients with acute and chronic disease, the researchers report. Their findings are published in the The Journal of Neuroscience.
“We all know what it means to feel ‘bad’ when we’re acutely ill. In particular, patients with chronic diseases experience a compromise in motivated behaviors. They don’t feel like getting up and doing anything. Yet the brain mechanisms behind this common experience have remained obscure,” said Daniel L. Marks, M.D., Ph.D., principal investigator and associate professor of pediatrics in the Papé Family Pediatric Research Institute at OHSU Doernbecher Children’s Hospital….
- For Men and Women, Response to Stress Is Very Different (fitsugar.com)
- Too Sick to Work? (webmd.com)
(Garrison, NY) In a feature article in The New Republic,(subscription only, check your local public library for availability) Daniel Callahan and Sherwin Nuland propose a radical reinvention of the American medical system requiring new ways of thinking about living, aging, and dying. They argue that a sustainable—and more humane— medical system in the U.S. will have to reprioritize to emphasize public health and prevention for the young, and care not cure for the elderly.
An interesting twist on their argument, which would aim to bring everyone’s life expectancy up to an average age of 80 years but give highest priority for medical treatment to those under 80, is that Callahan and Nuland are themselves 80 years old. Daniel Callahan, Ph.D., is cofounder and president emeritus of The Hastings Center and author most recently of Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System. Sherwin Nuland, M.D., is a retired Clinical Professor of Surgery at the Yale School of Medicine and author of How We Die and the Art of Aging. He is also a Hastings Center Fellow and Board member.
“The real problem is that we have medicine excessively driven by progress, which aims to rid us of death and disease and treats them as the targets of unlimited medical warfare,” said Callahan and Nuland. “That warfare, however, has come to look like the trench warfare of World War I: great human and economic cost for little progress. Neither infectious disease nor the chronic diseases of an aging society will soon be cured. Cancer, heart disease, stroke, and Alzheimer’s disease are our fate for the foreseeable future. Medicine and the public must adapt it to that reality, one that has mainly brought us lives that end poorly and expensively in old age.”
The article notes that the Affordable Care Act might ease the financial burden of this system, but not eliminate it. It reports, for example, that the cost of Alzheimer’s disease is projected to rise from $91 billion in 2005 to $189 billion in 2015, and to $1 trillion in 2025 – twice the cost of Medicare expenditures for all diseases now.
“We need to change our priorities for the elderly. Death is not the only bad thing that can happen to an elderly person,” the authors write. “An old age marked by disability, economic insecurity, and social isolation are also great evils.” They endorse a culture of care, not cure, for the elderly, with a stronger Social Security program and a Medicare program weighted toward primary care that supports preventative measures and independent living.
Callahan and Nuland point the way to a more sustainable path that reprioritizes the entire system. Among their recommendations:
- improve medicine at the level of public health and primary care, while reducing its use for expensive high-tech end-of-life care;
- shift resources for the elderly to greater economic and social security and away from more medical care;
- subsidize the education of physicians, particularly those who go into primary care, and decrease medical subspecialization;
- train physicians better to tell the truth to patients about the way excessively aggressive medicine can increase the likelihood of a poor death;
- shift the emphasis in chronic disease to care rather than cure;
- conduct a top-down, bottom-up, long-range study of the entire American system of health care, including the training of physicians, with a view toward reconstituting it along systematic lines that take science, humanistic concerns, economics, and social issues into account.
- Andrew Reinbach: Health Care Could Kill Us: We Don’t Have to Let It (huffingtonpost.com)
- New at Reason: Ronald Bailey on Health Care Reform (reason.com)
ScienceDaily (Mar. 29, 2011) — Members of California’s aging lesbian, gay and bisexual population are more likely to suffer from certain chronic conditions, even as they wrestle with the challenges of living alone in far higher numbers than the heterosexual population, according to new policy brief from the UCLA Center for Health Policy Research.
Half of all gay and bisexual adult men in California between the ages of 50 and 70 are living alone, compared with 13.4 percent of heterosexual men in the same age group. And although older California lesbians and bisexual women are more likely to live with a partner or a family member than their male counterparts, more than one in four live alone, compared with one in five heterosexual women.
A lack of immediate family support may impact aging LGB adults’ ability to confront statistically higher rates of diabetes, hypertension, poor mental health, physical disability and self-assessed fair or poor health, compared with demographically similar aging heterosexual adults.
The study, which draws upon three cycles of data from the biennial California Health Interview Survey (CHIS), underscores the importance of considering these unique needs and chronic health conditions in providing health care and social services to the estimated 170,000 self-identified aging LGB adults in California — a population that will double in size over the next 20 years.
“Many aging LGB Californians do not have biological children or strong family support,” said Steven P. Wallace, the lead researcher on the project. “Organizations that serve these communities need to take this into account and consider outreach and support mechanisms that enable these individuals to maintain their independence and ability to age safely and in good health.”
The policy brief, “The Health of Aging Lesbian, Gay and Bisexual Adults in California,” includes the first data published on aging LGB adults based on a large statewide population. And among a population whose health needs are too often associated only with HIV and AIDS, the study offers the first insights about broader health conditions and trends….
- Groundbreaking report released: ‘Bisexual Invisibility: Impacts and Recommendations’ (pinkbananaworld.com)
- Lesbians, gays, bisexuals at higher risk for severe mental health problems (news.bioscholar.com)
- San Francisco Human Rights Commission Approves Groundbreaking Report: Bisexual Invisibility: Impacts and Recommendations (pinkbananaworld.com)
- Day 27- Sexuality in the US (feministactivism.wordpress.com)
- Bullying, Harassment of Gay/Lesbian Teens: Expert Q&A (webmd.com)
- Strong link found between victimization, substance abuse (eurekalert.org)
- Physiological Impacts Of Homophobia (mccswu.wordpress.com)
- Americans Have Higher Rates of Most Chronic Diseases Than Same-Age Counterparts in England (jflahiff.wordpress.com)
- Doctors lack data on LGBT community: report
This February 28 2011 report is published by the Pew Research Center, a “nonpartisan “fact tank” that provides information on the issues, attitudes and trends shaping America and the world. It does so by conducting public opinion polling and social science research; by analyzing news coverage; and by holding forums and briefings. It does not take positions on policy issues.” [From the Pew Research Center About Page]
Some excerpts from the report
- Many Americans turn to friends and family for support and advice when they have a health problem. This report shows how people’s
networks are expanding to include online peers, particularly in the crucible of rare disease. Health professionals remain the central
source of information for mostAmericans, but “peer‐to‐peer healthcare” is a significant supplement.
- One in five internet users have gone online to find others like them.Eighteen percent of internet users say they have gone online
to find others who might have health concerns similar to theirs.
- In the moment of need, most people turn to a health professional for information, care, or support. When asked about the last time they had a health issue, 70% of adults in the U.S. say they receivedinformation, care, or support
from a health professional.
ICU communication study reveals complexities of family decision-making
While a much hailed communication intervention works for families making decisions for chronically-ill loved ones in medical intensive care units, Case Western Reserve University researchers found the intervention was less effective for surgical and neurological ICU patients.
Barbara Daly and Sara Douglas, the study’s lead researchers from the Frances Payne Bolton School of Nursing at Case Western Reserve, attribute the varied results to different types of patients served by the three types of ICUs and differences among ICU cultures.
“We found the same approach is not going to have the same results for everyone,” Daly said
With the number of ICU patients predicted at more than 600,000 patients annually by 2020, researchers search for ways to help families make critical decisions for their loved ones. This study contributes to those ICU practices involving complex communication issues.
The researchers repeated a study from a Boston hospital that resulted in shorter stays and less unneeded tests and treatments when families were routinely informed through a systemized communications intervention about their family member’s progress in a medical ICU. They compared the effect of the new communication system in 346 patients to usual practice in 135 patients.
The intervention involved a 30-minute communication meeting between the clinical staff and family, beginning five days after a patient requiring a ventilator was admitted to the ICU. The staff and family covered five components: medical update, preferences and goals for the patient, treatment plans, prognosis, and milestones (the markers that can tell whether a person is improving).
The meetings continued weekly until the patient was transferred to a regular hospital ward, to a long-term facility, went home or died.
According to Daly, the discussions are important because up to 40% of these ICU patients do not survive beyond two months if they have spent more than five days on a mechanical ventilator.
For survivors, the most likely outcome is for long-term care, which raises issues about the quality of life that the patient might want to have, she said.
Overall, the researchers found no significant differences between the control and intervention groups in length of stay in the ICU or in limitations of aggressive interventions.
“The Boston study had been the ideal situation where the director of the ICU was conducting the study and the ICU staff accepted the intervention as part of its routine practices, said Daly, professor of nursing and clinical ethics director at University Hospitals Case Medical Center. “We took the study into real-life situations.”
Daly attributes the varying effectiveness of the new communication system to different ages and needs of patients in the medical, compared to surgical units and to differences in clinical staff attitudes towards decisions to limit aggressive interventions, such as feeding tubes and tracheostomy.
In the medical units, the patients generally are older and chronically ill—many suffering several chronic illnesses. The other ICUs generally serve younger patients who are more likely to have suffered a sudden acute health crisis, such as an emergency surgery or trauma from a motor vehicle accident.
Daly said many treatments in the medical ICU will not sustain life, and families face complicated end-of-life decisions to stop or continue ineffective treatments.
The research group also tracked conversational interchanges between family members and doctors.
All families received medical updates. About 86% of the meetings covered treatment plans; 94%, prognosis; 78 percent, preferences and goals; and only 68%, milestones.
Daly said analyses of the types of conversations found that 98% of the time was spent relaying facts about the patient, and only 2% was spent on personal, emotional, or relationship conversation.
The researchers also found that on average, doctors asked families one question, which was: “Do you have any questions?”
The families asked an average of six.
“Better communications is needed. Overall the process is not working as well as we would like and there are missed opportunities to better support families in their decisions,” Daly concluded.
The full results of the National Institute for Nursing Research-funded study were published in the article, “Effectiveness Trial of an Intensive Communication Structure for Families of Long-Stay ICU Patients,” in the journal Chest.
The U.S. Department of Health and Human Services today issued its new Strategic Framework on Multiple Chronic Conditions― an innovative private-public sector collaboration to coordinate responses to a growing challenge.
More than a quarter of all Americans ― and two out of three older Americans ― have multiple chronic conditions, and treatment for these individuals accounts for 66 percent of the country’s health care budget. These numbers are expected to rise as the number of older Americans increases.
The health care system is largely designed to treat one disease or condition at a time, but many Americans have more than one ― and often several ― chronic conditions. For example, just 9.3 percent of adults with diabetes have only diabetes, according to the Medical Expenditure Panel Survey from the Agency for Healthcare Research and Quality (AHRQ). And as the number of chronic conditions one has increases, so, too, do the risks of complications, including adverse drug events, unnecessary hospitalizations and confusion caused by conflicting medical advice.
The new strategic framework ― coordinated by HHS and involving input from agencies within the department and multiple private sector stakeholders ― expects to reduce the risks of complications and improve the overall health status of individuals with multiple chronic conditions by fostering change within the system; providing more information and better tools to help health professionals ― as well as patients ― learn how to better coordinate and manage care; and by facilitating research to improve oversight and care.
“Individuals with multiple chronic conditions deserve a system that works for them,” said Assistant Secretary for Health Howard K. Koh, MD, MPH. “This new framework provides an important roadmap to help us improve the health status of every American with chronic health conditions.”
The management of multiple chronic conditions has major cost implications for both the country and individuals. Increased spending on chronic diseases is a key factor driving the overall growth in spending in the Medicare program. And individuals with multiple chronic conditions also face increased out-of-pocket costs for their care, including higher costs for prescriptions and support services.
“Given the number of Medicare and Medicaid beneficiaries with multiple chronic conditions, focusing on the integration and coordination of care for this population is critical to achieve better care and health for beneficiaries, and lower costs through greater efficiency and quality,” said Centers for Medicare and Medicaid Services Administrator Donald Berwick, MD.
The Affordable Care Act, with its emphasis on prevention, provides HHS with exciting new opportunities to keep chronic conditions from occurring in the first place and to improve the quality of life for patients who have them.
“We need to learn rapidly how to provide high quality, safe care to individuals with multiple chronic conditions. AHRQ’s investments assess alternative strategies for prevention and management of chronic illness, including behavioral conditions, in persons with varying combinations of chronic illnesses,” said AHRQ Director Carolyn M. Clancy, MD.
HHS has taken action in recent months to improve the health of individuals with multiple chronic conditions. Some examples include:
- Administration on Aging (AoA)/ Centers for Medicare and Medicaid Services Administrator (CMS)
AoA and CMS jointly announced $67 million in grants to support outreach activities that encourage prevention and wellness, options counseling and assistance programs, and care transition programs to improve health outcomes in older Americans.
- Agency for Healthcare Research and Quality (AHRQ)
AHRQ awarded more than $18 million dollars (American Recovery and Reinvestment Act) in two categories of grant awards to understand how to optimize care of patients with multiple chronic conditions.
- Assistant Secretary for Planning and Evaluation (ASPE)
As part of an existing $40 million ASPE contract, the National Quality Forum is undertaking a project to develop and endorse a performance measurement framework for patients with multiple chronic conditions.
CDC is supporting a new project ― Living Well with Chronic Disease: Public Health Action to Reduce Disability and Improve Functioning and Quality of Life ― in which the Institute of Medicine will convene a committee of independent experts to examine the burden of multiple chronic conditions and the implications for population-based public health action.
CMS has provided recent guidance to State Medicaid directors on a new optional benefit available Jan. 1, 2011, through the Affordable Care Act, to provide health homes for enrollees with at least two chronic conditions, or for those with one chronic condition who are at risk for another.
- Food and Drug Administration/ Assistant Secretary for Planning and Evaluation (FDA/ASPE)
FDA and ASPE launched a study to examine the extent to which individuals with multiple chronic conditions are being included or excluded from clinical trials for new therapeutic products.
- Indian Health Service (IHS)
IHS has expanded its Improving Patient Care Program to nearly 100 sites across the tribal and urban Indian health system to assist in improving the quality of health care for patients with MCC.
NIH has committed $42.8 million for a study to determine whether efforts to attain a lower blood pressure range in an older adult population will reduce other chronic conditions.
SAMHSA awarded $34 million in new funding to support the Primary and Behavioral Health Care Integration Program, which seeks to promote the integration of care with people with co-occurring conditions.
For more information about the new HHS Strategy on Multiple Chronic Conditions, go to:http://www.hhs.gov/ash/initiatives/mcc/