Saturday, December 24, 2016

My favorite public health and health care books of 2016

I took a different approach to this year's top 10 list: rather than selecting only books published in this calendar year, as I did in 2015, I decided to make eligible any book that I read this year, regardless of when it was published. Books are listed in alphabetical order rather than order of preference/enjoyment: they were all compelling reads in their own ways.

Merry Christmas, Happy Holidays, and Happy New Year to all!


1. Adventures of a Female Medical Detective: In Pursuit of Smallpox and AIDS, by Mary Guinan with Anne D. Mather

2. Dying and Living in the Neighborhood: A Street-Level View of America's Health Care Promise, by Prabhjot Singh

3. The Gene: An Intimate History, by Siddhartha Mukherjee

4. In A Different Key: The Story of Autism, by Jon Donvan and Karen Zucker

5. League of Denial: the NFL, Concussions, and the Battle for Truth, by Mark Fainaru-Wada and Steve Fainaru

6. Pandemic: Tracking Contagions, from Cholera to Ebola and Beyond, by Sonia Shah

7. The Practical Playbook: Public Health and Primary Care Together, by J. Lloyd Michener and co-editors

8. Pulse - Voices from the Heart of Medicine: Editor's Picks: A Third Anthology, by Paul Gross and co-editors

9. Religion As a Social Determinant of Public Health - by Ellen Idler, editor

10. Twelve Patients: Life and Death at Bellevue Hospital, by Eric Manheimer

Wednesday, December 21, 2016

Yes, health policy agendas can be bipartisan

Between the party-line Democratic votes to pass the Affordable Care Act in 2010 and the very likely party-line Republican votes to repeal critical parts of it in early 2017, a bipartisan group of state health policy leaders (Reforming States Group) recently released a letter to the incoming Administration that proposes a modest federal-state policy agenda designed to advance the Triple Aim.

Three members of the group summarized their proposals in a Perspective article in the New England Journal of Medicine that began with language that was music to my public health-trained ears:

State leaders understand that as a society we are spending our health care dollars in the wrong ways for the wrong things — emphasizing treatment over prevention and medical care over social services. ... High-cost, high-need patients swamp Medicaid programs; prisons have become de facto treatment systems for substance use disorders; today’s neglected children are tomorrow’s state responsibilities; low- and middle-income families struggle with rising health care payments; and the demands of an aging population increasingly tax families, health care systems, and communities.

The four key components of their agenda are as follows:

1) Support state efforts for broad reforms of health care payment and delivery.
2) Support state efforts to address causes and improve management of chronic illness.
3) Support state use of data to inform policy.
4) Strengthen the state-federal partnership on health to assure the greatest impact from federal investments.

Limited as it is, this bipartisan policy consensus has a chance to gain traction as a "long-term agenda for governing" because intentionally "avoids focusing on any single health care issue currently grabbing headlines." Improving population health is, after all, a long-term proposition that requires vision rarely seen in national politics these days. For example, buried in the acclaim heaped upon the recently enacted 21st Century Cures Act was that well over half of it was paid for by gutting the Prevention and Public Health Fund, which had already sustained substantial cuts in previous years to offset more visible or politically advantageous budget priorities.

In an era of increasing federal government paralysis, perhaps state leaders can find a way forward on priorities for health reform. Before Obamacare, there was Romneycare. There are still too many people in this country who can't access essential social services or medical care (even if they have health insurance). Too many people who have health insurance but delay dental care they can't afford and suffer permanently debilitating consequences. If President-Elect Trump wants to "make America great again," he can start by recognizing that we are far too great a nation to continue to allow these things to happen.

Monday, December 19, 2016

How can medical educators support students' well-being?

Even twenty years later, I remember well the pervasive despair that engulfed me for much of my first two years of medical school. Even with a personal support system that included my family and several former college roommates and friends who lived in the same city, I struggled to find my bearings, academically and emotionally. Now that I spend much of my time teaching first-year medical students, I have wondered if the learning environment that I and other faculty provide contributes negatively or positively to their well-being.

A recent systematic review in JAMA examined the self-reported prevalence of depression, depressive symptoms, and suicidal ideation in medical students from 43 countries who were surveyed from 1982 to 2015. Longitudinal studies showed that students' mental health worsened significantly after starting medical school, with a median absolute increase in symptoms of 13.5%. On average, 27 percent of students reported depression or depressive symptoms, but only 16 percent of those students sought formal treatment. In contrast to my own experience, which was feeling much happier once I began third-year clerkships, there was no significant difference in depression prevalence between the preclinical and clinical years. Most alarmingly, 11 percent of students in these studies reported having suicidal thoughts during medical school.

A second systematic review examined associations between learning environment interventions and medical student well-being. The evidence base was limited: only 3 of 28 included studies were randomized trials, and most studies were conducted at a single site. Interventions that appeared to be effective in improving students' well-being included pass/fail grading systems, increased time with patients during the preclinical years, mental health programs, wellness programs including mind-body stress reduction skills, and formal advising/mentoring programs. In an accompanying editorial, Dr. Stuart Slavin observed that the educational culture of some medical schools is often an obstacle to implementing these kinds of reforms:

When signals of problems involving student mental health arise, the reaction in medical education has commonly been failure to recognize that the main problem is often with the environment, not the student. The response has often been limited, such as advising students to eat well, exercise, do yoga, meditate, and participate in narrative medicine activities. These approaches ... may distract educators from recognizing that the learning environment is at the core of the problem, and more must be done to improve it.

To be sure, maximizing student well-being is not the only or even the most important goal of medical education. But just as it is possible to create positive practice environments that protect clinicians from burnout, educators can prepare students to practice medicine competently in learning environments that are least likely to harm their mental health.


This post first appeared on the AFP Community Blog.

Tuesday, December 13, 2016

Imitation may be a form of flattery, but plagiarism hurts

I don't envy Dr. Michael Dansinger, whose scientific paper on the effects of commercial diets on surrogate markers of cardiovascular disease, originally submitted to the Annals of Internal Medicine, was stolen by one of the paper's external peer reviewers and published as the reviewer's own research in another medical journal. But unlike others whose work has been plagiarized, he had the satisfaction of not only seeing the plagiarized article retracted with an apology, but being able to publicly call out the plagiarist in a letter published yesterday in the Annals. As further explained in an accompanying editorial from editor Christine Laine, the plagiarist, Italian researcher Carmine Finelli, invented an imaginary cohort of European patients to replace those in Dansinger's U.S. study and recruited seven co-authors to play supporting roles in this scientific charade: "They allowed their names to be used, apparently without contributing anything of value - not even verification of the study's existence."

When I tweeted a link to Dansinger's letter early yesterday evening, some followers responded with incredulity that Finelli (whose scientific stature was high enough that he was invited to review for such a prestigious journal) thought he could possibly get away with such a brazen act without having it ruin his career. But plagiarism in the medical literature is unfortunately quite common, and as the popular blog Retraction Watch illustrates, often goes undetected for years.

Although ripping off an entire study, as in this case, is relatively rare, more frequently authors will plagiarize only parts of articles and/or make perfunctory efforts to reword stolen paragraphs to obscure their original source. This actually happened to me in 2010, when the entire introduction to my previously published review of screening for prostate cancer ended up in a ghostwritten primary care supplement sponsored by the American Urological Association (which, ironically, has strongly disputed the findings of my review).

One of my miscellaneous duties as a medical editor for American Family Physician has been investigating accusations of plagiarism. In one year, my investigations led three different articles to be retracted from their respective journals for plagiarizing all or part of reviews published in AFP. Unfortunately, I found that many journal editors (especially those operated by predatory publishers) were not nearly as enthusiastic as Dr. Laine about getting authors to admit any wrongdoing. And in more than one case, after I contacted the plagiarist's academic institution, it was unclear to me whether he or she would be subject to any disciplinary action.

Nineteenth-century English cleric Charles Caleb Colton is generally acknowledged as the source of the quotation "Imitation is the sincerest form of flattery." But I agree with the unnamed author of this 2011 blog post that plagiarism is neither imitation nor flattery:

The reason I am against this notion of plagiarism as flattery is that it is used as a reason to discourage the aggrieved author from taking action or being less stern with the action they take. While it is one thing to try to provide comfort to someone who is upset, I routinely read on forums that the victim should just “drop it” as they should feel “flattered” by the use and “let it go”.

Strangely, this is one of only a few situations where we tell the victims of an act that they should feel flattered. We don’t tell people who had their car stolen to be grateful the thief thought they had a nice car or someone who was mugged that they looked like a wealthy person. ... Plagiarists aren’t misguided critics or failed creators who are giving tacit approval of a work as they plagiarize. The victims of plagiarism are chosen the same way as any other victims are chosen.

Kudos to Dr. Laine for publishing Dr. Dansinger's broadside against plagiarists everywhere, and putting intellectual thieves on notice that they can and will be called to account for their crimes.

Thursday, December 8, 2016

Signed Out Of Prison But Not Signed Up For Insurance, Inmates Fall Prey To Ills

Jay Hancock, Kaiser Health News and Beth Schwartzapfel, The Marshall Project

INDIANAPOLIS — Before he went to prison, Ernest killed his 2-year-old daughter in the grip of a psychotic delusion. When the Indiana Department of Correction released him in 2015, he was terrified something awful might happen again.

He had to see a doctor. He had only a month’s worth of pills to control his delusions and mania. He was desperate for insurance coverage.

But the state failed to enroll him in Medicaid, although under the Affordable Care Act Indiana had expanded the health insurance program, making most ex-inmates eligible. Left to navigate an unwieldy bureaucracy on his own, he came within days of running out of the pills that ground him in reality.

“I have a serious mental disorder, which is what caused me to commit my crime in the first place,” said Ernest, who asked reporters to use only his middle name to protect his privacy. “Somebody should have been pretty concerned.”

The health law was expected to connect Ernest and almost all other ex-prisoners for the first time to Medicaid coverage for the poor, cutting expensive visits to the emergency room, improving their prospects of rejoining society and reducing the risk of spreading communicable diseases that flourish in prisons.

But Ernest’s experience is repeated millions of times across the country, an examination by The Marshall Project and Kaiser Health News shows.

Most of the state prison systems in the 31 states that expanded Medicaid have either not created large-scale enrollment programs or operate spotty programs that leave large numbers of exiting inmates — many of whom are chronically ill — without insurance.

Local jails processing millions of prisoners a year, many severely mentally ill, are doing an even poorer job of getting health coverage for ex-inmates, by many accounts. Jail enrollment is especially challenging because the average stay is less than a month and prisoners are often released unexpectedly.

Ex-inmates with the worst chances of getting insurance and care are in 19 states that did not expand Medicaid. Only a small number qualify for coverage. Enrollment efforts by prisons and jails are almost nonexistent.

Nationwide, 16 state prison systems have no formal procedure to enroll prisoners in Medicaid as they reenter the community, according to a survey by The Marshall Project. Nine states have only small programs in select facilities or for limited groups of prisoners, like those with disabilities. These 25 states collectively release some 375,000 inmates each year.

Failure to link emerging inmates to health insurance is a missed opportunity to improve health and save money by cutting recidivism as well as visits to the hospital emergency room, advocates say. Studies have showed Medicaid access in Florida and Washington cut return trips to jail among the mentally ill by 16 percent.

“I hate to say it — it’s a captive audience. You have somebody there! You know they’re going to be released in a few weeks,” said Monica McCurdy, who as head of a clinic for Project HOME in Philadelphia constantly sees homeless, recently released prisoners without Medicaid coverage. “Why not do the handoff that’s needed to prevent this person winding up in the ER? It defies common sense.”

Health Risks Soar After Prison Release

Before the Affordable Care Act, state Medicaid programs covered mainly children, pregnant women and disabled adults, which included only a small number of ex-offenders. That’s still generally the case in the 19 states that didn’t expand Medicaid.

President-elect Donald Trump has vowed to repeal the health act and replace it with something else, leaving the law’s Medicaid expansion and eligibility for ex-prisoners in doubt. Rep. Tom Price, Trump’s pick to head the Departmetn of Health and Human Services — which oversees Medicaid — has been one of Obamacare’s most vociferous critics in Congress.

But some analysts expect parts of the law to survive, perhaps including Medicaid expansion managed more directly by states than by Washington.

Even some Republicans have supported the idea, suggesting that revoking Medicaid coverage from millions of new recipients would be difficult. Republican Gov. John Kasich expanded Medicaid in Ohio in part for ex-inmates, he has said, “to get them their medication so they could lead a decent life.”

Other parts of the health law received more attention, but advocates saw giving Medicaid coverage to ex-inmates as one of its most transformative aspects. Illness for illness, inmates are the sickest people in the country.

They have far higher rates of HIV, hepatitis and tuberculosis than the general population. They’re also more likely to have high blood pressure, diabetes and asthma. More than half are mentally ill, according to the Bureau of Justice Statistics, with up to a quarter meeting criteria for psychosis. Between half and three-quarters have an addiction problem.

Prisons and jails have their own doctors, but their responsibility to provide care stops upon an inmate’s departure. Inmates generally aren’t eligible for Medicaid while imprisoned.

No time is more critical than the days immediately after release. One study showed that in the first two weeks, ex-prisoners die at a dozen times the rate of the general population. Heart disease, drug overdose, homicide and suicide are the main causes.

But even in states that expanded Medicaid, the most vulnerable and sometimes dangerous ex-inmates are often left on their own.

Ernest went to prison for shooting and killing his daughter amid a psychotic religious delusion. Re-enacting the biblical story of the sacrifice of Isaac, he thought God would intervene to save the girl. News reports from the time say police found him naked, carrying the child’s lifeless body through the streets of an Indianapolis suburb.

Indiana expanded Medicaid under the health law in February 2015 and set up a system to enroll all eligible prisoners upon release. Yet when Ernest got out in August 2015, he was not enrolled in Medicaid, let alone connected to doctors.

Prison officials say they applied for Medicaid on Ernest’s behalf, but Medicaid records show he applied when he got home. It’s not clear where the system failed.

“It is important that the offenders have some accountability in the process,” said Douglas Garrison, a spokesperson for the Indiana Department of Correction. “The IDOC has worked diligently to ensure released offenders are receiving coverage.”

Ernest’s letters to Medicaid and a clinic before he got out didn’t help. He had to start the application process from scratch after he got home, making increasingly frantic calls and scrambling to find his birth certificate and other paperwork as his supply of lithium and perphenazine, an antipsychotic, dwindled.

“Somebody who’s committed a violent felony because of a mental illness is getting out of prison, and we don’t have anything set up yet?” he said.

Failure to sign up ex-inmates for health care is a common occurrence in states that expanded Medicaid under the health law, even in places such as Indiana where agencies have provided enrollment assistance.

No Enrollment For Thousands Of Chronically Ill

Two-thirds of the 9,000 chronically ill prisoners released each year by Philadelphia’s jails aren’t getting enrolled as they leave, said Bruce Herdman, medical director for the jails. The city lacks even the $2 million necessary to supply a month’s worth of medication for released inmates with prescriptions, he said.

“They give you like two weeks’ supply of medication,” said Ricky Platt, 49, who left the Philadelphia jail in 2015, quickly ran out of Zoloft antidepressants and became homeless. “They don’t give you any resource of where to go or get a doctor and get your prescription filled or anything.”

Emergency doctors at Thomas Jefferson University Hospital in Philadelphia often see released inmates with kidney failure who are at risk of dying if they don’t receive dialysis almost immediately, said Dr. Priya Mammen, one of the hospital’s emergency physicians.

“We’re kind of the go-to spot for many people, but particularly for people who have been released from prison,” she said. “Either in the first week we see them or when their prescriptions run out.”

Kara Salim, 26, got out of the Marion County, Indiana, jail in 2015 with a history of domestic-violence charges, bipolar disorder and alcoholism — and without Medicaid coverage. As a result, she couldn’t afford the fees for court-ordered therapy.

Without therapy she wasn’t allowed to see a psychiatrist for her medications. Without medication she spiraled downward, eventually threatening suicide at a court hearing. When court officers tried to bring her to a psychiatric hospital, she erupted, kicking and scratching them and landing back in jail, with new felony charges: battery against a public safety officer.

“I wish I could tell you she’s the exception,” said Sarah Barham, an addiction counselor with Centerstone, an Indiana nonprofit.

Medicaid enrollment requires resources that many prison systems and local jails — often overcrowded and operating in crisis mode for years — lack or have been reluctant to commit.

“Most of the county sheriffs don’t have the proper staff they need to even run the jails,” said Bill Wilson of the Indiana Sheriffs’ Association. Many jails are making an effort, but in some places “pulling the resources out to enroll an inmate in Medicaid is not something the sheriff’s able to do.”

In Minnesota, only those eligible for special release planning programs are offered assistance in applying; as a result, fewer than 1,000 of the 6,800 prisoners the state released last year applied for Medicaid, according to corrections officials there. Minnesota is one of seven states — Alaska, Hawaii, Arizona, Montana, Louisiana and Illinois are the others — that expanded Medicaid but have not implemented a large-scale enrollment program.

In many states, even prerelease registration requires a follow-up visit to a local Medicaid or welfare office to “activate” the coverage on release. Obtaining a phone, paying for minutes and navigating bus lines to state offices can be daunting for newly released inmates who often struggle with basic needs such as food and shelter.

Indiana officials applied for Medicaid on behalf of more than 7,000 state prisoners from March through September — nearly 90 percent of those released. (Many of the others were released to other states or deported, officials said.) Yet only a little more than half called to activate their coverage when they got home, according to state data. The state said in recent weeks it eliminated the requirement to activate coverage with a call.

Released prisoners also often need to reestablish identification by applying for Social Security cards and birth certificates. That can take weeks or months. Sometimes there’s another step: enrolling in one of the private, managed care networks that many states hire to administer Medicaid benefits.

In the chaotic days and weeks after release, red tape can mean the difference between joining Medicaid or remaining cut off from community caregivers.

William Santee, 46, released from Pennsylvania state prison this year, has diabetes, high cholesterol and high blood pressure. He learned about Medicaid enrollment requirements and the need to visit a welfare office from workers at a homeless shelter.

The prison “didn’t tell me about where to go or anything like that,” he said. “They don’t consider that their responsibility.” Waiting in line and completing the welfare-office paperwork took five hours.

Getting The Details Right

Almost as critical as successful enrollment is choosing a Medicaid plan that covers medicines and services ex-inmates need. Jail and prison workers are rarely equipped to wade through such details.

“That’s a huge issue for us,” said Susan Jo Thomas of Covering Kids and Families, a nonprofit that helps enroll people in Medicaid in Indiana. “You finally get a person to the place where they are ready … to go into detox, but if they have aligned with an insurance company that doesn’t cover the medicine that program uses, then you have a problem.”

In some extreme cases bureaucratic rules clash, leaving ex-prisoners stranded between agencies. In Indiana and several other states, corrections departments consider prisoners in work release programs, who report to jobs during the day, to be free. That means they’re not eligible for care from the prison system.

Medicaid, on the other hand considers them still incarcerated. So they can’t enroll in community health coverage, either.

“We got all excited when Obamacare came out, because everybody’s going to be covered,” said Peggy Urtz, who runs an Iowa work release facility for women. Instead, she said, the women “are going to ERs when they’re ill and racking up medical bills. We have good providers, well experienced in working with women, and they can’t go to them because they don’t have insurance.”

A few states and localities reap praise for innovative and comprehensive attempts to enroll emerging prisoners in Medicaid.

Ohio recently finished phasing in Medicaid registration at all state prisons and is one of the few states giving inmates a managed-care insurance card as they leave, said John McCarthy, that state’s Medicaid director. Chicago’s huge Cook County jail puts prisoners on the Medicaid books as they enter, rather than before they leave, to sidestep the common problem in jails of unpredictable release dates.

More often the process looks like what was happening one recent Friday in Indiana’s Marion County jail, where Lt. Debbie Sullivan was trying to rouse sleepy women to sign up for health insurance.

The document she distributed was three pages long, authorizing a Medicaid application on inmates’ behalf. It asked for names, addresses, birth dates and Social Security numbers. The handwritten information would later be entered into computers — a recipe for transposed digits and misspelled names.

“The program remains a work in progress,” said Katie Carlson, a spokeswoman for the Marion County Sheriff’s Office, which runs the jail. “It has proven a daunting task to enroll, track and provide meaningful information on both Medicaid and health care.”

Experts say such sessions require a half hour or more to get the details right and answer questions about picking the right plan and following up with doctors and insurance officials after release.

Sullivan’s knowledge of the women’s next steps was minimal. In response to questions, she simply told them to contact their local social service office when they get out. She walked out of the block with about 30 signed applications. It was over in 15 minutes.

“Thank you ladies!” she called on her way out, as the heavy steel door slammed behind her.


This post was originally published on Kaiser Health News (KHN), a national health policy news service and an editorially independent program of the Henry J. Kaiser Family Foundation. This article is published in partnership with The Marshall Project, a nonprofit news organization covering the U.S. criminal justice system, NPR, and Side Effects Public Media, a news collaborative covering public health.

Thursday, December 1, 2016

The USPSTF weighs in on statins for primary CVD prevention

In other blog posts, I have discussed the 2013 American College of Cardiology/American Heart Association cholesterol treatment guideline, offered additional perspectives on its 7.5% 10-year CVD event risk threshold for starting a statin, and noted that existing cardiovascular risk calculators tend to overestimate risk by significant margins. The ACC/AHA guideline's expansion of the proportion of adults recommended for statin therapy has remained controversial. The American Academy of Family Physicians partially endorsed the guideline with qualifications (disclosure: I am a member of the AAFP Commission that made this recommendation), and a 2014 guideline from the U.S. Departments of Veterans Affairs and Defense recommended higher thresholds for considering (6%) or starting (12%) statins.

Last month, the U.S. Preventive Services Task Force weighed in with a new recommendation statement on the use of statins for primary prevention of cardiovascular events. The recommendations are similar to those from the ACC/AHA; the USPSTF recommends initiating low- to moderate-dose statins in adults aged 40 to 75 years with at least one CVD risk factor (dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year CVD event risk of 10% or greater ("B" recommendation). They recommend shared decision making and selective statin prescribing for similar adults with a 7.5% to 10% CVD risk ("C" recommendation).

The USPSTF's higher risk thresholds for statin therapy may compensate for uncertainty regarding the accuracy of CVD risk calculators, and the "C" recommendation recognizes that in persons at lower risk, the benefits of statins are less likely to outweigh the harms, which include liver enzyme abnormalities and muscle toxicity and a small increased risk of new-onset type 2 diabetes.

Although a prior USPSTF statement had recommended screening for lipid disorders in adults as early as 20 years of age, a new systematic review found no direct evidence on the benefits and harms of screening for or treatment of dyslipidemia in adults aged 21 to 39 years. So when should family physicians check cholesterol levels in an asymptomatic adult, if statins don't become a treatment option until age 40? This is an area to exercise clinical judgment on an individual basis, keeping in mind that healthy lifestyle counseling is more likely to be beneficial in adults with CVD risk factors than in adults without known risks.


This post first appeared on the AFP Community Blog.