Posts Tagged ‘Harvard Medical School’

Brain Scans a Tool In Early Alzheimer’s Detection

Tuesday, January 3rd, 2012

Researchers believe they can see revealing brain shrinkage years before a person develops memory loss or other symptoms of Alzheimer’s disease. The new finding may ultimately let physicians detect the disease and treat patients earlier with the goal of keeping them functional longer.

Massachusetts General Hospital and the University of Pennsylvania researchers used magnetic resonance imaging (MRI) scans to measure how thick the brain’s outer layer is in 159 people who did not suffer from memory loss.  Earlier studies have linked Alzheimer’s disease with distinctive shrinkage in nine regions of the brain’s gray matter, or cerebral cortex.  This is what physicians call the “Alzheimer’s signature.”

According to researchers, the brain shrinks as it loses nerve cells – more commonly known as neurons.  They aren’t entirely sure what causes this.  One theory is that the cells die after they become choked by excess amounts of two kinds of protein — beta amyloid and tau.  “The neurons degenerating over time are really what we think causes the shrinkage,” said researcher Brad Dickerson, M.D., an associate professor of neurology at Harvard Medical School and director of the frontotemporal disorders unit at Massachusetts General Hospital.  “And that shrinkage in their size is something you can measure with an MRI scan.”

Alzheimer’s is the sixth leading cause of death in the United States, according to the Alzheimer’s Association.  The number of deaths has increased in recent years, and there is no cure.  In the new study, researchers focused on how thick the edges of the brain are.  “We’re looking at the parts of the cortex that are particularly vulnerable to Alzheimer’s disease, parts that are important for memory, problem-solving skills and higher-language functions,” Dickerson said.

The 15 percent of participants – who averaged 76 years old –who had the thinnest brain areas performed poorly on the tests: About one in five of them were experiencing cognitive decline, as well as increases in signs of abnormal spinal fluid, a possible sign of developing Alzheimer’s disease.  “That suggests they may be developing symptoms,” according to Dickerson.

Susan Resnick, PhD, who works at the National Institute of Aging, wrote:  “The ability to identify people who are not showing memory problems and other symptoms but may be at a higher risk for cognitive decline is a very important step toward developing new ways for doctors to detect Alzheimer’s disease.”

Dr. Simon Ridley, from the charity Alzheimer’s Research UK, said, “The ability to predict who will develop Alzheimer’s disease is a key target for dementia research, as it would allow new treatments to be tried early, when they are more likely to be effective.  These findings add weight to existing evidence that Alzheimer’s begins long before symptoms appear, although it’s important to note that the study did not assess who went on to develop the disease.  This research provides a potential new avenue to follow, but we need to see larger and longer-term studies before we can know whether this type of brain scan could accurately predict Alzheimer’s.”

Writing in Time, Alice Park notes that “Alzheimer’s disease has always been difficult to diagnose — the only way to identify it definitively is by autopsying the brain after death — but scientists may now have an easier way to spot the degenerative brain disease long before that, even before symptoms appear, using brain scans.  By studying people’s brain scans over time, they were able to see that these nine brain regions appear to be thinner in people who eventually go on to develop Alzheimer’s — but that it takes many years for this structural difference to show up as symptoms of memory loss or cognitive problems.  Using this brain-size signature as a yardstick, the researchers decided to confirm the correlation by testing the patients’ cognitive abilities three years after a baseline brain scan.  Indeed, they found that 21 percent of participants, who had the thinnest Alzheimer’s-related brain regions but showed no signs of memory problems or other cognitive deficits at the start of the study did show signs of cognitive decline three years later, compared with none of the subjects who did not have the same brain thinning and seven percent who showed moderately thinner brain areas.”

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America’s Healthcare System Needs Improvement: Study

Wednesday, November 2nd, 2011

The American healthcare system is not very healthy, according to a wide-ranging new assessment of the system that covers 42 measures of healthcare delivery, the United States scored just 64 out of 100.  “Costs are up sharply, access to care deteriorated, health system efficiency remains low, disparities persisted, and health outcomes fail to keep pace with benchmarks,” concluded the 2011 National Scorecard on U.S. Health System Performance. The report was issued by the Commonwealth Fund, a nonprofit healthcare policy foundation.

There are some bright spots on the report.  For one, the number of Americans who are controlling their high blood pressure rose from 31 percent in 2008 to 50 percent in 2009.  Additionally hospitals have improved their ability to care for patients with heart attacks, pneumonia, and other common conditions.

The Commonwealth Fund report also determined that the typical U.S. infant mortality rate is 35 percent higher than the top-performing states.  Other wealthy countries still have infant mortality rates that are significantly lower than the best-performing states in the United States.  If the U.S. did as well as the top-performing country in that category — France — 91,000 fewer babies would die prematurely each year, Cathy Schoen, senior vice president at Commonwealth Fund said.  “These statistics are real,” she said.  “They are real human lives.”  Other “areas of concern” include childhood obesity, preventive care and infant mortality.

Another issue is cost, an oft-cited statistic that the U.S. spends more per person on healthcare than any other country.  According to the Commonwealth Fund report, the nation in general spends twice as much as comparable countries, but doesn’t have better care to show for it.  “We are headed toward spending $1 of every $5 of national income on healthcare,” the report’s authors said.  “We should expect a better return on this investment.”  The high cost of healthcare takes a toll on personal finances, the report said.  By 2010, 40 percent of working-age adults had medical debt or difficulties paying medical bills, an increase of 34 percent when compared with 2005.

It is important to note that the majority of the report’s data is from 2007 – 2009, prior to the passage of the Patient Protection and Affordable Care Act (ACA).  The healthcare reform law is likely to lead to improved scores on some of the categories, particularly access and affordability.  For example, 25 percent of residents in 15 states lacked health insurance.  The ACA will require that all Americans have health insurance in 2014.  It also will reduce eligibility requirements for Medicaid so more low-income people will be eligible, and provide government subsidies to others who can’t buy insurance on their own.

The report’s authors remain optimistic that the health reform law will address many of the problems highlighted in the report.  “This scorecard illustrates that focused efforts to change the healthcare system for the better are working and are worth the investment,” said Maureen Bisognano, president and CEO of the Boston-based Institute for Healthcare Improvement.  “If we target areas where we fall short and learn from high-performing innovators with the United States, we should see significant progress in the future,” said Dr. David Blumenthal, commission chair and professor of medicine and healthcare policy at Massachusetts General Hospital and Harvard Medical School.

Writing in the Huffington Post, a Social Epidemiologist at Columbia University, thinks that the price Americans pay for their healthcare is too high.  “It’s well known that Americans pay more for less when it comes to healthcare than just about any other country in the world.  In 2009, we spent nearly $8,000 per person to provide medical care to just over 80 percent of our population — that compares, for example, to just under $3,500 spent per person in the U.K. to provide care for the entire population.  To add injury to insult: our counterparts across the pond get an extra year of life for their $3,500 than we do for our $8,000.

“Why do we pay more for less when it comes to our health?  Every policy wonk has his theory.  Common ones include the high cost of American medical education (which is too expensive), or that permissive tort laws in the U.S. enable lawyers to profit from the health system (which is true).  But while each of these theories, and others, explain small quirks in our health system that certainly contribute to it’s gargantuan price tag, they don’t address the fundamental issue with our health system.  And that’s that our market-driven system introduces perverse financial incentives for medical providers that don’t align with the health or wellbeing of Americans.  This leads to wasted money and lost lives.

“In our healthcare system, the fundamental billing unit is the “procedure” — doctors charge per action, diagnostic or curative, taken on the part of a patient.  While, on the surface, rewarding doctors for each step they take to make a patient better may seem fair, it has disastrous consequences for the structure of our health system.  Chief among them is our top-heavy specialty physician structure,” El-Sayed concluded.

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I’m So Sleepy…

Tuesday, September 13th, 2011

People who can’t sleep at night tend not to consider their problem to be an illness that requires treatment, or a good reason to call in sick.  That mindset could hurt employers and employees by making insomniacs drag themselves to work and sleepwalk through the day, according to a new study.  Researchers surveyed 7,428 employed people and found that 23 percent experienced some form of insomnia — such as difficulty falling asleep or waking up during the night — at least three times a week during the previous month, for at least one-half hour at a time.  It should come as no surprise that these sleep problems carry over to their jobs.  Insomniacs were no more likely than their coworkers who slept well to miss work, but were so consistently tired that they cost their employers the equivalent of 7.8 days of work in lost productivity every year — an amount equal to an average of roughly $2,280 in salary per person.  That adds up to $63.2 billion (and 252.7 workdays) for the entire nation.

The majority of study participants did not physically miss work as a result of insomnia, said lead author Ronald Kessler, Ph.D., a psychiatric epidemiologist at Harvard Medical School.  They frequently show up too tired to perform their job effectively (a phenomenon known as “presenteeism”).  “Employers these days want their workers to stay home if they’re sick.  If they know you’re absent, they can at least find ways to fill in for you,” Kessler said.  “But you can’t stay home every day if you’re chronically sleep deprived, so these people get in the habit of going to work and then not performing.”

According to Kessler, “It’s an underappreciated problem. Americans are not missing work because of insomnia.  They are still going to their jobs but accomplishing less because they’re tired.  In an information-based economy, it’s difficult to find a condition that has a greater effect on productivity.”

Fully 23 percent of employees were estimated to have insomnia; that statistic was verified by sleep medicine experts, who independently evaluated a sub-sample of the study group.  Researchers also found that employees aged over 65 are less likely to be insomniacs (14 percent) and that men were less likely (20 percent) to have trouble sleeping than women (27 percent).  Because the typical cost of insomnia treatment ranges from $200 annually for a sleep aid to $1,200 per year for behavior modification therapy, the study’s author believes that screening and treating workers’ sleep issues may be worthwhile for employers.

“When we actually did the calculations we were amazed at the extent of the problem,” Kessler said. “It seems unbelievable that more than 250 million days a year of lost productivity can be attributed to insomnia.  Yet this hasn’t really been on anyone’s radar.  Worker screening programs and programs to teach workers good sleep hygiene may be very effective and could actually save employers money.  These programs might help people feel a lot better and get more done on the job.”

Donna Arand, Ph.D., a spokeswoman for the American Academy of Sleep Medicine, says the study underlines a problem that is well recognized by sleep specialists.  “What struck me most about the study was the fact that workers really weren’t calling in sick,” she says. “People with chronic insomnia are going to work but they aren’t functioning at their maximum.  We all experience this from time to time, but for people with insomnia it could be happening every day.  One of the most important things is to try to get up at the same time every day and go to bed at the same time every night, even on the weekends.  Routine is the key.”

People can be described as insomniacs when they have trouble sleeping for at least a month.  The causes can be alcoholism, anxiety, coffee, and stress; it can also result from medical conditions like depression.  The more insomniacs think about getting enough sleep, the more stressed they become, and that results in even less sleep.

“Now that we know how much insomnia costs the American workplace, the question for employers is whether the price of intervention is worthwhile,” Kessler said.  “Can U.S. employers afford not to address insomnia in workplace?”

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Healthcare: Saving Lives or Prolonging Suffering?

Thursday, August 12th, 2010

There is a cacophony of voices in the media talking about healthcare reform, but it’s more heat than light.  That why Atul Gawande’s most recent article in The New Yorker is so important. Boston-based Brigham and Women’s Hospital general and endocrine surgeon Gawande examines how the trend to prolonging life is one of the reasons behind soaring healthcare costs.Is healthcare saving lives or prolonging suffering? Everyone needs to read this.

According to Dr. Gawande in Letting Go, “Twenty-five percent of all Medicare spending is for the five percent of patients who are in the final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit.  Medical spending for a breast-cancer survivor, for example, averaged an estimated $54,000 in 2003, the vast majority of it for the initial diagnostic testing, surgery, and, where necessary, radiation and chemotherapy.  For a patient with a fatal version of the disease, though, the cost curve is U-shaped, rising again toward the end – to an average of $63,000 during the last six months of life with incurable breast cancer.

The big question Gawande poses is thus:  What are we getting in return?  “Patients who were put on a mechanical ventilator,” Dr. Gawande continues, “given electrical defibrillation or chest compressions, or admitted, near death, to intensive care, had a substantially worse quality of life in their last week than those who received no such interventions.  And, six months after their death, their caregivers were three times as likely to suffer major depression.”

Dr. Gawande notes that in one study, “Researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure.  Surprisingly, they found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer.  Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months.  The lesson seems almost Zen:  you live longer only when you stop trying to live longer.”

In one case Dr. Gawande describes, “Aetna decided to let a group of policy-holders with a life expectancy of less than one year receive hospice services without forgoing other treatments.  A patient like Sara Monopoli (who was diagnosed with terminal lung cancer at the age of 34) could continue to try chemotherapy and radiation, and go to the hospital when she wished – but also have a hospice team at home focusing on what she needed for the best possible life now and for that morning when she might wake up unable to breathe.  A two-year study of this ‘concurrent care’ program found that enrolled patients were more likely to use hospice:  the figure leaped from 26 percent to 70 percent.  That was no surprise, since they weren’t forced to give up anything.  The surprising result was that they did give up things.  They visited the emergency room almost half as often as the control patients did.  Their use of hospitals and I.C.U.s dropped by more than two-thirds.  Overall costs fell by almost a quarter.”

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President Obama Sneaks Dr. Donald Berwick Past Republican Opposition to Head CMS

Wednesday, July 14th, 2010

President Obama bypasses Senate to make Dr. Donald Berwick the head of Medicare and Medicaid. Facing a hostile approval process from Republicans in the Senate, President Barack Obama is making a recess appointment of Dr. Donald Berwick to head the Centers for Medicare and Medicaid Services (CMS), the agency that oversees Medicare and Medicaid.

A sharp critic of the way healthcare is delivered in the United States, Berwick believes the system is inefficient and lacks an efficient information-sharing apparatus.  In addition to his practice and academic work, Berwick is the founder of the Institute for Health Care Improvement, a think tank that focuses on “cultivating promising concepts for improving patient care and turning those ideas into action.”

Berwick, a Harvard-educated pediatrician and Harvard Medical School professor, believes in improving the quality of healthcare so physicians are rewarded for better outcomes rather than on a per-procedure basis.  Although it’s unlikely that this idea could be applied to the whole medical profession, Medicare and Medicaid are large enough that changing the traditional way healthcare is delivered would echo throughout medicine.  Together, Medicare and Medicaid cover 100 million Americans – approximately one-third – and accounted for $750 billion of federal spending in 2009.  According to the Congressional Budget Office, that totals 20 percent of the federal budget.

“Many Republicans in Congress have made it clear in recent weeks that they were going to stall the nomination as long as they could, solely to score political points,” according to Dan Pfeiffer, White House Communications Director.  “But with the agency facing new responsibilities to protect seniors’ care under the Affordable Care Act, there’s no time to waste with Washington game-playing.”

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Postpartum Depression Hits New Dads, Too

Monday, June 7th, 2010

As many as 10.4 percent in fathers of new babies suffer from postpartum depression. It’s not only mothers of newborns who sometimes grapple with postpartum depression after childbirth.  Fathers of new babies also can suffer from the condition, according to a study from the Journal of the American Medical Association.  In fact, JAMA notes, approximately 10 percent of new fathers experience the condition.

“Other fathers felt happy and joyous,” said Joel Schwartzberg, who suffered postpartum depression after the birth of his son 10 years ago.  “Inside, I felt like my world had collapsed, and along with that, I felt a great and incredible sense of responsibility.  I thought I was the only person in the world who was a bad dad.  I thought I was deficient, that I was handicapped.  What I learned was that I was not alone by any stretch.  It helped me relax; it helped me not be so hard on myself.”  Eventually, Schwartzberg sought medical treatment for his postpartum depression.

The study, performed by researchers at Eastern Virginia Medical School in Norfolk, analyzed 43 studies involving 28,004 men and found that just 4.8 percent of men fit the diagnosis of depression under normal circumstances.  That number climbed to 10.4 percent in fathers of new babies; three months following birth, the study found that approximately one fourth of the men studied were depressed.  Sleep deprivation could be a root cause, says William Courtenay, a researcher, psychotherapist and founder of www.saddaddy.com, who noted that men often act out through anger and irritability.  “A man who’s depressed can look like someone who’s stressed, angry, irritable and getting into conflict with others, or being withdrawn or drinking,” Courtenay said.  “We can also see classic signs of depression, a sense of worthlessness and helplessness and sad mood.”

“Also, he may be grieving because he no longer has his wife to himself,” said Jean Cirillo, PhD.  “He has to share her with the baby, and the baby’s needs get taken care of first. This can be hard for a man.”

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Possible Medicare/Medicaid Chief Brings New Ideas to Medicine

Thursday, April 29th, 2010

Dr. Donald Berwick, nominated to head Medicare and Medicaid, wants to reward physicians for better outcomes. Dr. Donald Berwick, a Harvard-educated pediatrician and Harvard Medical School professor, is President Barack Obama’s choice to head the Centers for Medicare and Medicaid Services (CMS), the parent agency of Medicare and Medicaid.  A sharp critic of the way healthcare is delivered in the United States, Berwick believes the system is inefficient and lacks an efficient information-sharing apparatus.  In addition to his practice and academic work, Berwick is the founder of the Institute for Health Care Improvement, a think tank that focuses on “cultivating promising concepts for improving patient care and turning those ideas into action.”

Berwick believes in improving the quality of healthcare so physicians are rewarded for better outcomes rather than on a per-procedure basis.  Although it’s unlikely that this idea could be applied to the medical profession, Medicare and Medicaid are large enough that changing the traditional way healthcare is delivered would echo throughout medicine.  Together, Medicare and Medicaid cover 100 million Americans – approximately one-third – and accounted for $750 billion of federal spending in 2009.  According to the Congressional Budget Office, that totals 20 percent of the federal budget.

Berwick’s nomination, which requires Senate confirmation, has some opposition, primarily from Senator Tom Coburn (R-OK) who is a practicing obstetrician.  “One concern I have is that he’s an advocate of comparative effectiveness,” Coburn said.  “There may be one or two or three ways of doing something.  I want to do what’s best for the patient, not necessarily what’s cheapest.”

David Helms, CEO of AcademyHealth, is a Berwick supporter.  According to Helms, “I think Don Berwick as a practicing physician will be able to communicate with other practicing physicians in a way that’s persuasive.”

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Attacks on Healthcare Reform Similar to Medicare Battle in 1965

Tuesday, April 20th, 2010

Dr. Atul Gawande: “The battle for healthcare reform has only begunWhen President Lyndon Johnson signed Medicare into law on July 30, 1965, he faced a year of nearly crippling attacks from groups like the American Medical Association (AMA) and conservatives who feared an onslaught of “socialized medicine” and threatened to boycott the new program.  Although memories of the Medicare battle have faded over 45 years, similar battles could be fought over the passage of the Patient Protection and Affordable Care Act. This is the opinion of Dr. Atul Gawande, general and endocrine surgeon at Boston’s Brigham and Women’s Hospital and Associate Professor of Surgery at Harvard Medical School.

Writing in The New Yorker, Gawande notes that because most of the healthcare reform act’s provisions phase in at a slower pace than did Medicare, it is even more open to attack.  “The context, of course, is different.  The AMA endorsed the legislations; hospital associations were supportive.  Once the public option was dropped, most insurers favored the bill.  The medical world will wage no civil resistance.  This time, the threat comes from party politics.  Conservatives are casting the November midterm elections as a vote on repealing the health-reform law.  If they regain power, they are unlikely to repeal the whole thing.  Instead, they will try to strip out the critical but less straightforwardly appealing elements of reform – the requirement that larger employers provide health benefits and that uncovered individuals buy at least a basic policy; the subsidies to make sure that they can afford those policies; the significant new taxes on household incomes over $250,000 – and thereby gut coverage for the uninsured.”

Gawande notes that reform is hardly a government takeover of healthcare, as many opponents contend.  Rather, its success relies on communities and clinicians.  “We are the ones to determine whether costs are controlled and healthcare improves – which is to say, whether reform survives and resistance is defeated,” according to Gawande.  “The voting is over, and the country has many other issues that clamor for attention.  But, as L.B.J. would have recognized, the battle for healthcare reform has only begun.”

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The Checklist Manifesto

Wednesday, February 24th, 2010

Surgeon Atul Gawande believes that a simple checklist can cut deaths from operating room errors. Atul Gawande, general and endocrine surgeon at Boston’s Brigham and Women’s Hospital, Associate Professor of Surgery at Harvard Medical School, and columnist for The New Yorker, has written “The Checklist Manifesto:  How to Get Things Right”,  a book that describes how miscommunication in the operating room can lead to tragic results.  Currently, Gawande’s book ranks # 10 on the New York Times’ list of best-selling non-fiction books.

The book grew out of work Gawande did for the World Health Organization, which asked him to help them find a way to reduce surgical deaths.  According to Gawande, “We knew we had technology and incredible levels of training, people working unbelievably hard.  But we have more than 100,000 deaths just in the United States following surgery.  Half are avoidable, from our studies.  What could we do?  We have found this idea, this extra tool that others were using in aviation, in skyscraper construction, and thought, well, let’s give it a try.”

Surgeons, according to Gawande, are human.  “We miss stuff.  We are inconsistent and unreliable because of the complexity of care.”  To achieve better results, Gawande brings a simple checklist into the operating room to make certain that everything is in place to assure a successful procedure.  For example, when the operating team is introduced to each other by name, the average number of complications and deaths fell by 35 percent.

Commenting on the success of checklist use in the operating room, Gawande says “I have not gotten through a week of surgery where the checklist has not caught a problem.”

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“Positive Deviants” Will Revitalize the Healthcare System

Tuesday, June 30th, 2009

The solution to America’s healthcare crisis might just lie in deviant thinking.  This is the message of Dr. Atul Gawande, this year’s commencement speaker at the University of Chicago’s Pritzker School of Medicine.  Gawande is a general and endocrine surgeon at Brigham and Women’s Hospital in Boston, an associate director of their Center for Surgery and Public Health, an associate professor at the Harvard School of Public Health and at Harvard Medical School.

050102_Gawande_Atul_3.jpgHis concept of positive deviants identifies those communities and physicians who discover innovative ways to reduce costs and improve care  to deliver better outcomes.

Gawande cites a nutritionist who spent his career attempting to reduce hunger in Vietnamese villages.  This man asked villagers to identify which families had the best-nourished children to determine a “positive deviance” from the norm.  The answer was that those children’s mothers did not act in accordance with accepted village wisdom had the best outcomes.  Rather, they fed their children even when they had diarrhea; fed them several small meals daily rather than one or two large ones; and fed their children foods that others considered low class but were nutritious such as sweet potato greens.

In the American healthcare system, the positive deviants resist the tendency to view patients primarily as revenue streams – but as human beings.  Rather, these physicians deliver high-value healthcare without focusing too strongly on their practices’ bottom lines; they neither over-treat nor under-treat their patients with extraneous but profitable tests and procedures.

To quote Gawande, “Look for those in your community who are making healthcare better, safer and less costly.  Pay attention to them.  Learn how they do it.  And join with them.”

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