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Ebola Vaccine Could Start Testing In Africa By January

NPR Health Blog - Tue, 10/21/2014 - 6:08pm
Ebola Vaccine Could Start Testing In Africa By January October 21, 2014 6:08 PM ET Listen to the Story 3 min 53 sec  

The World Health Organization says that efforts are on track to distribute an experimental Ebola vaccine in West Africa in January.

Two potential vaccines are now being tested for safety in people, and Russia is developing another one. While quantities will be limited, scientists say even a relatively small supply of vaccine can help bring the epidemic under control.

“ Some vaccines are also in development in Russia. So we are contact with Russians to see when they could be available for testing in Africa.

There's no guarantee that any vaccine will be effective, so it's good that several are in the pipeline. That includes an Ebola vaccine being developed by GlaxoSmithKline, which has already been tested in a small number of volunteers in the U.S., Europe and Africa.

Marie-Paule Kieny, Assistant Director-General for Health Systems and Innovation at the World Health Organization says a Canadian vaccine licensed to NewLink Genetics in Ames, Iowa, is now being tested in people as well at the Walter Reed Army Medical Center and the National Institutes of Health, near Washington D.C.

Next month, those trials will be expanded to include several hundred volunteers in Europe. Those tests will involve 250 doses of each of these two front-running vaccine candidates, "and these data are absolutely crucial to allow decision-making on what dose level should go into the testing in Africa," Kieny says.

That's a critical question at the moment, because nobody now knows whether a tiny dose or a large dose would be required to protect someone from the Ebola virus. The largest dose in these tests will be nearly 1,000 times larger than the smallest dose.

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"Everybody would like to have the lowest dose because, of course, you could have so much more vaccine than if it's the highest dose," Kieny says.

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Health officials are hoping to have tens of thousands of doses available starting in January. But that could present a major manufacturing challenge, especially if each shot needed to contain a huge dose of the vaccine.

And while these two potential vaccines are the furthest along, they aren't alone. Three others are in earlier development stages at U.S. companies, and "some vaccines are also in development in Russia," Kieny told a WHO news conference in Geneva Tuesday. "So we are contact with Russians to see when they could be available for testing in Africa, and what kind of doses, in terms of quantity, could be available in the months to come."

She says it's not clear whether the Russian scientists have already started safety testing in people.

Until quite recently, public health officials figured that a vaccine would come along too late to be of any use in controlling the current Ebola outbreak. But that attitude is changing.

"We could use a strategy similar to the ring vaccination strategy that was used in the smallpox eradication program," says Stephen Morse, an epidemiologist at Columbia University's Mailman School of Public Health.

Patients in a clinic line up to get a smallpox shot on Feb. 24, 1962, Leopoldville, Congo. Health workers used vaccination campaigns to finally eradicate smallpox by 1980.

AP

The concept of ring vaccination is that you wouldn't need to immunize the many millions of citizens against Ebola in the affected West African countries. Instead, if health officials can see where the disease is heading next, they can focus on immunizing people who will soon be in harm's way.

That of course includes health care workers, who are at highest risk right now.

"That would not require large amounts of vaccine," Morse says, "but it probably would limit the spread of the epidemic considerably."

Using this strategy, the vaccine wouldn't have to be perfectly effective, and you wouldn't even need to vaccinate all people who are at risk in order to put brakes on the epidemic.

And drugs to treat Ebola would help as well.

Kieny says the French government is planning to test a Japanese antiviral drug called Favipiravir in Guinea. And there's an international partnership coordinated by England's Oxford University to bring a half dozen other potential drugs into the region as well.

She says the partnership is now visiting sites in the three African countries to identify which treatment centers would be adequate, and would also be willing to participate in the testing of drugs.

Of course, public health officials responsible for stopping Ebola are still relying most heavily on the tried-and-true method: Find people who are sick and isolate them, so the disease stops spreading.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Hospitals Struggle To Beat Back Serious Infections

NPR Health Blog - Tue, 10/21/2014 - 4:05pm
Hospitals Struggle To Beat Back Serious Infections October 21, 2014 4:05 PM ET

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Listen to the Story 3 min 58 sec  

An official at the University of Michigan Health System in Ann Arbor says its mix of patients helps explain the infection rates.

Scott C. Soderberg/Courtesy of University of Michigan Health System

While Ebola stokes public anxiety, more than 1 in 6 hospitals — including some top medical centers — are having trouble stamping out less exotic but sometimes deadly infections, federal records show.

Nationally, about 1 in 25 hospitalized patients gets an infection. Some 75,000 people die each year from them — more than from car crashes and gunshots combined. A Kaiser Health News analysis found 695 hospitals with higher than expected rates for at least one of the six types of infections tracked by the federal Centers for Disease Control and Prevention. In 13 states and the District of Columbia, a quarter or more of hospitals that the government evaluated were rated worse than average for at least one infection category, the Kaiser analysis found.

The missteps Texas Health Presbyterian Hospital made this month in handling an Ebola patient echo mistakes hospitals across the nation have made in dealing with homegrown infections. Dr. Kevin Kavanagh, a patient safety specialist from Kentucky, said hospitals often fail to strictly follow protocols to deal with infectious diseases, and the government's standard responses aren't specific enough. "Right now there are too many recommendations on how to handle infectious diseases, too much leeway," he said.

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A 2011 study in the New England Journal of Medicine underscored the problem. While hospitals have reduced the frequency of many infections over the last decade, they could do better if staff complied fully with recommendations. Those include diligent attention to hand-washing and using stringent barrier protection when tubes are being inserted, such as covering patients from head to toe with a sterile drape and wearing sterile caps, masks gowns and gloves.

"The percentage of time that health care providers do all of the things they are supposed to do when caring for a patient with a contagious disease can be pretty low," said one of the authors, Dr. Don Goldmann, chief medical and science officer at the Institute for Healthcare Improvement, a nonprofit in Cambridge, Mass. "There's a lot of room for improvement."

Goldmann said that hospitals tend to become more focused on following procedures when facing novel, highly publicized outbreaks such as Ebola. "When [an infection risk has] been around for a long time, it kind of becomes part of the background," he said.

Since 2012 the federal government has been analyzing and publishing the CDC rates for specific hospitals on Medicare's Hospital Compare website. Starting this fall, Medicare is considering infection rates when deciding how much to pay hospitals.

The CDC reports six categories of infections: those from flexible tubes inserted into veins to deliver medicines or nutrients; infections from catheters that drain bladders; two antibiotic resistant germs, Clostridium difficile and Methicillin-resistant Staphylococcus aureus; and two surgical site infections after hysterectomies and colon operations.

States with more than a quarter of hospitals having at least one high infection rate in the CDC data were Arizona, California, Colorado, Connecticut, Florida, Massachusetts, Montana, Nevada, New Jersey, New York, Rhode Island, South Carolina and Utah, according to the Kaiser analysis of the most current CDC records.

Three highly regarded institutions — New York-Presbyterian Hospital in Manhattan, Geisinger Medical Center in Danville, Pa., and the University of Michigan Health System in Ann Arbor — were among seven hospitals the CDC rated as having worse than average rates for four of the six infections, Kaiser found.

The CDC data, based on reports hospitals submit, are considered the most reliable assessments that exist. Still, many hospitals the CDC judged as having worse than average rates disputed those verdicts. They said that they look bad because they are more vigilant in identifying and reporting infections, or because they handle very sick patients who are more prone to catching a bug.

For instance, Dr. Darrell Campbell Jr., chief medical officer at the University of Michigan Health System, said hysterectomies are performed on cancer patients at four times the rate than at other Michigan hospitals that compare information with each other. Because cancer surgeries take longer than regular hysterectomies, often involving removal of pelvic lymph nodes, the chances of infection are greater, he said.

"When you adjusted for the cancer, we don't look different from any of the hospitals," he said. Campbell said none of Michigan's infection rates deserved being rated poorly. "Eventually, we'll get where we are more comfortable with this data, but we're not there now," he said.

New York-Presbyterian said in a statement it has made "significant improvements." Geisinger said in a statement that its infection rates have dropped since 2012 and that its MRSA rate appeared high because the hospital made a "data entry error" when it reported cases to the government. Geisinger also noted that many patients who test positive for C. diff never develop any symptoms, but hospitals still must report it as an infection.

Some major teaching hospitals, like Denver Health Medical Center, Duke University Hospital in Durham, N.C., and Mayo Clinic's hospitals in Rochester, Minn., have been able to maintain low infection rates, the KHN analysis shows.

Others are succeeding in controlling some infection types but not others, according to the CDC data. Yale-New Haven Hospital had lower than average rates of bloodstream infections caused by central lines, but higher than average rates of infections from catheters inserted into the bladder to remove urine. Since one of the main ways to avoid such infections is to remove the catheter as soon as it isn't essential, the hospital now allows nurses to take them out without a physician's order under certain conditions, said Dr. John Boyce, the hospital's director of epidemiology and infection control. "Busy physicians sometimes forget their patient has a catheter in, but the nurses know," he said.

Nationally, surgical site infections dropped by a fifth and central-line infections decreased by 44 percent between 2008 and 2012. MRSA decreased by a third during that period.

Battling C. diff is very different than fighting Ebola and in some ways harder, because it requires hospitals to restrain use of the antibiotics necessary for so many patients. When those drugs eliminate weaker bacteria from the intestines, C. diff is able to prosper. Patients can get massive diarrhea and, while C. diff can be treated, the worse cases may require surgery to remove the infected part of the intestines.

Other infections for which the CDC tracks but doesn't yet publish hospital-specific rates, known as gram negative, are impervious to nearly all antibiotics.

Reducing the frequency of C. diff and these kinds of infections requires hospitals to become more judicious in deploying antibiotics. But only about half of hospitals have established stewardship programs that help doctors use the appropriate antibiotics in the most effective doses without overdoing it, researchers say.

"We have increasing amounts of data that 30-50 percent of the antibiotics we are prescribing are inappropriate," said Dr. Kavita Trivedi, a consultant and former infection control official for California. "It sounds crazy to people who are not in medicine: Why would a patient be prescribed an antibiotic they don't need? But it happens frequently because we don't know what they need."

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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When The Economy Goes Down, Vasectomies Go Up

NPR Health Blog - Tue, 10/21/2014 - 1:04pm
When The Economy Goes Down, Vasectomies Go Up October 21, 2014 1:04 PM ET

Did worries about financial stability get more men to say no to fatherhood?

iStockphoto

The number of men getting vasectomies spiked during the Great Recession, rising one-third from 2006 to 2010, a study finds.

In 2006, 3.9 percent of men said they had had a vasectomy; in 2010, 4.4 percent reported having the surgery. That means an additional 150,000 to 180,000 men per year had vasectomies in each year of the recession.

That squares with earlier research that showed birth rates dropped during the recession, falling 4 percent between 2007 and 2009.

After the recession, man were making less money, were less likely to be working full time, and were less likely to have health insurance, according to the National Survey for Family Growth, which researchers at Weill Cornell Medical College used to come up with the vasectomy numbers.

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They reported their results Monday at the American Society for Reproductive Medicine conference in Hawaii.

OK, so what were women up to? The Weill Cornell researchers didn't look at this, but the survey did ask recession-era women about birth control, and there was no increase in the number of women who got birth control or had sterilization surgery from 2002.

Men typically aren't nearly as apt to embrace sterilization as a form of birth control as are women.

For women who use contraception, 26.6 percent chose tubal sterilization, which is permanent, compared to 27.5 percent for the pill, according to 2010 numbers from the Guttmacher Institute.

But just 10 percent of women said they're relying on their partner's vasectomy to avoid pregnancy, according to Guttmacher.

We'll have to stay tuned to see if guys' seeming embrace of vasectomy was just a recessionary blip, or if they really are saying no (or no mas) to fatherhood.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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More Insurers Put Spending Limits On Medical Treatments

NPR Health Blog - Tue, 10/21/2014 - 10:14am
More Insurers Put Spending Limits On Medical Treatments October 21, 201410:14 AM ET

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The California Public Employees' Retirement System has capped how much it will pay for some common medical procedures and tests.

Max Whittaker/Getty Images

To clamp down on health care costs, a growing number of employers and insurers are putting limits on how much they'll pay for certain medical services such as knee replacements, lab tests and complex imaging.

A recent study found that savings from such moves may be modest, however, and some analysts question whether "reference pricing," as it's called, is good for consumers.

The California Public Employees' Retirement System (CalPERS), which administers the health insurance benefits for 1.4 million state workers, retirees and their families, has one of the more established reference pricing systems.

More than three years ago, CalPERS began using reference pricing for elective knee and hip replacements, two common procedures for which hospital prices varied widely without discernible differences in quality, says Ann Boynton, who helps set benefits policies at CalPERS.

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Working with Anthem Blue Cross, the CalPERS set $30,000 as the reference price for those two surgeries in its preferred provider organization plan.

Members who get surgery at one of the 52 hospitals that charge $30,000 or less pay only their plan's regular cost-sharing. If member choose to use an in-network hospital that charges more than the reference price, however, they're on the hook for the entire amount over $30,000, and the extra spending doesn't count toward their annual maximum out-of-pocket limit, Boynton says.

"We're not worried about people not getting the care they need," says Boynton. "They have access to good hospitals; they're just getting it at a reasonable price."

In two years, CalPERS saved nearly $6 million on those two procedures, and members saved $600,000 in lower cost sharing, according to research published last year by James C. Robinson, a professor of health economics at the University of California, Berkeley, and director of the Berkeley Center for Health Technology. Most of the savings came from price reductions at expensive hospitals.

The agency recently set caps on how much it would spend for cataract surgery, colonoscopies and arthroscopic surgery, Boynton says.

Those who have studied reference pricing say it is most appropriate for common, non-emergency procedures or tests that vary widely in price but are generally comparable in quality. Research has generally shown that higher prices for medical services don't mean their quality is higher. Setting a reference price steers consumers to high-quality doctors, hospitals, labs and imaging centers that perform well for the price, proponents say.

Others point out that reference pricing doesn't necessarily save employers a lot of money, however. A study released earlier this month by the National Institute for Health Care Reform examined the 2011 claims data for 528,000 autoworkers and their dependents, both active and retired. It analyzed roughly 350 high-volume and/or high-priced inpatient and ambulatory medical services that reference pricing might reasonably be applied to.

The overall potential savings was 5 percent, the study found.

"It was surprising that even with all that pricing variation, reference pricing doesn't have a more dramatic impact on spending," says Chapin White, a senior policy researcher at RAND and lead author of the study.

Even though the results may be modest, a growing number of very large companies are incorporating reference pricing, according to benefits consultant Mercer's annual employer health insurance survey. The percentage of employers with 10,000 or more employees that used reference pricing grew from 10 percent in 2012 to 15 percent in 2013, the survey found. Thirty percent said they were considering adding reference pricing, the survey found. Among employers with 500 or fewer workers, adoption was flat at 10 percent in 2013, compared with 11 percent in 2012.

This spring, the Obama administration said that large group and self-insured health plans could use reference pricing.

The health law sets limits on how much consumers have to pay out of pocket annually for in-network care before insurance picks up the whole tab — in 2015, it's $6,600 for an individual and $13,200 for a family plan. But if consumers choose providers whose prices are higher than a plan's reference price, those amounts don't count toward the out-of-pocket maximum, the administration guidance said.

Leaving consumers on the hook for amounts over the reference price needlessly drags them into the battle between providers and health plans over prices, says White.

"You expect the health plan to do a few things: negotiate reasonable prices with providers, and not to enter into network contracts with providers who provide bad quality care," White says. "Reference pricing is kind of an admission that health plans have failed on one or both of those fronts."

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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When Reassuring Isn't: The Rush To Test Cruise Passenger For Ebola

NPR Health Blog - Mon, 10/20/2014 - 5:47pm
When Reassuring Isn't: The Rush To Test Cruise Passenger For Ebola October 20, 2014 5:47 PM ET

The cruise ship Carnival Magic floats behind a catamaran off Cozumel, Mexico on Oct. 17. The ship skipped a planned stop there Friday, the cruise line says, after Mexican authorities delayed granting permission to dock.

Reuters/Landov

Here's a question about the fine line between a prudent response and worrisome overkill: Is the sight of a U.S. Coast Guard helicopter hovering over a cruise ship to pick up a blood sample (which is to be tested for Ebola) a sight that should inspire feelings of reassurance, or a nagging sense that something is not quite right?

The question is still in the air after the weekend's effort to airlift a few milliliters of blood from a passenger who was on board what is now being called the Ebola Cruise.

"I understand the motivation to do as much as we can to reassure the public," says Dr. Thomas Inglesby, director of the University of Pittsburgh Medical Center's Center for Health Security. But when people act with an excess of caution, he says, "that can lead us to do things that are inadvertently making people more frightened."

"It's not clear to me why, for an asymptomatic person coming into port, we would need to get that test before docking," says Inglesby, who was not involved in making the decision.

“ We knew a cruise ship full of passengers would be concerned, and we wanted to reassure them that there was no risk.

The passenger on the ship was a lab worker who had handled clinical specimens from Thomas Eric Duncan, the Liberian man who died of Ebola in Dallas. She departed on the cruise before officials said they did not want people who might have been in close contact with Duncan to travel.

She had no symptoms of Ebola and had isolated herself in her cabin.

Previously, health officials such as Tom Frieden, director of the Centers for Disease Control and Prevention, have said that diagnostic tests of people with Ebola are not reliable until those people develop symptoms. And people who have no symptoms are not contagious, experts say.

The ship was on its way back to Galveston on Saturday when Carnival Cruise Lines learned that "the local health authorities in Galveston [not Texas state officials] were requiring a blood test," Jennifer De La Cruz, Carnival Cruise Lines noted in an email to Shots.

“ While such testing is 'reassuring,' it sets a bad precedent that grants too much credibility to the panic.

She explained that the U.S. Coast Guard provided the helicopter to bring the testing kit to the ship and bring the blood sample back to shore, "but it was local health authorities in Galveston who mandated the test. I need to refer you to them for an explanation as to why they felt it was necessary, as well as the timing."

Kurt Koopman, a spokesperson for the Galveston County Health District, told Shots by email that officials knew when the efforts to get a test began that the results might not come in before the ship's arrival.

"Had the patient remained asymptomatic she would have still been allowed to disembark," he noted. "The test was requested after careful consideration by local, state and federal officials who felt it could be reassuring to other passengers and crew."

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A spokesperson with the Texas Department of State Health Services, Carrie Williams, told Shots that the test was not required of the passenger; she agreed to it.

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"We wanted to test to give passengers that reassurance — given the anxiety and reaction we have been seeing across the country with regards to Ebola," Williams says. "We knew a cruise ship full of passengers would be concerned, and we wanted to reassure them that there was no risk."

But some say the series of events were a total — and emblematic — overreaction.

"A generalized panic is occurring worldwide and is largely disproportionate to the risk," says Dr. Amesh Adalja, a representative of the Infectious Diseases Society of America.

He says the facts that the passenger was tested while at sea and that the ship was refused entry by Mexico are "definitely part of that panic."

"While such testing is 'reassuring,' it sets a bad precedent that grants too much credibility to the panic," Adalja points out. "I also wonder how much scarce public health resources are being diverted to deal with these incidents, when they would be better-employed combating the epidemic at its source."

After all, around 9,000 people have fallen ill with Ebola in West Africa — and the death rate there from this disease is around 70 percent.

Oh, and the result of the Ebola test on that helicopter-delivered blood sample? Negative. There was no sign of Ebola.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Parkinson's Drugs Can Be A Gateway To Sin

NPR Health Blog - Mon, 10/20/2014 - 4:16pm
Parkinson's Drugs Can Be A Gateway To Sin October 20, 2014 4:16 PM ET

Drugs that are commonly prescribed to help people cope with Parkinson's disease have been linked to bizarre changes in behavior that patients and doctors should be on guard against, researchers say.

The disturbing side effects include compulsive gambling, uncontrollable shopping and a sudden obsession with sex.

The problems with the drugs, called dopamine agonists, are serious enough that the researchers say the Food and Drug Administration should require the medicines to carry what's called a black-box warning, one of the most prominent and serious cautions used for prescriptions drugs.

Some of the drugs are also prescribed for restless leg syndrome and hyperprolactinemia, a hormonal condition that can trigger milk production.

While the problems with the dopamine agonists have been noted in the past, the recommendation for a more prominent warning comes come after researchers sifted through 2.7 million reports of drug reactions submitted to an FDA database between 2003 and 2012.

The researchers from the Institute for Safe Medicine Practices, Harvard and the University of Ottawa found 1,580 adverse drug events involving impulse control disorders. A little less than half, or 710 reports, were associated with dopamine receptor agonist drugs.

The link was strongest for pramipexole, brand name Mirapex, and ropinirole, brand name Requip. The instructions for doctors who are thinking about prescribing Mirapex already carry a warning that says patients taking the medicine "may experience compulsive behaviors and other intense urges." Requip, a treatment for restless

The results were published online Monday by JAMA Internal Medicine.

Back in 2005, doctors from the Mayo Clinic reported 11 cases of patients who became compulsive gamblers after taking dopamine agonists. A 52-year-old man lost $100,000 in casinos after previously gambling only once in his life. He also became fixated on pornography and obsessed with sex, carrying on extramarital affairs. A month after stopping the drug, he was his old self.

Doctors and patients may have overlooked the problems. In a commentary accompanying the latest findings, two Johns Hopkins doctors wrote that nausea, dizziness and other physical side effects are more typical parts of the conversations between doctors and patients about drugs. "During an office visit, a patient is unlikely to spontaneously mention, 'By the way, doctor I lost $250,000 in casinos last week' or 'I spend all night on Internet pornography sites and am soliciting prostitutes,' " they wrote.

Neurologist Howard Weiss, a co-author of the commentary, tells Shots that these drug-related compulsive behaviors haven't gotten the attention in the medical community that they deserve. A heightened warning in the drugs' instructions could help make the risk clearer, Weiss says. The behavioral problems, he says, "are more important than 99 percent of the other side effects that are being listed."

Weiss says he's had at least three patients who have lost their homes because of bankruptcy after taking the drugs.

When he asked an elderly patients taking one of the drugs if she ever gambled, she replied, "Gambling is the work of the devil." But it turned out she had been buying hundreds of dollars' worth of lottery tickets a week, a habit she didn't consider to be gambling.

Weiss says the behavioral problems usually go away after patients stop taking the medicines. He also says the drug combination carbidopa-levodopa, another Parkinson's treatment, works better and doesn't increase the risk for impulsive behavior.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Eye Phone? Your Next Eye Exam Might Be Done With Your Phone

NPR Health Blog - Mon, 10/20/2014 - 2:46pm
Eye Phone? Your Next Eye Exam Might Be Done With Your Phone October 20, 2014 2:46 PM ET

Smartphones can now capture high-quality images of the front and back of an eye.

Courtesy of David Myung

A researcher shows a woman in Nepal how to use a visual field test on an iPad. It's used to diagnose glaucoma.

Dr. Suman Thapa/Courtesy of University of Iowa

Getting an eye exam typically involves big complicated machines. But eye doctors are trying to get the big and complicated out of the equation by using smartphones and tablets instead. That way, they figure, eye exams can be done just about anywhere — even a village in Nepal.

That's where Dr. Chris Johnson and his colleagues are using iPads to test people for glaucoma, a disease that often has no symptoms until it has irreversibly damaged eyesight. That's because it nibbles away at vision at the periphery of the visual field.

Finding that out usually involves sitting in front of a big machine and staring at a screen while gray dots appear and disappear.

Instead, Johnson tested an off-the-shelf free app called Visual Fields Easy to screen about 200 patients in Nepal. "I was skeptical at first; we did some tests and calibrated it."

The app was very good at identifying people with moderate to severe disease, less so at screening out people with normal vision. "It works much better than I expected," Johnson, who specializes in developing diagnostic tests, told Shots. He and his colleagues are now expanding the tests to India, with the aim of refining it. "I know I can make it better."

Visual field testing usually requires an expensive machine. This man in Nepal helped test an iPad app.

Dr. Suman Thapa/Courtesy of University of Iowa

Johnson presented his data Monday at the meeting of the American Academy of Ophthalmology in Chicago, and he was far from the only one tinkering with mobile tech. A number of researchers presented devices that clip onto iPhones to turn them into diagnostic tools.

Dr. David Myung, chief resident at Stanford University Hospital, wanted to come up with an easy way to photograph an eye inside and out. A big ophthalmology practice would have a machine that does that beautifully, but it costs tens of thousands of dollars and requires specialized training. Myung wanted something that a harried ER doctor or nurse could use on the fly.

"We wanted to find a low-tech way to do it," Myung told Shots. So he and his colleagues came up with a plastic arm that snaps onto an iPhone, holding an ophthalmology lens in front of the camera at just the right distance. "The plastic arm is about as low-cost as it gets."

To get around the fact that the photographer isn't an ophthalmologist, it's designed so that people take videos or multiple photos. "It's a little like trying to take pictures of your kids, and they're moving around all the time. If you take 10 or 15 photos, one of them going to be in focus."

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The gizmo is also being tested to see if it can reliably screen people at a public hospital for diabetic retinopathy, and Myung and colleagues are applying for FDA approval, since it's a medical device. "We originally developed this for ophthalmology work in developing countries," Myung says. "People do have smartphones and digital capability. We think it could be very useful there."

And maybe closer to home, too.

Since the goal is cheap, simple tests using available technology, couldn't I just do my eye exam at home skip the two hours sitting in the waiting room with my eyes dilated? There are plenty of eye tests apps ready for download right now. But it's complicated, Johnson says.

"Did they get a bad result because they didn't do the test right, or is there a change in their visual status?" Johnson says. He's worried that people will skip an eye exam, then get frightened by a false negative result to a home test. "I think having that as a screen that's available for people who don't have good access to health care is the first thing. Home testing will require some additional things to make it bulletproof."

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Halting Schizophrenia Before It Starts

NPR Health Blog - Mon, 10/20/2014 - 4:23am
Halting Schizophrenia Before It Starts October 20, 2014 4:23 AM ET Listen to the Story 8 min 45 sec  

Meghan, 23, began experiencing hallucinations at 19. "Driving home, cars' headlights turned into eyes. The grills on the cars turned into mouths and none of them looked happy. It would scare the crap out of me," Meghan says.

Marvi Lacar for NPR

The important thing is that Meghan knew something was wrong.

When I met her, she was 23, a smart, wry young woman living with her mother and stepdad in Simi Valley, about an hour north of Los Angeles.

Meghan had just started a training program to become a respiratory therapist. Concerned about future job prospects, she asked NPR not to use her full name.

Five years ago, Meghan's prospects weren't nearly so bright. At 19, she had been severely depressed, on and off, for years. During the bad times, she'd hide out in her room making thin, neat cuts with a razor on her upper arm.

Meghan had been depressed off and on for years, but the hallucinations signaled a subtle shift in her symptoms.

Marvi Lacar for NPR

"I didn't do much of anything," Meghan recalls. "It required too much brain power."

"Her depression just sucked the life out of you," Kathy, Meghan's mother, recalls. "I had no idea what to do or where to go with it."

One night in 2010, Meghan's mental state took an ominous turn. Driving home from her job at McDonald's, she found herself fascinated by the headlights of an oncoming car.

"I had the weird thought of, you know, I've never noticed this, but their headlights really look like eyes."

To Meghan, the car seemed malicious. It wanted to hurt her.

Kathy tried to reason with her.

"Honey, you know it's a car, right? You know those are headlights," she recalls pressing her daughter. "You understand that this makes no sense, right?"

"I know," Meghan answered. "But this is what I see, and it's scaring me."

In other words, Meghan had insight, defined in psychiatry as the ability to understand that one's unusual experiences are attributable to a mental illness.

What Meghan saw did not fit with what she believed. She knew she was hallucinating.

Meghan keeps a photo of her cat, Boo, on the wall in her bedroom. "She would stay in her room and keep to herself," Kathy, Meghan's mother, says. "Sometimes that was a good thing because her depression just sucked the life out of you."

Marvi Lacar for NPR

It's the loss of insight that signals a psychotic break. This can lead to several different diagnoses, but in people ultimately diagnosed with schizophrenia, the break signals the formal onset of the disease. Typically, a first psychotic break occurs in a person's late teens or early 20s. In men, the range is 15 to 24; in women, 25 to 34.

That first psychotic break can lead to a series of disasters: social isolation, hospitalization, medications with sometimes disabling side effects, and future psychotic episodes.

So, what if you could intervene earlier, before any of that? Could you stop the process from snowballing?

At 19, Meghan hadn't had a psychotic break. She still had insight. That made her eligible for a new type of program taking shape in California that aims to prevent schizophrenia before it officially begins.

The program draws on research suggesting that schizophrenia unfolds much more slowly than might be obvious, even to families.

"You start to see a decline in their functioning," says Dr. Daniel Mathalon, who studies brain development in the early stages of psychosis at the University of California, San Francisco.

"They were doing better in school, now they're doing worse," he says. "Maybe they had friends but they're starting to be more isolated."

Eventually, these subtle behavioral shifts may take on a surreal quality. A young person may hear faint whispers or hissing, or see flashes of light or shadows on the periphery.

"They lack delusional conviction," explains Mathalon. "They're experiencing these things; maybe they're suspicious. But they're not sure."

"I valued my ability to think and learn," Meghan says. "To know that the one thing I valued so highly was dissolving away, that I was losing chunks of my sanity with every hallucination. ... That was more terrifying than the monsters that I saw could ever be."

Marvi Lacar for NPR

Psychiatrists have a word for this early stage: prodromal.

Meghan took a screening test developed at Yale University Medical School that identified her as possibly within the prodromal stage of psychosis. That is, her symptoms could be indicative of early psychosis, but weren't predictive.

She was referred to a clinic in an office park about an hour from her house called Ventura Early Intervention Prevention Services, or VIPS, operated by Alameda-based Telecare Corp.

VIPS is one of a handful of programs that have sprung up in California in recent years, based on a model developed in Maine by psychiatrist Dr. Bill McFarlane.

McFarlane believes that psychosis can be prevented with a range of surprisingly low-tech interventions, almost all of which are designed to reduce stress in the family of the young person who is starting to show symptoms.

McFarlane cites research done at UCLA suggesting that certain kinds of family dynamics — families that don't communicate well, or are overly critical — can make things worse for a young person at risk of schizophrenia.

Meghan's family credits the VIPS program for her transformation. "She's not the broken little girl that she was three years ago," Meghan's stepfather, Charlie, says.

Marvi Lacar for NPR

"Our theory," says McFarlane, "was that if you could identify these young people early enough, you could alter some of those family patterns. Then you could work with the family to start behaving not just normally, but in a way that was smarter."

McFarlane's programs bring families in for twice-monthly multifamily group therapy sessions, where participants take a nuts-and-bolts approach to resolving disputes at home and softening their responses to what the young person is going through.

"We assume parents can't figure this out alone," says McFarlane.

In some cases, participants are also prescribed antipsychotic drugs, especially one called Abilify, which McFarlane and others believe can stem hallucinations.

McFarlane himself is careful about recommending antipsychotic medications.

The drugs, he says, should be used cautiously, at lower doses than would be prescribed for full psychosis, and even then only in young people who aren't responding to other treatments.

But in programs inspired by his model, the drugs appear to be widely prescribed, including in clients as young as 10 or 13. This fact has become a flashpoint in the conversation around schizophrenia prevention.

"No one is harder to diagnose than a child or a teenager," says Dr. Allen Frances, a former chair of the psychiatry department at Duke University and chair of the task force that produced the fourth revision of the Diagnostic and Statistical Manual, or DSM-IV, the standard reference for psychiatric diagnoses.

"There are rapid developmental changes from visit to visit," he says. "The tendency to overdiagnose is particularly problematic in teenagers."

Frances points to studies showing that if you take three kids, all experiencing those surreal early symptoms, only one will get schizophrenia.

So what about the other two?

“ We have to be careful of any new fad in psychiatry. The field has been filled with fads in the past, and often we learn in retrospect that they've done much more harm than good.

Frances says these kids are wrongly labeled and stigmatized. Their parents are terrified. And in many cases, they will be prescribed antipsychotic drugs, which can have serious side effects and haven't been studied well in children.

"We have to be careful of any new fad in psychiatry," says Frances. "The field has been filled with fads in the past, and often we learn in retrospect that they've done much more harm than good."

But what Frances calls a fad is to others a model for mental health care.

To see these programs in action, the best place to go is California, where over the past few years a handful of programs have sprung up based on McFarlane's PIER model.

One, in San Diego, is called Kickstart. Like the others, it's paid for by a state tax on millionaires, passed by voters in 2004, that funds mental health. Services — everything from homework help to family therapy and outings such as kite-flying expeditions — are offered for free.

Joseph Edwards, Kickstart's assistant program director, says for teenagers who might be developing schizophrenia, just being outside, with friends, is a kind of therapy.

"They'll want to isolate," says Edwards. "There's sensitivity to a lot of stimulation. And a lot times we'll see what we call day/night reversal, where they'll stay up all night and go to sleep in the daytime."

Edwards says if a teenager is really isolating, a Kickstart worker will drive to his or her house and cajole the person out. Anything, he says, to keep them engaged, with friends in school or at work.

Tony, 13, spends an afternoon at an arcade with Ashley Wood, his occupational therapist in the Kickstart program in San Diego.

Marvi Lacar for NPR

At an arcade in a strip mall, we meet Ashley Wood, one of Kickstart's occupational therapists. Wood brought her client, 13-year-old Tony, here as a reward for being cooperative in therapy.

We aren't using Tony's full name because he's a minor, at the request of his parents.

Wood has an easy laugh and teases Tony gently to pull him out of his shell.

"When we first met, he was so quiet," she says, laughing. "He's like, 'Who is this chick?' "

"Nah," says Tony, smiling shyly. "I was being a jerk."

Tony had been getting in fights. He was angry at his mom, angry in school. And there was something else.

"I used to see stuff and hear [stuff]," he tells me.

"Like what?" I ask him. "Like ... weird objects," he responds. When I press him for more details, he shakes his head.

Are Tony's symptoms the beginning of schizophrenia? Or just the routine weirdness of a teenage brain taking shape?

No one — not Wood, not his therapists — can say for sure.

Wood says what she's teaching him will be helpful either way: "When he's frustrated at school or at home, instead of immediately responding, kind of finding a way to communicate. So we're trying to work on the impulse control as well."

Impulsive, unruly, prone to angry outbursts, Tony sounds like a lot of 13-year-old kids.

That's one reason that last year, the American Psychiatric Association opted to exclude the idea of "psychosis risk syndrome" from the DSM-5, the latest version of the manual of mental disorders. The screening test is generally considered to be only 30 percent accurate.

In 2011, a review of prodrome intervention programs called the idea of intervention in pre-schizophrenia "inconclusive."

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"This is an experiment far before its time," says Allen Frances.

McFarlane believes the benefits of these programs are borne out in the work done at his clinic and others based on his model. In July, he published the results of a two-year study of two groups of young people at risk for, or in the early stage of, schizophrenia, which showed better functional outcomes for those who went through treatment.

TED Radio Hour Is It Possible To Live With The Voices In Your Head?

He and other proponents say schizophrenia's early window may be too precious to miss.

"We're running up against the limits of what we can do for patients who develop schizophrenia, once it goes to chronic stages," UCSF's Mathalon says. "I think this is a direction we have to go in, but we have to do it carefully."

When you talk to people who have been through these programs and ask them what helped them, it is not the drugs, not the diagnosis. It's the lasting, one-on-one relationships with adults who listen, like Ashley Wood.

“ I thought she'd forever be marginal, forever be medicated. I thought we'd just have to get used to it.

Tiffany Martinez, an early client of Bill McFarlane's in Maine, chokes up when asked to describe what she thinks helped her climb out of an incipient mental health crisis that began when she was in college.

"To share such personal intimate details, you know? To have these people working so hard on it and so devoted and invested in the work," Martinez, now age 26, says, "it's like getting a chance. Just the program, what the program stands for alone, is hope."

That same relief is palpable when you talk to Meghan's mom, Kathy, and stepfather, Charlie.

"I thought we were going to have to take care of her for the rest of her life," says Kathy. "I thought she'd forever be marginal, forever be medicated. I thought we'd just have to get used to it."

Today Meghan is off all her medications. She's animated, playing board games with her family, excited about being back in school.

Her family credits the VIPS program.

"We were blessed to have this for her," Charlie says. "We really were. It saved her life."

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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U.S. To Temporarily Halt Funding For Controversial Virus Research

NPR Health Blog - Fri, 10/17/2014 - 4:44pm
U.S. To Temporarily Halt Funding For Controversial Virus Research October 17, 2014 4:44 PM ET

Avian influenza, or bird flu, causes an infectious and contagious respiratory disease. In the lab, several scientists have made the H5N1 strain more contagious, a controversial line of research.

James Cavallini/ScienceSource

The federal government will temporarily stop funding any new studies that could make three high-risk infectious diseases even more dangerous. The government is asking all scientists involved in this research now to voluntarily halt their current studies.

The unusual move comes after a long controversy over experiments with mutant forms of a bird flu virus.

The White House Office of Science and Technology Policy said that the government will launch a review of the potential risks and benefits of certain experiments with three viruses: SARS, MERS and influenza.

The concern is that so-called gain-of-function studies would probe how these viruses work by altering them in ways that could make them more pathogenic or contagious.

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Scientists have been arguing about the wisdom of doing such experiments ever since two studies of the H5N1 bird flu virus created mutant forms that could potentially spread between people and cause a pandemic, if they ever got out of the lab.

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The prestigious National Research Council will be involved in the government's new deliberations, as will a government advisory committee called the National Science Advisory Board for Biosecurity, which is meeting October 22 after not meeting for over a year.

"It sounds like very good news," says Marc Lipsitch of the Harvard School of Public Health, who has been critical of experiments that could create new pathogens with the potential to cause human pandemics. "I was pleased to see they are at least asking the existing projects to pause."

Until officials adopt a final policy on these experiments, which they expect to do next year, new proposals won't be funded by the National Institutes of Health.

"Public involvement in this deliberative process is key, and the process is thus designed to be transparent, accessible, and open to input from all sources," NIH Director Francis Collins said in a statement.

"NIH has funded such studies because they help define the fundamental nature of human-pathogen interactions, enable the assessment of the pandemic potential of emerging infectious agents, and inform public health and preparedness efforts," Collins noted. "These studies, however, also entail biosafety and biosecurity risks, which need to be understood better."

Updated at 5:25 p.m.:

Yoshihiro Kawaoka, a virologist at the University of Wisconsin-Madison whose lab has done studies with influenza, told NPR by email that he would initiate no new projects and would consult with NIH officials on projects that have experiments underway.

"I hope there will be an eventual resolution of the issues that surround research that is important to protecting public health and advancing influenza virus research," Kawaoka wrote, adding that he would participate in the upcoming NSABB meeting and looked forward to constructive discussions.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Why Won't The Fear Of Airborne Ebola Go Away?

NPR Health Blog - Fri, 10/17/2014 - 4:18pm
Why Won't The Fear Of Airborne Ebola Go Away? October 17, 2014 4:18 PM ET

Audio for this story from All Things Considered will be available at approximately 7:00 p.m. ET.

Ebola Virus, Transmission Electron Micrograph Of The Ebola Virus, Rna Virus, Cause Of Hemorrhagic Fever.

BSIP/UIG via Getty Images

Experts keep saying Ebola can't spread through the air but some Americans seem deeply skeptical.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Why Won't The Fear Of Airborne Ebola Go Away?

NPR Health Blog - Fri, 10/17/2014 - 4:18pm
Why Won't The Fear Of Airborne Ebola Go Away? October 17, 2014 4:18 PM ET Listen to the Story 4 min 12 sec  

The Ebola virus as seen under an electron microscope.

BSIP/UIG via Getty Images

How many times do top officials have to say that the Ebola virus is not airborne?

A lot, apparently.

Here is President Obama Thursday: "This is not an airborne disease. It is not easy to catch."

And the day before: "It is not like the flu. It is not airborne."

And Friday, a reporter asked the inevitable question about airborne Ebola when Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, held a press briefing about nurse Nina Pham's transfer to the National Institute of Health.

Shots - Health News No, Seriously, How Contagious Is Ebola?

"There is no evidence whatsoever that this virus is airborne-transmitted," said Fauci emphatically. "Everything we know about this virus is that it is direct contact with bodily fluids."

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This gets said over and over. It's backed up by epidemiological studies of past outbreaks. Yet the possibility of Ebola spreading through the air keeps being raised.

At a hearing Thursday, for example, lawmakers grilled Dr. Thomas Frieden, the director of the Centers for Disease Control and Prevention.

"You've already said a couple of times that you don't believe that this is airborne," said Republican Congresswoman Renee Ellmers from North Carolina. And yet, she noted, the two nurses still got sick. "They followed precautions, I am sure, and now we are having this conversation and I'm very concerned about that."

Frieden responded that the investigation is ongoing but the nurses treated the Ebola patient when his vomit and diarrhea contained a lot of virus: "We are confident this is not airborne transmission."

When government officials keep saying this isn't airborne, it seems like what they're really trying to tell the public is, "Don't worry about catching this virus in the course of your normal daily activities."

"I think that what they are trying to convey with the idea that 'it's not airborne' is that you likely need to be relatively close to the person where there are some bodily fluids present," says Rachael Jones, who studies infectious disease transmission at the University of Illinois at Chicago.

She says if someone down the hall from you had Ebola and threw up vomit that contains the virus, "those particles are not going to travel hundreds of feet or hundreds of meters to cause an infection."

But if a health care worker or a family member gets very close to someone who has a lot of symptoms, which is when people with Ebola are most contagious, Jones says droplets of body fluid could potentially travel through the air for short distances.

"If you vomit there are projectile droplets that could spray up," she notes.

And she says there's reason to be concerned that an Ebola patient might produce even smaller droplets that someone in close quarters could inhale and get sick from — during medical procedures like putting in a breathing tube.

"A lot of these medical processes that health care workers perform produce small aerosols," says Jones. This is why she and a colleague recently wrote a commentary saying this needs to considered when protecting health care workers.

So even though Jones takes issue with the White House's flat statement that the Ebola virus cannot spread through air, she says this is really not a concern for the public.

"There is not epidemiological evidence that community-based exposure, such as being at a shopping mall or walking down the street or riding a bus, is associated with disease transmission," she notes.

Still, what if the Ebola virus mutates? That's another fear that keeps surfacing. The chairman of the Joint Chiefs of Staff, Gen. Martin Dempsey, spoke about that on CNN this week.

"I'm worried about it because we know so little about it," he said. "You'll hear different people describe whether it could become airborne." He said that scientists did not agree. "I don't know who's right. I don't want to take that chance. So I'm taking it very seriously."

It's true that researchers can't absolutely rule out the idea that mutations might change how the virus spreads, but this seems unlikely, says Alan Schmaljohn, a virologist the University of Maryland School of Medicine. He said the chance of that is "very low, probably in the range of winning the multi-state lottery."

On Capitol Hill, the CDC's director said his team has been on the lookout for any significant genetic mutations. "What we've seen is very little change in the virus," Frieden told lawmakers. "We don't think it is spreading by any different way."

Chances are that's not the last time he'll have to say that.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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California Nurses' Union Pulls Ebola Into Contract Talks

NPR Health Blog - Fri, 10/17/2014 - 4:04pm
California Nurses' Union Pulls Ebola Into Contract Talks October 17, 2014 4:04 PM ET

fromKQED

Listen to the Story 2 min 23 sec  

Members of the California Nurses Association rallied in Sacramento, Calif., in May, in anticipation of contract negotiations with Kaiser Permanente that began in this fall.

April Dembosky / KQED

The powerful California Nurses Association has put Ebola on the bargaining table in its negotiations for a new contract with Kaiser Permanente.

Contract talks have been going on for months, and the nurses' most recent demands are focused on Ebola — better training, more staffing, protective gear that goes beyond what's recommended by federal officials and even a special life insurance policy.

Shots - Health News Nurses Want To Know How Safe Is Safe Enough With Ebola

"We'd like to have an extra supplemental coverage, for specifically Ebola, if we were to contract Ebola while we're at work," says Diane McClure, a nurse at Kaiser Permanente's hospital in Sacramento, where a patient suspected of having Ebola was treated in August. He later tested negative for the virus.

She says even a month after the Ebola scare at her hospital, nurses hadn't received any meaningful hands-on training.

"They felt that all they had to do was pull up some [Centers for Disease Control and Prevention] information online and put some flyers on the tables and in the bathroom and that was it," says McClure, who is a member of the nurses' bargaining team.

Leaders from California's union and its partner in lobbying, National Nurses United, are quick to label the problems with training as a symptom of the country's fragmented health care system. The CDC issues guidelines, state departments of public health pass them on, then it's up to each hospital to take it from there.

The unions say fragmentation and a lack of protocols are the reasons two nurses at Dallas' Texas Health Presbyterian hospital were infected with Ebola. They've hosted several rallies for the nurses at the Dallas hospital, while noting that it isn't unionized.

Shots - Health News California Nurses Union Braces For Contract Battle

Joanne Spetz, an economics professor at the nursing school of the University of California San Francisco, says National Nurses United is doing what any other group that's looking to gain membership would do.

"Of course it's opportunistic," says Spetz, but "Texas is a state that has had virtually no union representation for registered nurses. So NNU may view this as an opportunity to demonstrate to nurses in the state what the value of their representation might be."

Kaiser Permanente has yet to respond to all of the California Nurses Association's demands. In a statement, Kaiser Permanente said that it is rolling out new training this week, including videos and simulation exercises. And it is supplying protective gear that is consistent with current CDC guidelines.

This story is part of a reporting partnership that includes KQED, NPR and Kaiser Health News. Kaiser Health News is not affiliated with Kaiser Permanente.

Copyright 2014 KQED Public Media. To see more, visit http://www.kqed.org.
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Spike In ER, Hospital Use Short-Lived After Calif. Medicaid Expansion

NPR Health Blog - Fri, 10/17/2014 - 2:02pm
Spike In ER, Hospital Use Short-Lived After Calif. Medicaid Expansion October 17, 2014 2:02 PM ET

fromKQED

One rationale for extending Medicaid coverage to more people is to help them get to a doctor or clinic before a minor illness becomes a medical emergency.

iStockphoto

While the expansion of Medicaid under the Affordable Care Act may lead to a dramatic rise in emergency room use and hospitalizations for previously uninsured people, that increase seems to be largely temporary and should not lead to a dramatic impact on state budgets, according to an analysis from the UCLA Center for Health Policy Research released Wednesday.

Researchers reviewed two years of claims data from nearly 200,000 Californians, including patients who had enrolled in public health programs well in advance of last January's expansion of Medi-Cal, the state's version of Medicaid.

These programs were designed to ease the expansion of Medicaid by providing insurance to low-income adults who weren't eligible for Medi-Cal at that point but would be when the health law's expansion went into effect. The researchers divided the group into four categories, based on the researchers' assessment of each category's pent-up demand for health care.

“ What our findings say to the country is, concerns about Medicaid expansion being financially unsustainable into the future are unfounded.

In July 2011, after being enrolled in California's Low Income Health Program, the group with the highest pent-up demand had a rate of costly emergency room visits that was triple or more that of the other groups. But from 2011 to 2013, that high rate dropped by more than two-thirds and has remained "relatively constant," according to the analysis.

"We were hoping that this would be the case," says lead author Jerry Kominski, director of the UCLA Center for Health Policy Research, "because we think that, that's what access to care does for low-income individuals." Among people who haven't been able to afford to see a doctor, you see an additional increase in demand for services initially, he says. But "that demand, or utilization, drops off pretty rapidly."

Rates of hospitalization for the "highest pent-up demand" group also started high and dropped by almost 80 percent over the two-year period. Interestingly, you might think that as ER and hospitalization rates drop, outpatient visits might rise, as newly insured people who had been accustomed to heading to the ER for sore throats and rashes now consult their family doctor instead. But that wasn't the case; the rate of outpatient visits was largely unchanged during the two-year period.

Kominski says that one of the fears raised about the Medicaid expansion was the potential high cost of low-income patients. He thinks that this analysis should ease those fears.

"What our findings say to the country is, concerns about Medicaid expansion being financially unsustainable into the future are unfounded," he says. Under the Affordable Care Act, the federal government pays states 100 percent of the cost of the newly eligible under the Medicaid expansion, but in 2017 that contribution will phase down until it reaches 90 percent in 2020.

Twenty-seven states and the District of Columbia are implementing the Medicaid expansion; 21 have not, and in two states, Indiana and Utah, the question of expansion is an "open discussion," according to a tally from the Kaiser Family Foundation.

Matt Salo, executive director of the National Association of Medicaid Directors, says the study was "certainly consistent with what we hope to do" by expanding health insurance access. Insurance is "just the first step," he says. "The next step is health care homes so that the individual can actually get better care."

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One factor in helping drive down the higher rates of use, Kominski says, is better coordination for Medi-Cal beneficiaries. For example, virtually all Medi-Cal beneficiaries are now enrolled into a Medi-Cal managed care plan. "To the extent that other states don't have adequate coordinated care mechanisms in place for their Medicaid populations, then the kinds of drop-off that we observed in California may not occur there," Kominski said.

The UCLA analysis makes explicit reference to — and rebuts — a similar study, the Oregon Health Insurance Experiment. In Oregon in 2008, 10,000 residents literally won Medicaid coverage in a lottery, creating a true randomized controlled trial opportunity for researchers who compared those who won coverage with those who didn't. In the Oregon study, researchers reported a 40 percent increase in ER visits in the 18 months after that expansion.

Kate Baicker, a health economist at the Harvard School of Public Health, was one of the social scientists who analyed the Oregon experiment. She says her team did not find "any evidence of utilization tailing off over that 18-month window."

Still, Baicker says, an increase in the use of health care services, such as emergency room visits or hospitalizations, "does not mean that Medicaid should not be expanded; part of the goal is to increase access to health care."

The UCLA study was funded by the California Department of Health Care Services and Blue Shield of California Foundation.

This story is part of partnership that includes NPR, KQED, and the Kaiser Family Foundation.

Copyright 2014 KQED Public Media. To see more, visit http://www.kqed.org.
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Take Your Medicine, Tap Your Phone And Collect A Prize

NPR Health Blog - Fri, 10/17/2014 - 11:37am
Take Your Medicine, Tap Your Phone And Collect A Prize October 17, 201411:37 AM ET

A view of the rewards screen on the Mango Health app.

Meredith Rizzo/NPR

As a neurosurgeon in Connecticut, Dr. Katrina Firlik saw too many patients make the same mistakes, over and over again.

At her hospital in Greenwich she'd see patients with hemorrhagic strokes that could have been prevented. "They didn't take their hypertension medications for the last couple decades," she says.

A new tool from HealthPrize syncs with your smartphone to let the company know when you've taken your medication so you can reap your rewards.

HealthPrize

Firlik wanted to try to stop these problems. In 2009, she co-founded the company HealthPrize with two other health care entrepreneurs, Tom Kottler and James Jorasch, to create an app that would motivate people to take their meds.

HealthPrize offers reward points, much like Candy Crush or Fruit Ninja, to get people to stick with their prescriptions.

The company has recently partnered with West Pharmaceutical Services, a company that makes specialized devices for drugs that are injected, such as insulin. The customized tools ping a patient's smartphone when a drug has been injected. HealthPrize tracks the pings to verify that people have taken their medicines.

Patients who don't take their medicines, as Firlik saw, are at risk for strokes, heart attacks, blood clots and even death. The failure to follow through on doctors' prescriptions leads to problems that cost the U.S. health care system more than $290 billion a year, according to a report conducted by the New England Healthcare Institute. The costs include additional hospital admissions and extra emergency room visits.

The reasons patients don't take their drugs range from unwillingness to fork over a copay to worries about side effects. Another reason is that many chronic conditions, such as high blood pressure, don't have symptoms. And unlike an antibiotic or painkiller, the drugs people take to control many chronic conditions don't make them feel better.

Cholesterol-lowering statins are among the most-prescribed drugs in the U.S., but about 50 percent of patients don't take them as they should. "The No. 1 reason people don't take statins is because they don't really believe they need them," says Josh Benner, founder of RxAnte, a company that consults health groups on what types of patients don't take their medications. People don't think they're going to get a heart attack or a stroke, so they pass on the pills.

That's why startups like HealthPrize and Mango Health use rewards to make taking medicines part of a larger game to give people a boost of motivation.

Running through HealthPrize's blood are ties to Priceline and research in consumer motivation, casinos and gaming. "We understand consumers when it comes to Las Vegas, vending machines, lottery tickets," says Firlik.

Similarly, Mango Health's brightly colored fruit logo and friendly mobile interface sprang from the minds of former gaming industry executives. It makes sense to use a gaming angle to get you to take your meds, says Jason Oberfest, the CEO of Mango Health, because "our [demographic] looks very similar to mobile games."

He describes the average user of the Mango Health app as a woman, early to mid-50s, who enjoys Instagram and uses mobile banking apps. She would like a simple app on her phone to help her manage her recently diagnosed condition and the drugs her doctor told her she needs to start taking.

HealthPrize and Mango Health partner with health care groups, such as pharmaceutical companies, health insurance companies or physicians, to offer specific incentives for medical conditions and associated prescriptions. They verify that patients are refilling their prescriptions through the drug companies or pharmacies, while patients enter data on an app or mobile website, saying they took their medication.

Patients who take their medicines can collect various rewards, including gift cards to Amazon or Starbucks, cookbooks or donations to their favorite charities. "It's the immediacy of the reward that's critical," says Firlik. For HealthPrize, "the most common items that are redeemed are for $5 or $10 gift cards."

Depending on the app, the bill for the rewards is footed by a pharmaceutical company (HealthPrize) or the company itself (Mango Health).

In a study of 300 patients using HealthPrize over 20 months, they were, on average, 54 percent more likely to take their blood pressure medication than patients taking the same drugs but not in the program, according to the company.

In a study of 7,800 patients taking an acne prescription, those using HealthPrize refilled their prescription nearly three times as much as those not using it. Mango Health's first six months of data indicate that the rates of patients taking their medication with Mango Health are 20 to 25 percent higher than those not enrolled in the program.

However, neither HealthPrize nor Mango Health has published peer-reviewed studies, which leaves some cautious of the claims. "It's hard for me to imagine the apps overcoming understanding the need for treatment or fear of side effects," says Benner. "Those are, in our experience, best addressed by health care professionals."

However, Benner says he hopes the companies will sharpen their focus on people who could get help from apps. "They're just not going to be appropriate or effective for everybody," he says. But for those experiencing their first long-term everyday pill, an app could provide just the kick they need.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Just Seeing Charts And Graphs Makes Drug Claims More Credible

NPR Health Blog - Fri, 10/17/2014 - 8:02am
Just Seeing Charts And Graphs Makes Drug Claims More Credible October 17, 2014 8:02 AM ET

When people see charts like this, they think the drug is more effective than if they just read about the data, a study finds.

Source: Cornell University

Graphs and formulas say "Science!" to consumers, so much so that simply seeing claims about a new drug that were accompanied by data visualizations made people more likely to believe the claims.

The effect is especially true if people have a strong belief in science to begin with.

That's the conclusion of a study published online in the journal Public Understanding of Science. It includes three experiments. In the first, 61 people read a paragraph saying that a nonexistent new drug enhances immune function and reduces the likelihood of catching a cold by 40 percent. Half of the people also saw a graph that repeated the numbers but contained no new information.

Of those who saw the text and the graph, 97 percent said they believed the drug worked, compared with 68 percent for the people who saw only the text.

The Salt Eaters Worldwide Are Skeptical of Manufacturers' Health Claims

The researchers, from the Cornell Food and Brand Lab, wanted to be sure that difference wasn't just because one group had the information repeated for them in graph form. So a separate group of 56 people saw the text and the graph, or the text plus an extra sentence repeating some of the information.

Again, the people who saw the graph rated the medication as more effective – especially those who said they believed in science.

Finally, the researchers wanted to make sure that the effect didn't just hold for visual representations of information such as a graph.

Shots - Health News Big Data Peeps At Your Medical Records To Find Drug Problems

So a different group of 57 people received information about another hypothetical drug. For half, that included the drug's chemical formula. Those who saw the formula believed the drug would work two hours longer than those who didn't get the formula.

Even "trivial elements that are associated with science ... can enhance persuasion," the authors said. That's important in an era of sometimes-dubious health claims for foods and supplements as well as medications. Indeed, a Nielsen survey a few years back found that while most people say they don't believe the claims on food labels, they were more likely to believe claims backed by numbers.

Cornell behavioral economist Aner Tal, an author of the study, says there's nothing inherently illegitimate about product information, marketing materials or advertisements that include graphs or formulas. It's just that those elements make the marketing message more convincing. So he warns that it's important to consider the source of all that information, no matter the form it takes. Is it from the company itself or a source funded by the company? Or is it from an independent source?

He says it can't hurt to approach "science-y" information like graphs or formulas with a more critical attitude. But he doesn't know if putting your guard up can make you immune to the bias.

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Women Can Freeze Their Eggs For The Future, But At A Cost

NPR Health Blog - Thu, 10/16/2014 - 5:19pm
Women Can Freeze Their Eggs For The Future, But At A Cost October 16, 2014 5:19 PM ET Listen to the Story 4 min 6 sec  

A doctor uses a microscrope to view a human egg during in vitro fertilization (IVF), which is used to fertilize eggs that have been frozen.

Mauro Fermariello/ScienceSource

Until recently, freezing a woman's eggs was reserved mainly for young women facing infertility as a result of cancer treatments like chemotherapy.

But recent advances in technology have made freezing eggs easier and more successful, and likely have a lot to do with the recent decisions by Facebook and Apple to offer female employees a health benefit worth up to $20,000 to freeze their eggs.

Making Babies: 21st Century Families Egg Freezing Puts The Biological Clock On Hold

The benefit is intended for women who don't need to freeze eggs for medical reasons, but rather as a choice. This would likely appeal to women who want to focus on their careers instead of child rearing, as well as women who just haven't yet met "Mr. Right."

Doctors have had the technology since the mid-1980s. But, according to Dr. Richard Paulson, director of the fertility program at the University of Southern California, it just didn't work very well. "Everybody figured there was something wrong with the eggs after freezing them; you just couldn't get them to fertilize," he says. Then, about 10 years ago, someone came up with the smart idea to use technology typically used to help weak sperm fertilize an egg.

No Longer Experimental, Egg Freezing May Appeal To More Women

"I think it would be fair to say the 'ah-ha' moment came when someone figured out that you could bypass the hardened egg shell," he says.

When eggs are frozen, their "shells" harden. Researchers bypassed the hardened shells by injecting sperm through the shell and directly into the egg. Then, within a few years, a rapid new freezing method enabled eggs to be quickly frozen with their quality preserved, putting the eggs into a "state of suspended animation," says Paulson.

Even so, age remains a major caution. Since eggs degenerate with age, the younger a woman is when she freezes her eggs, the better. For example, if a 30-year-old freezes her eggs and then uses them at age 38 or 40, she will be getting pregnant with the eggs of a 30-year-old with lower risk of miscarriage and genetic defects, including Down syndrome.

Health With Egg-Freezing So Expensive, Should Long-Term Boyfriends Chip In?

Egg freezing doesn't stop the biological clock, says Paulson. It just sort of "pauses it," he says, giving women the option to delay childbearing until they're ready.

While egg freezing is "an exciting new option," it shouldn't be relied on to make family-planning decisions, says Dr. Valerie Baker, a fertility specialist at Stanford University Medical Center. "We wouldn't want to have people think this is a substitute for making family building decisions in a broader context. It's not a guarantee that if a woman freezes her eggs she's eventually going to be able to have a baby with one of those eggs."

Baker says it's more reliable for women to try to get pregnant at a younger age, if possible, rather than banking eggs and hoping to get pregnant later in life. Even so, in vitro fertilization, or IVF, either with fresh or frozen eggs certainly boosts a woman's chance of getting pregnant at any age.

But egg freezing is costly, both emotionally and financially. Many women will have to undergo the procedure more than once. It cost about $10,000 to harvest eggs from the ovaries, after a woman has taken medications for several weeks to stimulate egg production. Then the eggs need to be frozen and stored, at a cost of about $500 a year. Each time eggs are thawed, fertilized and transferred to the uterus with IVF it costs about $5,000.

Baker adds another caution: Not all women have the same biological clock. "Some women are running out of eggs when they're in their late 20s/early 30s, whereas other women may have reasonably good fertility into their mid- to late 30s," she says. Reproductive specialists can help women figure out which category they are in, which is an important factor to consider when thinking about freezing eggs.

Most insurance companies don't cover the cost of egg freezing, not even for medical reasons when a young woman's fertility is jeopardized by cancer. So the decision by Facebook and Apple to foot the bill is a significant benefit for women who want to freeze their eggs.

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Poll: Majority Of Americans Worried About U.S. Ebola Outbreak

NPR Health Blog - Thu, 10/16/2014 - 2:04pm
Poll: Majority Of Americans Worried About U.S. Ebola Outbreak October 16, 2014 2:04 PM ET

An ambulance carrying Amber Vinson, the second health care worker to be diagnosed with Ebola in Texas, arrives at Emory University Hospital in Atlanta on Wednesday.

David Tulis/AP

How are Americans sizing up the threat from Ebola?

A Harvard School of Public Health poll finds that more than a third of Americans (38 percent) are worried that Ebola will infect them or a family member over the next year.

Most (81 percent) believe Ebola can spread from someone who is sick and has symptoms. And that's correct.

Body fluids, such as blood, urine and feces, can carry the virus from one person to another. And almost all of the poll respondents (95 percent) agreed that direct contact with body fluids from a person with Ebola symptoms was likely to cause infection.

A large proportion (85 percent) of people believe the virus can be transmitted by a sneeze or cough. That's highly unlikely. "Common sense and observation tell us that spread of the virus via coughing or sneezing is rare, if it happens at all," the World Health Organization says.

Shots - Health News Ebola In The United States: What Happened When

Dr. William Schaffner, an infectious disease specialist at Vanderbilt University Medical Center, says there is no known case of Ebola being spread that way.

"I think the public has received Ebola 101, but not Ebola 102," he said of the Harvard poll results on Wednesday's All Things Considered. "Those kinds of subtleties actually are pretty hard to communicate."

The telephone poll of 1,004 adults was conducted Oct. 8-12. Thomas Eric Duncan died in Dallas the day the poll was put into the field. The death of the first person diagnosed with Ebola in the U.S. may have weighed on poll respondents.

More than half of them (52 percent) said they were worried about an Ebola outbreak in the U.S. within a year. When asked the same question in August, 39 percent of people polled said they were concerned about an Ebola outbreak here.

While there have been setbacks already in dealing with Ebola in the U.S., public health officials say the country can cope with the virus.

"As we learn from the recent importation case in Dallas and subsequent transmissions, and continue the public health response there, we remain confident that Ebola is not a significant public health threat to the United States," CDC Director Dr. Thomas Frieden said in written testimony submitted for a House oversight committee Thursday.

Ebola, he wrote, "is not transmitted easily, and it does not spread from people who are not ill, and cultural norms that contribute to the spread of the disease in Africa — such as burial customs and inadequate public-health measures — are not a factor in the United States. We know Ebola can be stopped with rapid diagnosis, appropriate triage and meticulous infection-control practices in American hospitals."

Americans appear confident that if someone in their community gets sick with Ebola, they will receive good care. Some 80 percent said that someone infected with Ebola would survive an infection if he or she got prompt medical care.

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Despite Legal Reprieve On Abortion, Some Texas Clinics Remain Closed

NPR Health Blog - Thu, 10/16/2014 - 10:37am
Despite Legal Reprieve On Abortion, Some Texas Clinics Remain Closed October 16, 201410:37 AM ET

from

Listen to the Story 2 min 4 sec  

A man walks past the former site of a clinic that offered abortions in El Paso, Texas.

Juan Carlos Llorca/AP

Texans on both sides of the abortion issue are taking stock after the U.S. Supreme Court intervened in a lawsuit over a state law that would require clinics that provide abortion services to conform to standards for ambulatory surgery centers.

The court issued an order late Tuesday saying 13 Texas clinics that had to close can reopen their doors for now.

The clinics had shut down Oct. 3 because they couldn't meet the standards of ambulatory surgery centers. That's one of the Texas law's requirements. But now the U.S. Supreme Court has said those clinics can continue to operate while the law is appealed.

"I was really surprised and really delighted in a way I hadn't expected," said Amy Hagstrom Miller, founder and chief executive of Whole Woman's Health. Whole Woman's is the lead plaintiff in the lawsuit for this case. The company once had six clinics in Texas, but the law forced all but one to close.

Miller said she will reopen her clinic in McAllen by Friday, which would make services available to low-income women in the Rio Grande Valley. Women in the area had to travel to San Antonio, but many couldn't afford the trip or take time off from work, she said.

"To begin with there were only two clinic facilities in the Rio Grande Valley, and both of us had to close, which meant that women had to travel upwards of 250 miles round-trip in order to get an abortion safely," Hagstrom said.

Hagstrom is also working to reopen a second clinic in Fort Worth.

But even with this ruling, the legal fight in Texas appears to have fundamentally changed the landscape for abortion providers, and not all the clinics are likely reopen.

Whole Woman's clinic in Austin no longer has a lease or a state license. The company once had a clinic in Beaumont, but doctors there can't obtain admitting privileges at nearby hospitals, so Miller closed it in March.

In addition, any clinic that reopens might have to close again if the 5th Circuit Court of Appeals eventually rules the Texas law can stand.

Planned Parenthood in Houston was one of only eight places left in the state to get an abortion after the noncompliant clinics closed Oct. 3.

"Limiting abortion access to eight in Texas — eight simply isn't enough," said Rochelle Tafolla, a Planned Parenthood spokeswoman. "We were overwhelmed with phone calls."

Texas is the country's second-most populous state, with about 26 million people.

When the other clinics closed, Planned Parenthood received over 500 calls in just one day, about six times the normal volume.

Some women whose appointments were canceled drove to the Houston clinic off the Gulf Freeway. "Women were scared, they were nervous, they didn't understand what was happening," Tafolla said. "We're just thrilled the court stepped in to stop this terrible law and we hope that it will eventually and ultimately be overturned."

The Supreme Court's intervention means that the cycle of emergency motions is over. The 5th Circuit has agreed to expedite the full appeal, which could be heard as soon as December.

Houston-based Texas Right to Life supports the law and its strict new rules for providers. Emily Horne, a legislative associate, says the surgery center rule will make abortion safer for women.

Horne said it's discouraging that some clinics can now reopen, because she believes they don't offer good medical care. But she remains optimistic the law will stand in the long term.

"The encouraging thing for us is that this case is still before the 5th Circuit, and the 5th Circuit has already said a lot of positive things about the state's merit and likelihood of success," Horne said. "And none of that actually changed with what the Supreme Court said."

This story is part of a reporting partnership between NPR, Houston Public Media and Kaiser Health News.

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How A No-Touch Thermometer Detects A Fever

NPR Health Blog - Wed, 10/15/2014 - 6:03pm
How A No-Touch Thermometer Detects A Fever October 15, 2014 6:03 PM ET

A school official shows a pupil an infrared digital laser thermometer before taking his temperature in Lagos, Nigeria, in September. Starting this week, similar hand-held devices are checking foreheads for fever at some U.S. airports.

Akintunde Akinleye/Reuters/Landov

In the battle to stop Ebola's spread, health officials worldwide have been deploying thermometers in hopes of detecting the earliest symptoms among people who might be sick. The no-contact thermometer, already broadly used in some airports in Africa, has come to U.S. airports this week — now at New York's John F. Kennedy Airport, and, starting Thursday, at D.C.'s Dulles, Chicago's O'Hare, Atlanta's Hartsfield-Jackson, and Newark's Liberty.

The goal is to detect fever; for public screening purposes, according to guidance from the Centers for Disease Control and Prevention, an elevated temperature higher than 100.4 Fahrenheit (if you have reason to think you might have been exposed to Ebola) merits follow-up.

Of course, lots of illnesses — many that are mild and others that are severe — can cause fever, and checking for fever at airports didn't start with Ebola. In 2003, some Asian airports used thermometers as part of their screening of passengers for symptoms of severe acute respiratory syndrome, or SARS. And in 2009, with prompting from the World Health Organization, airports checked the temperature of some travelers, looking for symptoms of H1N1 flu.

As the NPR blog Goats & Soda reported previously, there are pros and cons to different types of temperature-taking devices, from the fairly common ear gun thermometer to the full-body scanner.

The CDC rush-ordered 80 Caregiver thermometers this week to five airports around the U.S., according to the manufacturer.

Thermomedics

The hand-held, no-touch thermometer seems to have emerged as the most popular for Ebola screenings, doctors say, because it's fast, easy to use, noninvasive, pretty accurate, relatively inexpensive, and minimizes the chance of spreading illness.

No-touch thermometers were originally used in industry, from manufacturing to firefighting, and they're a trusted resource, says physiologist Dr. Benjamin Levine at the University of Texas Southwestern Medical Center.

"It's very accurate at measuring whatever it's pointed at," Levine tells Shots. In this case, that's a forehead, which doesn't precisely reflect the human body's internal temperature, but is a close enough match for the rough purposes of screening, Levine says. "It's a quantitative way of having your mother put her hands or lips against your forehead."

The thermometer tells how hot a person is by measuring the infrared energy coming off the body. "Human skin is a very good — or very efficient — emitter of infrared energy," says Gary O'Hara, chief technology officer for Sanomedics, which manufactures CareGiver, the brand of thermometer now being used in some airports.

CareGiver captures that energy coming off the body, and the device is calibrated to translate that energy reading into the temperature of an object. A sensor relies on a silicon lens to focus the infrared energy so the reading isn't "of the wall, or of your hair," says O'Hara, "We want to read the temperature of a precise spot on your forehead." That's part of what differentiates a human no-touch thermometer from an industrial one, he says — the narrow field of view. The other difference is the algorithm the machine uses in its translation.

"That's our special sauce," says Keith Houlihan, CEO of Sanomedics. CareGiver's algorithm is based on data from clinical studies of patients, some with fevers and some without. "We crunch that data and put it into a mathematical algorithm so that it converts the temperature taken from the forehead into this oral equivalent," says O'Hara. The result, he says, is a thermometer that matches an oral thermometer typically within two-tenths of a degree and ASTM International's thermometer standard to within four-tenths of a degree.

No-touch thermometers are useful, in part, because they're unlikely to pass infection from person to person, according to the Centers for Disease Control and Prevention. However, the CDC also notes that this particular type of fever detector is most accurate when measuring the temperature of dry skin, in a draft-free room.

"If someone is sweating or has been in front of a fan and the forehead skin has become cool," he could register at a normal temperature when he is actually running hot, says Levine. And, of course, aspirin and some other pain relievers can reduce body temperature, too, and mask a low fever. No thermometer is perfect.

But for the fast pace of airport screenings, health officials say, if the goal is to pick up symptoms in some people before they even realize they're sick, no-touch thermometers are the best bet.

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Ebola In The United States: What Happened When

NPR Health Blog - Wed, 10/15/2014 - 12:51pm
Ebola In The United States: What Happened When October 15, 201412:51 PM ET

When Ebola virus resurfaced in West Africa in December 2013, public health officials were hopeful that it could be contained, as it had been in past outbreaks.

But the virus continues to ravage communities in Africa and has now spread to the United States and Europe. The number of new cases in Africa make it likely that there will be more cases in other countries.

We've put together a timeline to track the U.S. response to Ebola, with the most recent events at the top. (International coverage by NPR continues at the Goats and Soda blog.) Check back, as we'll be updating this list.

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