Can A Damaged Heart Heal Itself? With a Little Help, Maybe.

Posted on | January 13, 2016 | 2 Comments

Source: AHA Journals

Mike Magee

At last night’s State of the Union address, President Obama placed Vice President Joe Biden in the command seat as director of the scientific assault on cancer. The destination – a cure for the dreaded and stubbornly complex myriad of disorders that have created so much suffering and loss of life. Near equal as a plague has been cardiovascular disease, and especially heart attacks and strokes. In this arena, we may be getting closer to the promised land.

We’re all familiar with the idea of a “heart attack”. Most know the cause is obstructed blood flow through the coronary arteries to the heart muscle. Most also can tell you that heart muscle dies, turns to scar, and as a result the “heart pump” doesn’t work as well, often leading to disability and early death. But what actually happens on a cellular level, at the time of the heart attack, and in the recovery period?

An article in the New England Journal of Medicine this week addresses these questions. Here are a few of the insights:

1. Cardiomyocytes, contracting heart muscle cells, are the cells we lose with a heart attack.

2. The interruption of blood flow not only damages these cells, but is also responsible for a measurable decrease in a natural chemical called follistatin-like1 (FSTL 1) produced in the outer layer of the heart or the epicardium.

3. Heart muscle cells aren’t known for their rapid cell division. In fact only 1% undergo cell division each year. They speed up a bit when there is a heart attack, but not enough to allow repair.

4. In the past decade, researchers have tried to infuse adult stem cells into ischemic cardiac scarred areas, in the hopes of increasing the number of healthy cardiomyoctes in the damaged area. These attempts have largely failed to get the cells to stick to the injured areas where they are needed, and when they have stuck, the stem cells have often refused to differentiate or transform into cardiomyocytes.

5. It turns out that the heart does possess in its outer layer a group of endocrine like protein chemical stimulators that possess the ability to naturally enhance cardiomyocyte survival if blood flow is restricted, and also stimulate small vessel growth to help deliver additional oxygen to the ischemic areas. These are called “cardiokines”, and FSTL1 is one of them.

6. Surgical suturing of an FSTL1 infused patch onto an ischemic cardiac scar in mice has successfully induced reparative growth of cardiomyocytes in the damaged area.

7. How FSTL1 actually works, the intermediaries and number of steps, remains to be fully elucidated. The mice researchers are also looking at amphibians which have the ability to regenerate their own hearts for clues. But clearly, for the many individuals who have suffered major heart attacks and survived, only to face eventual failure of their heart pumps, with heart transplant then the only option, there is hope.

Lewin Report: “Uh Oh – Health Care Costs Are Skyrocketing Again!”

Posted on | January 11, 2016 | Comments Off on Lewin Report: “Uh Oh – Health Care Costs Are Skyrocketing Again!”

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Jack Lewin

Health care costs went up by over 5% in 2015 after a mind boggling 7-year run of relatively flat costs. But in 2016 — and for the next few years — the annual increase is thought by CBO and others to be 8% or more. Private insurance and even the new Affordable Healthcare Act (ACA) “exchanges” may be increasing as much as 15% this year. That’s ugly for patients, businesses, and government.

The GOP will blame rising costs on the ACA. Same cause for global warming? The US Senate in late 2015 for the first time sent a bill to repeal the ACA. And Paul Ryan sent a similar House bill to Mr. Obama this week. Yawn. C’mon, the House has done that 63 times?. Obama killed the Senate Bill and Ryan’s latest bill and the ACA lives on; but there are some worrisome new storm clouds forming. Congress quietly buried in the December omnibus budget bill the delay of two ACA taxes that were to go into effect. One, the “Cadillac tax,” a tax on employers and employees for high cost insurance policies, was opposed by business and labor, and thus by both R’s and Dem’s. Like another unpopular provision of the ACA called the IPAB (Independent Payment Advisory Board—a powerful cost cutting body), I doubt if the ACA’s Cadillac Tax will ever go into effect. But, these delayed issues will somewhat undermine the ACA’s cost-saving capacities as costs are starting to rise again.

Dems realize the ACA didn’t manifest as a divine tablet, but they appreciate its value, with 15 million more Americans insured, fully funded prevention coverage, and many other positives. But they – especially Bernie Sanders – instead blame recent cost increases on insurers and on rising drug costs and profits. Hillary also believes the rise in drug costs is alarming – and it is. But, the proliferation of new biologic and ‘personalized’ drugs are therapeutically amazing, even though increasingly unaffordable. Yet so far, the percentage of pharmaceutical costs to total health costs hasn’t yet risen much (because all costs are rising). But patients cannot afford their share of these drugs, nor can state Medicaid programs.

Scientific progress is stunning, and the population is aging. Costs are going to go up. The NY Times this week highlighted the Kaiser Family Foundation recent study revealing that even insured people are increasingly being bankrupted by their out-of-pocket health care costs. Yes, health care is going to be even more unaffordable in the years ahead, unless…….. ?

Unless our next President and the Congress chart a new course (hold our breaths?). Well, President Rubio (my guess as to the R nominee) or President Cruz or President Paul Ryan (could be also!) would all change Medicare from an entitlement to a voucher-based income-indexed concept, shifting more costs to consumers over time. They would all also cap state Medicaid funding. These moves could definitely save government money, but make affected patients very mad (and oops– Medicare patients vote). These guys would also kill off the ACA, which would NOT save money (quite the contrary).

But, wait. What would President Trump do? Build a wall around Medicare? (J) No, but he thinks (along with his Vice President Sanders?) that Canada’s single payer model works remarkably well! Hmm.

So, what do I predict? OK, I predict we as a nation – in the nick of time – will finally take bold action to curtail rising health care costs. Of necessity. We will. Otherwise, health care will vampirise everything else in the economy from wages to business viability. Only one thing mentioned above among the potential candidate platforms might actually make our system much more efficient: a single payer or Medicare-for-all concept designed to drastically reduce administrative costs and also require that hospital and drug costs be negotiated down by an 800 pound gorilla.

But that isn’t politically viable…yet. And, I predict that a US single payer would be different from Canadian and EU models, and we would retain private insurers and private physician groups and hospitals –patients want and deserve choices—but choices that will be working in competition to achieve lower costs and higher quality around standardized benefits and more uniform charges for services. Some people call this approach an ‘all-payer’ model. Whatever we call it, I predict it’s coming.

The other positive (but very controversial) transition that is happening already across about one-third of US health care is that payment is rapidly shifting from paying for units of service (volume) to paying for value (better outcomes at lower costs). The ultimate and probably only viable and demonstrated way to accelerate paying for value is when doctors and hospitals are paid by ‘capitation,’ meaning they must form groups and networks that receive a fixed global budget for the patients they care for. This is how Kaiser Permanente and Geisinger and many large systems are currently paid. This is how Medicare Advantage largely works today. This is what is already happening more commonly in California and the western states than in the eastern and southern states.

But yes, capitation is destined to increase. Many physician colleagues and hospitals hate and resist that concept (equated by many to medical Communism), and I may have to enter the witness protection program for predicting it, but without this shift to incentivize value based payment concepts, we will never contain rising costs effectively. Never. And, it pretty much puts Dr. Wellby right out of business. But Dr. Wellby could join a group, or decide to become a concierge cash-only doctor. CAPG, the California-based national association of physician groups, added 35 very large groups across the country to its already impressive membership in 2015 —and all of them are capitated medical groups. The trend is growing.

So what does all of this mean to you and me as patients? It means we will increasingly choose branded and largely capitated medical groups and systems (like Mayo, Cleveland, Kaiser, university systems, and many others), but within the medical group or system we will hopefully still choose our own personal physician and/or specialist. We will also increasingly choose where to receive our care based on credible evidence of improved quality, fair cost, and higher patient satisfaction. The future will ideally still value the patient-physician (clinician) relationship and the best science over the dollar, but a viable future will have to be different from the status quo. To enable health care to be better, more affordable, and accessible to all, big change must happen. Actually, it’s already in process, even if a lot of folks aren’t too happy about it.
My hope is that doctors, clinicians, and consumers (patients) will participate together in preserving what is good about our current non-system in terms of choice and quality while effectively addressing the growing cost dilemma.

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The Lewin Report represents the personal thoughts and reflections of health policy, science advocate, and would-be futurist Jack Lewin, M.D., President and CEO of the Cardiovascular Research Foundation; Chairman of the National Coalition on Health Care; and former chief executive of the American College of Cardiology, the California Medical Association, and the State of Hawaii’s Department of Health and its public hospital systems. Comments as desired to [email protected]

Category: health reform
Tags: aca > health care costs > health reform > Jack Lewin MD

The Risks and Benefits of Home-Centered Deliveries in America.

Posted on | January 1, 2016 | Comments Off on The Risks and Benefits of Home-Centered Deliveries in America.

CDC, 1990-2012

Mike Magee

In the final week of 2015, there was a great deal of coverage on the relative risks of home delivery versus hospital-based delivery in the United States. The coverage derived from a NEJM study of Oregon databases in 2012 and 2013 that listed the intended site for delivery for all births for the first time. This allowed for a comparison of deaths rates and Apgar scores. The study was augmented in this week’s NEJM with a case study and an editorial.

The issue is a complicated one, made no more discernible by comparisons to the UK obstetrics approach, which more heavily emphasizes home deliveries, but also maintains a higher level of integration between out-of-hospital and in-hospital systems. Translation: they are better prepared to support their home based program and better able to access hospital settings for emergent problems should they arise during a home delivery.

At the core of the debate are the risk/benefit profiles of these two very different settings for delivery. What are the facts as we know them?

1. Thirty five years ago, the risk of death at hospital delivery for a single baby was approximately 1 in a thousand, and the Caesarean rate was 15%. Today, the risk is roughly the same, and the U.S. Caesarean rate has more than doubled.

2. In the current study of Oregon women in 2012 and 2013, the Caesarean rate of women who had chosen home-delivery as their primary option was 5.3%. For women who chose hospital delivery, it was 24.7%.

3. The Oregon study included 75,923 planned and completed hospital deliveries, 1968 completed home births, and 1235 completed free-standing birth-center deliveries. Unplanned home births were excluded and only singleton, term, normally developed fetuses in cephalic presentation were included in the analysis.

4. Comparisons of fetal death were based on “intended site” of delivery, not on where the delivery actually took place. Thus, a labor that began at home and ran into trouble requiring emergency transfer to the hospital fell into the “at-home” category.

5. Comparing those who intended a home delivery with those who intended hospital delivery, there was a statistically significant higher rate of fetal death in the at-home group – 1.8 per 1000 for planned hospital births versus 3.9 per 1000 for planned out-of-hospital births. That risk was conuter-balanced by risks associated with the more than four-fold increase in C-section rates among women chosing a hospital-based birth.

6. Approximately 16% of women who intend a home-based birth require emergency transport to a hospital.

7. Wilbur’s NEJM case study succinctly summarizes the complex pro’s and con’s for those chosing home deliveries with these words: “Cesarean delivery imposes substantial risk, including a rate of serious maternal complications and death that is three times as high as the rate with vaginal delivery, even among low-risk women. In addition, one in four women giving birth in a hospital report feeling overwhelmed, frightened, or anxious. The consistent, one-on-one support of a home-birth attendant and the familiar environment of the home may improve the experience for some women. However, even in the patient who is at lowest risk, unpredictable events can occur during labor, and immediate access to an operating room and a neonatal resuscitation team could improve outcomes.”

Where is there consensus? All parties appear to agree that their are risks and benefits to both approaches. For the U.S., that likely means the growth of hybrid models and a better trained and accessible goup of home-based birth support professionals as well as greater integration (as exists in the UK) to allow emmergency access to hospital settings if required.

Category: maternity care, obstetrics
Tags: caesarean sections > emergency deliveries > home deliveries > hospital deliveries > intrapartum deaths > maternity care > midwives > obstetrical care > UK home delivery

Michael Millenson on How To Make Medical Errors Less Profitable.

Posted on | December 22, 2015 | Comments Off on Michael Millenson on How To Make Medical Errors Less Profitable.

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Michael Millenson’s column in Forbes last week drew attention to the profitability of hospital errors, and attempts to interrupt the perverse cycle. In his words, “…the push for safer care has had much less urgency and been much less far-reaching than it can or should be. Perhaps the latest results of the HHS-hospital partnership herald a new patient safety culture finally taking hold. That’s a nice thought this holiday season. Meanwhile, it remains critically important to support better data collection, greater transparency of individual hospital results and more focused purchasing by health plans, employers and consumers alike in order to reward those whose first priority is, truly, ‘first do no harm’.”

You can find Michael’s entire article HERE.

Category: Health Financing, Health Safety
Tags: hospital Errors > Micheal Millenson > To Err is Human

Holiday Greetings: What is Health?

Posted on | December 19, 2015 | Comments Off on Holiday Greetings: What is Health?

Magee Grandchildren

In this country, we continue to struggle in answering the fundamental question “What is health?” A large part of our thought process has involved defining what health is not. It is not the health care system. It is not the reactive elimination of disease. It is not a simple commodity to be weighed against all other commodities in society. It is different from these things, and more than these things.

Health is universal and common to the people of the world, independent of geography, race, income, gender, and culture. Health is an active state of well being that encompasses mind, body and spirit. It is the capacity to reach one’s full human potential, and, on a larger scale, a nation’s potential for development. Dr. Gro Brundtland, former director-general of the World Health Organization, wrote in the World Health Report 2000 that “The objective of good health is twofold – goodness and fairness; goodness being the best attainable average level; and fairness, the smallest feasible differences among individuals and groups.”

Now, fifteen years later, the notion that health is a preferred state of being, rather than a set of disconnected functions or services, is increasingly being embraced. With this in mind, it becomes impossible to ignore a significant modern-day truism. Health is profoundly political.

Why is this the case?

For multiple reasons: Health is a collection of resources unequally distributed in society. Health’s “social determinants” such as housing, income, and employment, are critical to the accomplishment of individual, family, and community well being and are themselves politically determined. Health is recognized by many throughout the world as a fundamental right, yet it is irreparably intertwined with our economic, social, and political systems. And growth in health, health care, and health systems requires political debate and political consensus.

For these reasons and more, it is entirely reasonable to acknowledge and attempt to structure in a purposeful manner the politics of health. To do so requires mention of some of the major forces shaping health worldwide. These include aging demographics, the growth of home-based caregivers, the dual burden of disease, the Internet, and consumer empowerment and activism.

In the United States, nearly 50 percent of all 60 year olds have a parent alive, and by 2050 there will be 1 million people over age 100. This means that the three-generation family has been supplanted by the four- and five-generation family. Twenty-five percent of American homes have an elder caregiver in place, and 85 percent of them are volunteer family members. The vast majority of these caregivers are third generation women, managing parents and grandparents on the one hand and children and grandchildren on the other. In the United States, their focus is predominately on chronic diseases, seven of which cause 90 percent of the disability in senior populations.

In the developing world, the health focus remains primarily on infectious diseases, nutrition, and maternal and fetal issues, which are challenging the human and financial resources of these countries. But urbanization and the influx of tobacco and unhealthy foods are accelerating the onset of chronic diseases and creating a dual burden of disease.

And finally, consumer empowerment is being fueled by the Internet and supported by physicians, nurses and other caregivers. This has led to emancipation and engagement of an increasingly activist-oriented public. We desire education, behavioral modification, home-based care solutions, inclusion in the health care team, and financial incentives to reward wellness.

As these trends play out and the definition of health continues to evolve, we will see the seat of political power in health continue to shift. It will move away from paternalism toward partnership. It will move away from individual care models to team approaches. And it will move away from intervention toward prevention. It will embrace evidence-based clinical care but incorporate educational and social missions as well. It will move away from hospitals and outpatient care sites toward home settings. And it will move away from thought elites toward patients and their care teams.

Despite this shifting environment, there is a growing political disconnect between those who make health policy and those most affected by health policy. While the former continue to reinforce silos and the status quo, the latter seek broad, fundamental and comprehensive reform. Such reform has included expansion of insurance coverage under the Accountable Care Act, realignment of financial incentives toward prevention, increased reimbursement of physicians and nurses for team coordination that include home health managers, support for early diagnosis and screening, and expansion of education and behavioral modification for individuals and families.

Due to its profound impact on the future of individuals, families, communities, and societies, the politics of health deserves broad debate, active public participation, and focused scholarly pursuit.

Here are two suggested areas for growth.

First, we need to step up consumer education empowerment. We can build on the strong success we’ve already seen with increased understanding of the scientific lexicon, organ function, and disease management. To move another step forward, we must now offer strategies and incentives in home health management, lifespan planning, and customized health system design.

Second, in the area of scholarly pursuit, we must harness the best scholars in medical sociology, political sociology and political psychology, health economics, public health, medicine, nursing, pastoral care, and bereavement, to create interdisciplinary social health leadership curricula and degrees that are equipped to manage the rapidly evolving health environment. Such a commitment will empower us to more effectively challenge outdated thinking, outdated systems, and outdated approaches to health.

We are pleased to continue to offer you Health Commentary, an advertisement free and open, free resource for all. We appreciate our loyal subscribers in this tenth year of service, and wish you and your family a happy and healthy holiday season!

Mike Magee

Category: health policy

Dealing with Cholera – Educational Video and WHO Cholera Vaccine Position Paper.

Posted on | December 17, 2015 | Comments Off on Dealing with Cholera – Educational Video and WHO Cholera Vaccine Position Paper.

As the recently reported cholera epidemic in Kenya illustrates, this infectious disease remains a killer. The video above, produced in 2006, provides an open source summary of Cholera well worth viewing. The original program (Health Politics) no longer exists. But the transcript of this program can be downloaded HERE. The 2010 WHO position paper on the Cholera Vaccine is available HERE. Cholera epidemics still challenge Public Health professionals worldwide.

Category: Uncategorized