Author Archives: Carey Goldberg

Ebola: As Other Doctors Die, Heading Straight Into The Outbreak To Help

Dr. Nahid Bhadelia is in protective gear with Dr. Guillermo Madico at the National Emerging Infectious Diseases Laboratory in Boston, where she directs infection control. This gear is slated to be donated to the Ebola-fighting efforts in Sierra Leone when she goes there in mid-August. (Jackie Ricciardi/BU Photo Services)

Dr. Nahid Bhadelia is in protective gear with Dr. Guillermo Madico at the National Emerging Infectious Diseases Laboratory in Boston, where she directs infection control. This gear is slated to be donated to the Ebola-fighting efforts in Sierra Leone when she goes there in mid-August. (Jackie Ricciardi/BU Photo Services)

If all goes as planned, Dr. Nahid Bhadelia will soon head straight into the heart of the Ebola outbreak that has already killed more than 700 people in western Africa, including at least 50 health care workers. Global and U.S. health authorities announced Thursday that they would ramp up efforts to bring the epidemic under control, but that it would likely take at least three to six months.

Dr. Bhadelia is director of infection control at the National Emerging Infectious Diseases Laboratory in Boston and a hospital epidemiologist at Boston Medical Center. She’s slated to travel to Sierra Leone in mid-August, to share her expertise on infection control and also care directly for Ebola patients. Our conversation, edited:

This is the biggest Ebola outbreak ever, as far as we know. Is it notable in other ways?

This is the first time Ebola has been present in these three countries: Sierra Leone, Guinea and Liberia. Because these countries haven’t seen the infection before, that impacted their ability to recognize and manage the infection early on.

Also, because of the recent travel of the American Patrick Sawyer to Lagos [where he died of Ebola], I think it has raised a lot more concern about transfer of Ebola abroad, which has not been much of an issue in the past.

A lot of the U.S. media coverage has focused on, ‘Could it come here?’ Part of that fear seems to stem from the sense that Ebola, with its hemorrhages and high death rate, is particularly horrible. Is it?

In some ways yes and in others no. Ebola Zaire, the strain we’re seeing right now, is one of the most deadly strains; it’s been shown in the past to have 90 percent mortality when no treatment is given. But in some ways, it’s much harder to transmit at a population level compared to respiratory viruses we’ve been hearing about such as SARS or MERS. It requires close contact with bodily fluids. So, for example, there’s been a lot of concern about travel of folks from the areas impacted to the developed world, and I think the reason it’s less likely to spread is because it’s limited to people who come into contact very closely with the person who’s impacted.

So many health care workers have been getting infected. Do you have a sense of why? Are there practices that might be easily correctable that you could have an impact on?

There are a lot of talented people there in the field already, not just from international organizations but people who’ve been working there a very long time. In Sierra Leone, for example, though they haven’t had Ebola before, they’ve dealt with Lassa fever, another viral disease that causes hemorrhagic fever, at Kenema — one of the places where Dr. Khan, the leading physician who just died of Ebola, worked. That center has dealt with Lassa fever for over 25 years, and there are nurses there who have long experience. The issue is the amount of patients. You have nurses there who were taking care of maybe a dozen Lassa patients and now they have to see 70 Ebola patients. I think the major issue is the fact that the health care system is so overwhelmed.

One of the major ways to alleviate that would be the presence of more personal protective equipment and more sterile medical equipment in general. I know that the PPE — the personal protective equipment — is a major concern because there’s a dearth of it right now in the field.

Also, we understand that the virus can be transmitted from surfaces — so if someone comes into contact with bodily fluids with the virus in them on a surface, that’s another way to get it. The virus can live outside the host for a couple of days. So this contamination of the environment is another important component — and that’s very difficult if you can imagine 70 patients in a small space. Ebola is not hard to kill, so it’s easy to avoid contamination in general. It’s only because of the number of people and poor health infrastructure that it becomes difficult.

Still, it’s so baffling that these leading, incredibly knowledgable doctors are getting infected. How can that happen? Continue reading

‘Cowboy’ Doctors Could Be A Half-A-Trillion-Dollar American Problem

youngcowboy

When Dartmouth economics professor Jonathan Skinner was speaking recently at the University of Texas about the “cowboy doctor” problem, an audience member objected: “You have a problem with cowboys?”

Well, actually, we all have a problem with cowboys — when they’re doctors. Including the Texans. New research written up in a National Bureau of Economic Research paper finds that “cowboy” doctors — who deviate from professional guidelines, often providing more aggressive care than is recommended — are responsible for a surprisingly big portion of America’s skyrocketing health costs. The paper concludes that “36 percent of end-of-life spending, and 17 percent of U.S. health care spending, are associated with physician beliefs unsupported by clinical evidence.”

Whoa, Nelly. That means cowboy doctors are a half-a-trillion-dollar problem. But mightn’t they also be good? Wouldn’t many of us want a go-for-broke maverick when we’re in dire medical straits? I asked Prof. Skinner, who’s also a researcher at the Dartmouth Atlas of Health Care, to elaborate. Our conversation, lightly edited:

So how would you define a cowboy doctor?

Cowboys go it alone. They have developed their own rules and they don’t necessarily adapt those rules to what the clinical evidence would suggest. So if you actually talked to what we term a ‘cowboy doctor,’ he or she would say, ‘I get good results with this procedure for this type of patient.’ That’s why we found it so interesting: they go beyond what the professional guidelines recommend. And it’s not as if they were out there before the professional guidelines got there. Sometimes pioneers are doing things that the guidelines haven’t figured out yet. But we found no suggestion that subsequent guidelines were consistent with what these physicians were actually doing.

So is it stubbornness, then?

I don’t know if it’s stubbornness but it’s individuality. It’s the individual craftsman versus the member of a team. And you could say, ‘Well, but these are the pioneers.’ But they’re less likely to be board-certified; there’s no evidence that what they’re doing is leading to better outcomes. So we conclude that this is a characteristic of a profession that’s torn between the artisan, the single Marcus Welby who knows everything, versus the idea of doctors who adapt to clinical evidence and who may drop procedures that have been shown not to be effective.

This graph shows 64  hospital referral regions, with the size of the blob proportional to the number of doctors surveyed. It shows  that in regions with a larger share of “cowboys,”  risk-adjusted end-of-life Medicare spending is higher.(Courtesy Jonathan Skinner)

This graph shows 64 hospital referral regions, with the size of the blob proportional to the number of doctors surveyed. It shows that in regions with a larger share of “cowboys,” risk-adjusted end-of-life Medicare spending is higher. (Courtesy)

Yes, the extent of the variation in medical practice is striking. But I was most struck in your paper by how big a piece of the health-cost problem this could be. Can you quantify that?

We were surprised, too. What we show is that the opinions of these physicians — in particular, opinions that are outside of the clinical guidelines — explain as much as 17 percent of total variation in health care spending, which is, roughly speaking, 3 percent of GDP.

Wow. What is that in billions?

The association we found suggests it’s almost half a trillion dollars.

Can you give me a concrete example of how a cowboy doctor could drive up costs? Continue reading

Mass. Substance Abuse Bill Responds To Tide Of Sadness And Fear

Massachusetts State House (Wikimedia Commons)

Massachusetts State House (Wikimedia Commons)

In response to stories that seem to be on the rise in communities across the state — stories of parents trying to revive children after a heroin overdose, of young people seeking treatment their insurance plan won’t cover, and of babies born addicted to opiates — state lawmakers on the last day of their formal session approved a bill they say will help save the lives of those addicted to heroin, prescription painkillers and alcohol.

The measure, among several major bills passed just after midnight Friday, requires insurers to pay for any care a doctor decides is medically necessary. Insurers say this and other requirements included in the bill are a mistake.

In outlining the House and Senate compromise on the substance abuse bill Thursday afternoon, Sen. John Keenan of Quincy talked about his father.

“He was a good, decent, hard-working man, he was a great husband, a great father, but he was an alcoholic.” Keenan remembered an afternoon when his family told his father he had to get help. His dad resisted, but finally agreed. Someone got on the phone and found him a bed in a treatment program that was paid for by the Keenan’s insurance plan.

“That very day changed lives. My father had 26 years of sobriety before he passed away last year,” Keenan said. “He had 26 years with my mother, 26 years as a great father, 26 years with his seven children and their spouses, and 26 years as a great papa to his 20 grandchildren. So this can work.”

“This” being a requirement that insurers pay for up to 14 days of overnight detox and rehabilitation treatment as well as counseling, medication and any other services a clinician says are “medically necessary.”

Continue reading

Lessons From Boston Children’s: When Hackers Attack Your Hospital

Boston Children's Hospital (Wikimedia Commons)

Boston Children’s Hospital (Wikimedia Commons)

Last April, during the parents-versus-hospital custody dispute over teenager Justina Pelletier, Boston Children’s Hospital found itself under cyberattack, apparently by the hacker group Anonymous. The hospital’s website was flooded by traffic that hindered its operation, and other online operations were affected as well.

The assault brought widespread condemnation — BetaBoston called the attackers not activists but “criminals” — and subsided after about a week.

Now, Dr. Daniel Nigrin of Children’s offers some details and lessons from the assault in the latest New England Journal of Medicine: When Hacktivists Target Your Hospital.

He writes that the attack began with a warning message on Twitter relaying a set of demands, and then the hackers posted “the home and work addresses, phone numbers, and e-mail addresses of some of the people involved in the case (a tactic called ‘doxing’). The hackers also posted technical information about the hospital’s public-facing website, suggesting that it might become a target.” A few weeks later, the “distributed denial of service” — the flood of traffic — attack began.

Nigrin writes:

Over the course of the next week, the hospital was subjected to several other attacks that were intended to do more than affect its Internet connectivity. These included multiple attempts to penetrate its network through direct attacks on exposed ports and services, as well as through the use of “spear phishing” e-mails, which are intended to get recipients to click embedded links or open attachments that would provide a means for the attackers to gain access to the portion of the hospital’s network behind its firewall.

No patient data were damaged or exposed, Nigrin writes, but the experience underscores the important of planning for the possibility of losing Internet connectivity. Continue reading

2,780-Calorie French Toast: Cheesecake Factory Tops The (Calorie) Charts

(atobest/Flickr via Compfight)

Veronica Thomas
CommonHealth Intern

The Cheesecake Factory doesn’t just have the biggest menu. It also has the biggest calorie bang for your buck, according to this year’s Xtreme Eating awards from the Center for Science in the Public Interest.

Consider their Bruléed French Toast, described in the menu as: “Extra thick slices of rustic French bread baked and grilled golden brown. Topped with powdered sugar and served with maple-butter syrup with bacon or grilled ham.”

French toast seems innocent enough, and it’s even “bruléed.” If the French do it, it must be healthy. After all, French women don’t get fat, right? But at a whopping 2,780 calories, this breakfast treat is enough to satisfy an average person’s energy needs for the entire day—and half of tomorrow. To burn off that toast, you’d have to run a marathon. Yes, you read that right. A marathon.

This custard-stuffed toast, along with the Farfalle with Chicken and Roasted Garlic and the Reese’s Peanut Butter Chocolate Cake Cheesecake (yes, that’s double the “cake”), placed The Cheesecake Factory as the clear winner of this year’s Xtreme Eating awards.

Ranked by the Center for Science in the Public Interest each year, these nine awards go out to the meals highest in calories, sugar and salt sold at chain restaurants around the country. The center is making a point: It’s pushing for the federal government to require calorie counts on chain-restaurant menus – and the numbers certainly do pack a punch.

So, who are the other six offenders—or should I say, winners?

  • Red Robin’s A.1 Peppercorn Burger, a serving of Bottomless Steak Fries, and a Monster Salted Caramel Milkshake (3,540 calories and four days’ worth of sodium)
  • Famous Dave’s “Big Slab” of St. Louis-Style Spare Ribs with a corn muffin, Famous fries, and Wilbur (baked) beans (1.5 pounds of meat and 2,770 calories)
  • BJ’s Signature Deep Dish Chicken Bacon Ranch Pizza (2,160 caloriesor what you burn while swimming for four hours straight)
  • Chevys Fresh Mex’s Super Cinco Combo (1,920 calories, not including the bottomless basket of greasy tortilla chips)
  • Joe’s Crab Shack’s Big “Hook” Up Platter (3,280 calories and three days’ worth of fried saturated fat)
  • Maggiano’s Prime New York Steak Contadina Style (2,420 calorieshalf of which come from the sausage-and-potato garnish alone)

I must admit, I got a little hungry writing this post. But if I ever do get one of these meals, I think I’m going to have to take the long way to the restaurant — as in walk to the location in the next state over.

Food Stamps For Heirloom Tomatoes? Diet Effects Of Farmers Market Vouchers Studied

(Lindsay_NYC/Flickr via Compfight)

Veronica Thomas
CommonHealth Intern

Heirloom tomatoes for three dollars a pound. A four-dollar bunch of purple and yellow carrots. Well-heeled women stopping for local produce on their way to Whole Foods and the neighborhood juice bar.

That’s what comes to mind when I think of a farmers market. Bargain buys for low-income families? Not so much. But according to a new study, published in the journal Food Policy, vouchers for farmers market produce might improve the diets of low-income families—well, at least for those who go there anyway.

“Farmers market vouchers are a way to place all consumers on the same playing field,” says Carolyn Dimitri, an associate professor of food studies at NYU and the study’s lead author.

Low-income families often receive federal food assistance from two government programs: Women, Infants, and Children (WIC) and Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps. While these programs help ensure access to food, they do not guarantee its nutritional quality. In fact, most food assistance funds can be spent on anything, from potato chips to ice cream.

In general, low-income families don’t eat a lot of fruits and vegetables, often because they live in “food deserts” where options are limited. Some local governments and non-profits are aiming to increase these families’ access to fresh produce by offering vouchers—which are basically coupons—to use at farmers markets.

This year’s landmark Farm Bill created the first federal program to provide nutritional incentives in farmers markets and maybe even grocery stores. Before the program is implemented, this study’s investigators were interested in seeing if the incentives actually work.

The New York University researchers recruited 281 women from five farmers markets in New York, San Diego and Boston—one market in Lynn and the other at Copley. The women, who were already receiving federal food assistance, were offered up to $10 in produce vouchers every time they shopped at the market. Continue reading

As Mass. Lawmakers Take Up Addiction Bill, What’s Most Effective Treatment?

Hydrocodone pills, also known as Vicodin. (Toby Talbot/AP)

Hydrocodone pills, also known as Vicodin. (Toby Talbot/AP)

As Massachusetts lawmakers work on differences in the $20 million bill designed to address the state’s opioid crisis, questions remain about which treatments are best.

Several business and insurance leaders have written to Gov. Deval Patrick saying that some parts of the bill may not encourage the most effective addiction treatment. Essentially, they say, more beds may not be the answer, but more medication and longer outpatient care might be better.

The House bill requires insurers to pay for at least 10 inpatient days of addiction treatment if that’s determined to be medically necessary; the Senate bill requires up to 21 days of inpatient coverage.

“We just believe patients should have a choice.”
– Leominster Sen. Jennifer Flanagan

But the American Society of Addiction Medicine estimates that 95 percent of opioid-dependent patients do not need inpatient care, and might be better off with medication maintenance and several months of outpatient therapy. Lawmakers maintain that they do not want to mandate any form of treatment.

“If we have this epidemic that continues to grow, we’re essentially in uncharted territory, and current treatment options aren’t working,” said Leominster Sen. Jennifer Flanagan, one of the bill’s co-sponsors. “If people want inpatient treatment or medication maintenance, they should be able to decide that with their doctors.”

At the same time, a new report contains some surprising findings about medication maintenance addiction treatment. It says that methadone, long used to treat heroin addiction, may be the most effective and cheapest treatment.

The report, from The New England Comparative Effectiveness Public Advisory Council, found that when comparing methadone with suboxone (Buprenorphine) or naltrexone (Vivitrol), more patients stayed in treatment longer if they were taking methadone. Continue reading

Legal Experts Call For More Regulation Of Mobile Health Apps

smartphone (Stephan Geyer/Flickr)

(Stephan Geyer/Flickr)

Veronica Thomas
CommonHealth Intern

Want to hypnotize yourself thin? There’s an app for that. Want to monitor your heart rate without buying another gadget? There’s an app for that too. With the emergence of countless mobile health applications, smartphones are quickly transforming health care at our fingertips.

Mobile health—“mHealth”—apps have the potential to help promote healthy behaviors, expand health care access, and manage costs. But in order to protect the safety of consumers, health law experts say there needs to be more regulation by the Food and Drug Administration.

According to the new report, just published in the New England Journal of Medicine, only about 100 out of 100,000 mHealth apps available on the market have been FDA-approved.

Many mobile health developers, however, worry that FDA oversight will hinder creativity and growth. The FDA approval process can cost tens of thousands of dollars and take months or even years to complete. Before committing time and money to FDA endorsement, many developers first look to consumers for a stamp of approval.

From the study’s press release:

“Consumers will be spending a lot of money on these products, and venture capital is flying into the industry,” says the article’s lead author, SMU Dedman School of Law Associate Dean of Research Nathan Cortez, adding that by 2017 mHealth apps are expected earn $26 billion— up from $2.4 billion in 2013.

The FDA needs “additional funding and in-house technical expertise to oversee the ongoing flood of mHealth products,” the authors note. An under-regulated mobile health industry could create “a Wild West” market, says Cortez, who has conducted extensive research into FDA regulation of mobile health technologies.

While consumers might trust that iTunes and Android would only sell legitimate health apps cleared by the FDA, that just typically isn’t the case, Cortez says. Continue reading

When Hand, Foot And Mouth Disease Sweeps Through: What To Know

(Bob Reck via Compfight)

Veronica Thomas
CommonHealth Intern

Summer is not only the season for watermelon and zucchini. It’s also the time for Hand, Foot and Mouth Disease. Typically found in younger kids, it’s a contagious viral illness marked by a fever and rash — either skin or mouth blisters.

Hand, Foot and Mouth swept through several WBUR employees’ families recently, so we checked in with an expert: Dr. Clement Bottino, a pediatrician at Boston Children’s Hospital in the Division of General Pediatrics who sees a lot of the illness in the Primary Care Center. “Nothing unusual,” he says, “just the summertime viruses.”

“Viruses are kind of like vegetables,” he explains. “There are winter and summer varieties. The winter ones cause illnesses like the common cold, while those in the summer cause fever-plus-rash-type illnesses, like Hand, Foot and Mouth.”

Hand, Foot and Mouth typically affects children under the age of 5, but older children and even adults can catch it as well. Symptoms can vary. Some children may only have a fever and mouth blisters, while others have the characteristic rash without other symptoms. The rash may present with classic red bumps on a child’s hands and feet, or a more diffuse rash that includes the diaper area.

Some people, particularly adults, may show no symptoms at all, but they can still spread the illness to others. Hand, Foot and Mouth is transmitted through direct contact with saliva, mucus or feces. Daycare is notorious as a hotbed of activities for spreading infection: hugging, sharing cups, coughing and sneezing, and touching infected objects. While patients are most contagious during their first week of illness, they can spread the virus for weeks after the symptoms fade.

According to Dr. Bottino, the most important thing for parents to know is that the virus is mild and “self-limited,” meaning it usually goes away on its own, causing no scars or lasting problems. Most patients feel better in seven to 10 days without any treatment at all. I asked Dr. Bottino what else parents should know about Hand, Foot and Mouth Disease. Our conversation, edited: Continue reading

Project Louise: Exercise Every Single Day? Says Who?

(Bjørn Giesenbauer via Compfight)

(Bjørn Giesenbauer via Compfight)

OK, this is getting interesting. One week into the challenge laid down by Editor Carey and Coach Allison — to exercise every single day before 7 p.m., and to post a comment reporting that I did so before 11 p.m. — I have made several discoveries.

  1. Carey was right. Exercising every day makes you feel better.
  2. The sweatier the exercise is, the better you feel.
  3. I hate being told what to do.

Let’s focus for now on No. 3, because we all know that Nos. 1 and 2 are true. Right? We do know that, yes? We just don’t do it because … well, because of No. 3.

At least that’s what I’m concluding about myself. Even though I signed up for Project Louise of my own free will, and even though I did it because I really, truly want to change my habits for good and live a longer and healthier life, and even though I know that Carey Goldberg, Allison Rimm and all the other wonderful people who are helping me on this journey are truly here to help, not to push me around, a huge part of my brain reacts to all this support and encouragement and expert advice with a simple, all-too-familiar refrain:

You’re not the boss of me.

Yes, this is the week when I’ve been getting in touch with my inner child. Or, more precisely, my inner brat.

As soon as I wrote that, I realized that I have heard that phrase before — from a wonderful woman named Pam Young, who has written a lot about this idea that we all have an inner “brat” whom we need to learn to love. Because it’s that little bratty voice that keeps us from doing all the good, mature, responsible things we all know we should do. And as long as you keep fighting the brat, you’re going to lose — as any mother of a 2-year-old can tell you.

Likewise, as that same mother can tell you, the secret to success is to persuade the 2-year-old that what you’re telling her to do is actually fun — to make her want to do it, and even to make her think that it’s her own idea. Continue reading