When you’re settling in to watch a movie, and the music starts playing, it’s hard to ignore the names that flash first in the opening credits: The Director. The Big Stars.

Name placement matters in academia, too. A recent study reveals there’s a gender gap in who gets top billing on medical studies published in several of the most prestigious research journals.

Dr. Carolyn Lam, a cardiologist and faculty member of the Duke-NUS medical school in Singapore, says getting top billing isn’t just about ego. The number of times you nab that “first author” spot on a research paper shapes how you’re evaluated at work — everything from tenure possibilities to pay.

“This is our livelihood,” Lam says. “It’s important.”

Traditionally, the last name in a series of authors on a science paper is also prestigious — it’s reserved for the most established colleague. First and last in the series is best. That’s why she was upset when she heard about the study in the British Medical Journal showing women are under-represented in that first position.

Giovani Filardo and Briget da Graca, with Baylor Healthcare System in Dallas, took a close look at the names atop original research articles published in six of the world’s leading medical journals over two decades.

While women were better represented as first authors in 2014 than 20 years earlier, their numbers have plateaued in recent years, the scientists found, and have declined in some journals.

Though women have been attending U.S. medical schools in roughly equal numbers as men since 2003, “substantial gender differences in rank and leadership remain in academic medicine,” notes Dr. Kathryn M Rexrode, an associate professor of medicine at Harvard Medical, in an editorial accompanying the study.

And that may also be a problem for women’s health, it turns out. In the same way that having more women as writers and directors in the movie business makes it more likely a film will have a female protagonist, research shows that studies of new drugs or therapies that have women as first authors are more likely to include a significant number of women as research subjects.

Dr. Deborah Diercks, who chairs the department of emergency medicine at UT Southwestern, says when she designs studies of why women are more likely to die from heart attacks, she approaches it differently than some male doctors do.

“I think a little bit more than some of my colleagues do about outside pressures,” Diercks says. “Such as, the reasons women delay going to the hospital — is because they’re a caretaker or because they have pressures to finish the wash or pick up the kids?”

She wonders if those pressures might also help explain why women less often get top billing on research papers. Another factor that might contribute, she says, is bias in the review process. The editors who make the decisions about who gets published are often men.

“I struggle with that a lot,” Diercks says. “I do believe it’s truly unconscious and unintentional but it amazes me that [that bias] is still there.”

Gender bias, intentional or not, is something Carolyn Lam thinks about often.

Just one in five students in her medical school class in Singapore in the early 1990s were women. After graduation, Lam entered a male-dominated specialty — cardiology. Still, she doesn’t fault the system entirely for the gender gap among first authors. In part, she blames herself.

For example, Lam was recently working with two male colleagues on a journal submission when they started talking about whose name should appear first. She stayed silent. And her name went second.

“I started examining myself a bit,” Lam says. “Why didn’t I ask to be first author?” She realized she should have advocated for herself.

“I think that sort of behavior is pervasive in many, many fields,” she says.

So, last month, when Lam was finishing up another study she’d worked on with two different men and the question of authorship came up, she spoke out.

“My colleague — whom I totally respect — he wrote himself as first author, our senior colleague as last, and me as second,” she says. “I was about to shoot off an email saying, ‘OK, as long as our data get published.’ “

But she caught herself and, instead, asked to be first author. Her colleague agreed.

This story is part of a NPR’s reporting partnership with local member stations and Kaiser Health News.

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Two years ago, when the federal government first released data on how much Medicare paid physicians, the media coverage was widespread. Doctors who earned significant sums were dubbed “Medicare millionaires” and journalists highlighted unusual patterns in how some doctors bill for services.

When Medicare released its third round of data last Thursday, the coverage was practically nonexistent. In some ways, that’s because data releases from the Centers for Medicare and Medicaid Services have become almost routine.

ProPublica has used CMS data to build our Treatment Tracker, another tool called Prescriber Checkup and a third called Dollars for Docs, among others.

On Monday and Tuesday, hundreds of people will gather in Washington, D.C., for Health Datapalooza, a conference devoted to the uses of health data. One of its main planners is Niall Brennan, chief data officer at CMS. (I am on the steering committee for the event.)

I spoke to Brennan last week about the agency’s efforts to open up its data and what it means for the public. The interview has been edited for length.

CMS seems to have released a lot of data lately. Can you give us a rundown of what the agency has released?

One of the reasons for our success is that we actually started with relatively small and modest data releases — things like releasing data at the regional level on differences in Medicare spending among states and counties. And then we gradually built up to releasing more detailed information on discharges at hospitals; how physicians practice medicine in the Medicare program; how they prescribe drugs in the Medicare program; how they prescribe durable medical equipment such as wheelchairs. Most recently, we’ve released a lot of information on skilled nursing facilities and home health agencies, giving people a glimpse for the first time at the types of care that those providers provide.

The openness and transparency go significantly beyond this. We’ve released Sunshine Act Open Payments data, which is information on the payments that drug and device manufacturers make to physicians and hospitals. And we’ve also worked really hard on the [Affordable Care Act] marketplace and Medicare Advantage side of the house to give consumers information to choose their health care plan. Are my doctors in the plan I’m looking at? Are my drugs covered by the plan I’m looking at?

Tell me what’s changed. Why are there now so many data releases?

I think a lot of the change, in addition to the administration’s focus on open data, was the Affordable Care Act and the realization that data was moving from a byproduct of our claims payment operations to really a core function of the agency. It was not only essential for us, but for the general public, for patients, to have better data, better information to be able to navigate this move to value-driven care.

Do you think these data sets will be released each year?

I do. We’re creating a good track record of consistency around releases. Unless something drastically changes in terms of agency priorities, I think people should expect to see these data releases on a regular basis for some time to come.

Why can’t the data you’re releasing be more current? We’re only seeing 2014 data now.

One of the reasons is that it takes quite a lot of internal CMS time and resources to crunch through the data and make it ready for publication. We have a responsibility when we release the open data to ensure the data is as accurate as possible and does not lead people to make wrong inferences or conclusions about any given provider. Another reason is the inherent time lag in the bills that providers submit to Medicare for adjudication and payment. It often, particularly for hospitals and facilities, can take six to nine months for the very final bills at the end of the tail to be adjudicated and finally settled.

How should people use these data?

We obviously hope that consumers will use the data to understand more about their doctors. We know based on frequent feedback that there are a lot of data innovators and data entrepreneurs and researchers and journalists using this data to understand more about the health care system, ask important questions about physician practice patterns.

Do these data sets fit together? Can they be set up to communicate with each other?

I think they can communicate with each other in a couple of different ways. The easiest example of this is at the individual physician level. Now at the individual physician level, you have a data set that shows the different procedures and doctor visits that they provide under Medicare. There’s a second data set that provides information on the prescription drugs that they prescribe. And there’s a third data set that lists the payments that they receive from drug and device manufacturers. You could potentially combine all three, or two of those three data sets and get enhanced insights into how physicians practice care. Others ways that I think they can be combined is at the local geographic, zip code or county level. You can start to use mapping software and the like to start grouping providers into geographic clusters and start to see if there are relationships between how hospitals provide care in a given area or skilled nursing facilities provide care in a given area.

What about data involving Medicare Advantage plans and state Medicaid program? Those haven’t been released yet. Any sense of when they might?

I think generally with both programs, we have not necessarily had available data that is as mature and as high quality as we enjoy with the Medicare program. The good news is that for the past couple years, we have been collecting very detailed granular data from Medicare Advantage plans and we are analyzing that very heavily at the moment trying to get an overall gauge of the quality of the data and if it’s suitable for public release. I would hope to have some positive news to report on Medicare Advantage data releases in the next 12 months or so.

Regarding Medicaid, for many years, we’ve been in a situation where I don’t think anybody felt that the quality or the timeliness of the data we were getting from states was optimal. However we’ve invested resources in the last few years to revamping the data submissions process from state Medicaid agencies to CMS. That system went live a little earlier this year and there are several states submitting data into that system and we’re not quite as far ahead as with Medicare Advantage data.

Is CMS putting pressure on the private sector to follow its lead and release more data?

Clearly we’re leading by example. I don’t think we can order or require transparency from private-sector companies but I do think that our efforts are having an impact. I think that providers in particular are more and more aware that this data has been made available. There are organizations like the Health Care Cost Institute, which is an organization to which many of the major health care insurers in the U.S. have contributed data, and they have also launched transparency tools. There’s a tool called Guroo which allows people to look up the prevailing cost of procedures or interventions in their area. I think I see some positive developments in that regard.

Give us a clue of data sets you are going to release over the rest of the year.

In general, I hesitate to try and forecast too far in the future what we’re going to release because our priorities are changing all the time and frankly we’re releasing so much data now that the annual re-release cycle is consuming more and more of our time. I think what I’d say is that our Medicare provider releases now cover more than 85 percent of Medicare fee-for-service spending. I would certainly hope to continue to make inroads into that number and push it even higher over the rest of 2016.

ProPublica is a nonprofit newsroom based in New York. You can follow Charles Ornstein on Twitter: @charlesornstein.

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“In Aleppo, We Are Running Out of Coffins” was the title of an op-ed from Syrian doctor Osama Abo El Ezz. NPR’s Lynn Neary speaks with him about attacks on hospitals in Syria.

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The Food and Drug Administration is banning the sale of electronic cigarettes to minors as part of a broad set of regulations the agency finalized Wednesday.

With the rules that were more than two years in the making, the agency is expanding its authority over e-cigarettes, cigars and hookah tobacco, in much the same way it already regulates traditional cigarettes.

In addition to barring sales of tobacco products and e-cigarettes to people under age 18, the FDA would impose other restrictions, including:

• A prohibition on distribution of free samples
• A ban on selling e-cigarettes in vending machines unless they are in secure places that never admit young people
• A requirement that e-cigarettes carry warnings that they contain nicotine, which is addictive

The rules also require companies to get FDA approval for any products that were put on the market after Feb. 15, 2007. Also, e-cigarette makers will have to go back to the agency within two years for approval of the products they already sell.

E-cigarettes consist of plastic or metal tubes that contain a heating element that vaporizes a liquid solution containing nicotine.

The popularity of “vaping” has grown in recent years. The FDA says about 16 percent of high school students used e-cigarettes in 2015.

Some have welcomed the devices as an alternative to traditional cigarettes, whose dangers are well-known, and as an aid to help smokers quit.

In the U.K., for example, the Royal College of Physicians in April embraced e-cigarettes as a way to reduce smoking, which the group says is far more dangerous. “In the interests of public health it is important to promote the use of e-cigarettes,” the group said in a statement released April 28.

The industry trade group has pressed that point. E-cigarettes “provide smokers with a viable path to reducing their tobacco consumption and quitting altogether,” said Tony Abboud, national legislative director of the Vapor Technology Association, the trade group for e-cigarette makers.

Others fear the devices will addict nonsmokers to nicotine and eventually lead to more people smoking.

Health and Human Services Secretary Sylvia Burwell nodded to that concern in a statement released with the new rules that said use of e-cigarettes has risen as traditional smoking has declined. “All of this is creating a new generation of Americans who are at risk of addiction,” she said.

The FDA had previously attempted to regulate e-cigarettes, but that effort was thwarted in court.

Public health advocates such as the American Lung Association and the American Academy of Pediatrics welcomed the new rules.

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One of the country’s most outspoken abortion providers has filed a civil rights complaint against the hospital where she works, saying that it has wrongly banned her from giving media interviews.

Last fall Diane Horvath-Cosper, an obstetrician and gynecologist, did a lightning round of media interviews after a shooting attack killed three people at a Colorado Planned Parenthood clinic, raising new safety concerns at health care facilities that perform abortions.

“I want women to be able to access abortion in a safe, legal, compassionate environment. So no, I’m not deterred,” she told MSNBC then.

But one week after that, Horvath-Cosper says, she was called to a meeting with top officials at MedStar Washington Hospital Center in the District of Columbia. They said it was a security matter.

“I was told that that the hospital was happy with the care we were providing for patients, but that they didn’t want to put a Kmart blue-light special on the fact that we provided abortion,” she says.

In the following weeks, the complaint says, MedStar denied a string of requests for Horvath-Cosper to speak with media and at another public event about abortion.

Horvath-Cosper’s federal civil rights complaint says that the hospital’s actions violate the decades-old “Church amendment.” That bans federally funded health care providers from discriminating based on a doctor’s moral conviction about abortion.

There’s an irony to that.

“It’s a provision that has been commonly used by and associated with those who oppose abortion,” says Gretchen Borchelt of the National Women’s Law Center, which helped file the complaint.

Borchelt also says MedStar’s security argument doesn’t make sense. According to the complaint, the hospital did hire a security guard for the family planning department, and put in cameras there. But Borchelt says it ignored other suggestions from the department.

“They could put in shatterproof glass, they could do ID checks, they could do bag checks,” she says. “They have not done any of those things.”

MedStar Washington declined an interview request for this story. In a statement, the hospital says it is “committed to providing family planning services for our community, and we do so in a respectful, private and safe environment.”

Jeff Young is sympathetic. He heads the International Association for Healthcare Security and Safety, a professional organization. “The more outspoken a person is, a security person would say that the risk to that person, and to the facility they work in, would go up because of the publicity associated to it,” he says.

But Young can’t recall one of the hospitals who belong to the association ever banning a doctor from talking to the media — even after an abortion provider in Vancouver, British Columbia, was shot in the leg at his home years ago. In that case, the hospital did increase security and provided a personal security plan for the physician, Young says.

Horvath-Cosper is at MedStar Hospital through a fellowship, and she says advocacy is a key part of that job. Especially now, which she says is a tough time for abortion providers.

State lawmakers continue to pass a record number of abortion restrictions. The National Abortion Federation recorded a sharp rise in harassment and death threats after undercover videos that targeted Planned Parenthood last year.

Horvath-Cosper’s complaint notes that there is a severe shortage of abortion providers.

“The message that we’ve all gotten in society is that abortion is shameful, and that people who have abortions should be ashamed, and I think that’s something that we need to work against,” she says.

Horvath-Cosper says she respects the many abortion providers who choose to stay silent, especially those in more conservative parts of the country with stricter laws. But she hopes her case will send the message that those willing to speak out have a right to do so.

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A year after Indiana declared a state of emergency because of an HIV outbreak fueled by drug abuse, the availability of drug treatment continues to lag.

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A study by researchers at Johns Hopkins Medicine says medical errors should rank as the third-leading cause of death in the United States — and highlights how shortcomings in tracking vital statistics may hinder research and keep the problem out of the public eye.

The authors, led by Johns Hopkins surgeon Dr. Martin Makary, call for changes in death certificates to better tabulate fatal lapses in care. In an open letter, they urge the Centers for Disease Control and Prevention to immediately add medical errors to its annual list reporting the top causes of death.

Based on an analysis of prior research, the Johns Hopkins study estimates that more than 250,000 Americans die each year from medical errors. On the CDC’s official list, that would rank just behind heart disease and cancer, which each took about 600,000 lives in 2014, and in front of respiratory disease, which caused about 150,000 deaths.

Medical mistakes that can lead to death range from surgical complications that go unrecognized to mix-ups with the doses or types of medications patients receive.

But no one knows the exact toll taken by medical errors. In significant part, that’s because the coding system used by CDC to record death certificate data doesn’t capture things like communication breakdowns, diagnostic errors and poor judgment that cost lives, the study says.

“You have this over-appreciation and overestimate of things like cardiovascular disease, and a vast under-recognition of the place of medical care as the cause of death,” Makary said in an interview. “That informs all our national health priorities and our research grants.”

The study was published Tuesday in The BMJ, formerly the British Medical Journal.

Bob Anderson, chief of the mortality statistics branch for the CDC, disputed that the agency’s coding is the problem. He said complications from medical care are listed on death certificates, and that codes do capture them.

The CDC’s published mortality statistics, however, count only the “underlying cause of death,” defined as the condition that led a person to seek treatment. As a result, even if a doctor does list medical errors on a death certificate, they aren’t included in the published totals. Only the underlying condition, such as heart disease or cancer, is counted, even when it isn’t fatal.

Anderson said the CDC’s approach is consistent with international guidelines, allowing U.S. death statistics to be compared with those of other countries. As such, it would be difficult to change “unless we had a really compelling reason to do so,” Anderson said.

The Johns Hopkins authors said the inability to capture the full impact of medical errors results in a lack of public attention and a failure to invest in research. They called for adding a new question to death certificates specifically asking if a preventable complication of care contributed.

“While no method of investigating and documenting preventable harm is perfect,” the authors write, “some form of data collection of death due to medical error is needed to address the problem.”

Anderson, however, said it’s an “uncomfortable situation” for a doctor to report that a patient died from a medical error. Adding a check box to the death certificate won’t solve that problem, he said, and a better strategy is to educate doctors about the importance of reporting errors.

“This is a public health issue, and they need to report it for the sake of public health,” he said.

Dr. Tejal Gandhi, president of the National Patient Safety Foundation, said her organization refers to patient harm as the third-leading cause of death. Better tracking would improve funding and public recognition of the problem, she said.

“If you ask the public about patient safety most people don’t really know about it,” she said. “If you ask them the top causes of death, most people wouldn’t say ‘preventable harm.’ “

Dr. Eric Thomas, a professor of medicine at the University of Texas Houston Medical School whose research was cited in the Institute of Medicine’s landmark To Err is Human report, said existing estimates aren’t precise enough to support immediately listing errors as the third-leading cause of death.

But collecting better cause-of-death data is a good idea, said Thomas, who agreed that medical errors are underreported.

“If we can clarify for the public and lawmakers how big a problem these errors are,” he said, “you would hope it would lead to more resources toward patient safety.”

Have you or a loved one been harmed during medical care? Join the discussion at ProPublica’s Patient Safety Facebook group or fill out the Patient Harm Questionnaire.

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When the health insurance premiums got to the point that they were higher than her mortgage, Renee Powell started to become cynical.

“There was something in me that just kind of switched,” said the mother of two from Bartlesville, Okla. “I was okay with paying $750, but when it became about $100 more than my housing costs, it upset me.”

Powell is an epidemiologist and used to work for the state in Oklahoma City. She had affordable insurance through that job.

But when her husband graduated from dental school, she stopped working, and the family moved to their current home, about 10 miles from the Kansas border.

She shopped for insurance through the Obamacare exchange and learned that rates in her new area were much higher than they had been in Oklahoma City. She bought a health plan from Blue Cross and Blue Shield of Oklahoma for $750 a month with a manageable deductible.

Then last year Blue Cross eliminated that plan — which is pretty common as insurers adjust to the Obamacare markets — and Powell was forced to buy the more expensive policy with a deductible of $3,000 for each person in her family. The insurance pays for check-ups and prescriptions, but if anyone gets sick, Powell has to pay the full doctor bill until the deductibles are met.

Insurance Just Isn’t Enough

While the Affordable Care Act managed to bring basic health insurance to almost everyone in the country – about 90 percent of Americans are covered — for many people it’s not enough.

Rising deductibles and co-payments can mean people don’t get much benefit from paying monthly premiums. A recent study from the Kaiser Family Foundation shows deductibles rose about eight times faster than wages in the last 10 years.

That’s taking a toll on people like Powell, even though they have insurance.

“The nature of insurance has been changing over the last decade, to the point where people’s out of pocket costs are becoming a real struggle,” said Larry Levitt of the Kaiser Family Foundation. “More people are insured, but in many ways people are not insured enough.”

High deductible plans like Powell’s, he said, are now the norm.

Powell has spent about $4,400 so far this year in premiums for that Blue Cross policy, and she said the plan has only paid a few dollars for antibiotics one of her boys needed when he was sick.

“I felt like we were paying money to the insurance company so that they could just sit on it and put it in stock,” she said.

Now she and her husband are planning to buy insurance through his dental business, which is over the border in Kansas where for some reason, policies are much cheaper.

Surprise Costs

It’s not just individual policies that are getting costly.

Melody Simon, a biomedical research project manager who lives in Detroit, is struggling to pay her bills, even though she has insurance through her work.

Simon was born with a birth defect that has required her to undergo 7 surgeries. She needs medication and physical therapy.

Her insurance seems generous on its face — moderate co-pays and a $1,000 deductible for in-network care.

But her costs are also shooting skyward, in part because she moved last year to Detroit from Austin, Texas, and her insurance plan isn’t as popular in her new city.

“It takes hours to find a provider that’s not an hour away, that accepts my insurance and can also see me for my particular condition,” she said.

She found a good doctor – in-network – who performed her most recent surgery in December. But when she went back to see him at a different hospital for a cortisone shot to ease the pain in her arthritic foot — something she’d done many times back in Texas for about $40 — she was in for a surprise.

“It was like I was going into surgery. They brought me into the operating room and everything. And of course in my mind I’m like, ‘What is all this pomp and circumstance for an injection?'” she recalled. “Of course I should have known it was going to cost something… and it did.”

It cost her $832.96.

Simon’s recovery from her December surgery has not gone well and she’s out of work on disability — which means she’s only getting about 60 percent of her former salary. She’s become totally dependent on her partner to get to physical therapy appointments and pay her bills.

Now they’ve decided to get married, just so Simon can get on her partner’s health insurance, which is more generous than her own.

She said she hates the fact that they’ve made such a big decision for financial reasons.

“I don’t think marriage should be an economic choice,” she said. “It’s pretty exciting, but I just wish this wasn’t the circumstance that brought it about.”

A recent poll from NPR, the Robert Wood Johnson Foundation and Harvard’s T.H. Chan School of Public Health showed that 26 percent of people say health care costs are still a very or somewhat serious problem for them or their families.

Those rising costs are not providing people with a sense of better care. According to that same poll, 45 percent say the cost of their health insurance premium has increased and 35 percent say their co-pays and deductibles have risen in the past two years, even though just 16 percent say their benefits have improved during that same time.

And voters are concerned as well. Almost 20 percent of Democrats and 12 percent of Republicans ranked health care as one of their top two concerns in the upcoming presidential election, according to the Kaiser Family Foundation. The economy and jobs were the top issue in both parties.

The candidates for the White House have an array of ideas to deal with the issue:

Democrats

Bernie Sanders has proposed “Medicare for All,” which would give everyone free access to health care – meaning out-of-pocket costs would disappear altogether.

But that would come with a price tag – tax increases of 2.2 percent for individuals and 6.2 percent for employers. The Sanders campaign says that would save most people a lot of money in the end, while shifting the burden of health costs to wealthy taxpayers.

But some critics – even many left-leaning economists – say his numbers don’t add up and that the tax increases would have to be much higher.

Hillary Clinton‘s proposal builds on Obamacare and some provisions attack out-of-pocket costs directly. Most significantly, she’s proposing a refundable tax credit to cover costs that exceed five percent of a person’s income. That could potentially help people like Renee Powell.

Clinton also proposes capping costs for prescriptions, trying to limit how much premiums can rise and protecting people from surprise bills like Melody Simon got after her cortisone injection.

Republicans

All three Republican candidates want to completely repeal Obamacare.

Donald Trump says he’ll cut people’s costs by allowing them to deduct the cost of insurance premiums from their taxes and to put more money in a tax-deferred health savings account to pay for health care expenses.

He also wants to allow insurers to sell policies in any state, rather than only in those states where they are licensed.

Ted Cruz is also a proponent of this idea.

Both candidates say the increased competition will reduce insurance premiums so people can afford better policies. But some say this could lead to lower quality insurance because some states have lower standards than others.

John Kasich is proposing ways to cut overall health spending, which, he says, will lower costs for everyone. He’s pointing to initiatives in Ohio where the state is changing the entire payment system – rather than paying for each service separately the state is putting a single price on all the care needed for an illness. That means doctors and hospitals don’t have any incentive to order excessive tests or medications.

Powell and Simon both said they don’t expect much from these candidates.

“I think it would help for them to know just how much this costs and what families are going through,” Powell said. “I’m slightly disillusioned with pretty much everybody in the race.”

Editor’s Note: Politics in Real Life is a new NPR series looking at issues impacting people’s lives and how they match up with rhetoric on the campaign trial. Follow along and join the conversation on social media: #PoliticsIRL

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At some hospitals, posters on the wall in the emergency department list the drugs that are in short supply or unavailable, along with recommended alternatives.

The low-tech visual aid can save time with critically ill patients, allowing doctors to focus on caring for them rather than doing research on the fly, said Dr. Jesse Pines, a professor of emergency medicine and director of the Office for Clinical Practice Innovation at the George Washington University School of Medicine and Health Sciences. He has studied the problems created by shortages.

The need for such workarounds probably won’t end anytime soon. According to a new study, shortages of many drugs that are essential in emergency care have increased in both number and duration in recent years even as shortages for drugs for non-acute or chronic care have eased somewhat. The shortages have persisted despite a federal law enacted in 2012 that gave the Food and Drug Administration regulatory powers to respond to drug shortages, the study found.

For this report, which was published in the May issue of Health Affairs, researchers analyzed drug shortage data between 2001 and 2014 from the University of Utah’s Drug Information Service, which contains all confirmed national drug shortages, according to the study.

They divided the drugs into acute and non-acute categories. Acute-care drugs were those used in the emergency department for many of the urgent and severe conditions handled there and include remedies such as pain medications, heart drugs, saline solution and electrolyte products.

Overall, the study found that 52 percent of the 1,929 shortages during the time period studied were for acute-care drugs. Following passage of the federal law in 2012, the number of active shortages of non-acute care drugs began to decline for the first time since 2004, but there was no corresponding dropoff in shortages of drugs that emergency departments and intensive care units rely on, the researchers reported.

Shortages of the drugs for emergency care lasted longer as well, the study found. Half of the shortages of drugs for acute care lasted longer than 242 days, compared with 173 days for non-acute care drugs.

Seventy percent of the drugs that were difficult to get were injectable drugs, which emergency departments rely on to a much greater degree than other types of providers. The most common acute-care drugs affected were those to fight infections, such as antibiotics; those that affect the central nervous system, including painkillers and sedatives; and the drugs that suppress or stimulate the autonomic nervous system, which controls heart and breathing rates.

When patients come to the emergency department who have been seriously injured and are having trouble breathing, for example, it’s often necessary to administer drugs that sedate them and cause their muscles to relax so that emergency personnel can insert a breathing tube in the windpipe.

“All of a sudden you have a life-critical procedure and you’re using your second-best drug or a drug you’re less familiar with,” said Dr. Arjun Venkatesh, an assistant professor of emergency medicine at Yale School of Medicine and a study co-author.

Venkatesh said his own experience with recurring shortages of such basic but critical medicines as saline solution while working in the emergency department at Yale-New Haven Hospital was the impetus for the study.

Patients are naturally often unaware of drug shortages in the emergency department, and there’s no data to show that substituting a preferred drug with one that a doctor is less comfortable with results in patient harm, experts say.

“But if you extrapolate this problem over 140 million emergency department visits annually, I don’t see how patients couldn’t have been harmed by [substitutions],” said Dr. Frederick Blum, an associate professor of emergency medicine at West Virginia University School of Medicine who is a former president of the American College of Emergency Physicians.

The Food and Drug Administration Safety and Innovation Act of 2012 contains provisions aimed at stemming these problems, including requiring reporting of shortages by drug manufacturers to the FDA and expediting inspections and reviews by the FDA of alternative products and manufacturing facilities.

“We need more,” Venkatesh said. “At the national level, they need to provide more support around generic injectables and antibiotics, the two areas that are ripe for improvement.”

The FDA continues to work closely with manufacturers to resolve shortages, said agency spokesman Christopher Kelly.

“In the past couple of years, numbers of new shortages have gone down and that’s largely due to increased notifications by manufacturers,” Kelly said in a statement. Injectable drugs “are particularly susceptible to shortages and can be difficult to solve.”

Changing the economics of these drugs could help, said George Washington’s Pines, noting that profit margins are thin and there’s not a lot of extra capacity in the system if one manufacturer stops producing a drug. The Health Affairs study suggests tax credits, rebates or temporary market exclusivity as potential strategies to improve the supply of generic injectables, among other things.

David Gaugh, senior vice president for sciences and regulatory affairs at the Generic Pharmaceutical Association, said drugmakers’ efforts have helped decrease the shortages but acknowledged more is needed. He called for continued communication between regulators and generic drug manufacturers on the issues and improvements in the drug review process. “The only way to mitigate current shortages and prevent future shortages from occurring is a collaborative effort,” he said.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

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