Imagine yourself stuck in the hospital.

Would you rather your doctors be well-rested, with a limit on how many hours they can work? Or would you rather they work longer shifts, seeing you through the critical hours of your illness and with fewer handoffs of your care?

That’s the choice being reexamined after a study published in March in the The New England Journal of Medicine found that longer shifts for medical residents were just as safe as shorter shifts.

The results, which support an earlier study that also found no association between shift length and patient safety, have led some physicians to suggest that the issue of how long residents should work has now been “laid to rest.”

University of Pennsylvania’s Dr. David Asch, one of the study’s lead investigators, said in a statement that despite concern about lengthy shifts for residents, “they really don’t seem to have an effect on any important domains.”

Sixty-three internal medicine residency programs participated in the latest study. Half of the programs adhered to limits on how long residents could work. First-year residents were restricted to 16-hour shifts, while more senior residents could work up to 28 hours. For the other half, there was no limit on how long residents could work.

The researchers focused on patients’ mortality rates. They found that the number of patients who died within 30 days of admission to the hospital was similar between the two groups. Though the study didn’t examine medical errors directly, the implication is that the rate of medical error was also similar.

The findings are reassuring, given what we know about the effects of sleep deprivation on cognitive performance. Some studies have found that sleep deprivation can lead to a similar level of impairment as heavy drinking.

Concerns about exhausted physicians in training have been around since at least 1984, when a college freshman named Libby Zion died in a New York hospital from an error made by a sleep-deprived resident. After a high-profile investigation, New York state instituted the first limits on how long physicians in training could work — no more than 24 hours in a shift, and no more than 80 hours in a week. These limits were extended to all residency programs in 2003 and strengthened in 2011.

It seemed like a prudent change. As many have argued, we don’t let our pilots fly without adequate rest.

But some physicians challenged the limits, pointing out that we had no direct evidence to support the change. It had simply never been studied.

Shift limits could have unintended consequences. For example, shorter shifts mean more handoffs between physicians, during which important information can sometimes be lost.

Does the latest study mean that strict limits on shift length should be rolled back, since they’ve not been proven to help patients? Or is there more to the story than medical errors and patient safety?

Just as sleep deprivation has been shown to impair cognition, so too has it been found to dampen empathy for others.

Studies show that a single night of sleep deprivation interferes with our ability to perceive emotions in others and compromises our ability to empathize. Longer periods of sleep deprivation reduce measures of emotional intelligence and interpersonal functioning.

One of the darkest moments of my medical training came at the end of a 28-hour call in the ICU. Firefighters had rescued a woman from a house fire, badly burned and barely alive. She was at the threshold of death when she arrived. Her suffering must have been unbearable, but I’m ashamed to say that all I could think about was how long her death paperwork would keep me awake.

I don’t think I’m alone in finding that sleep deprivation warps my ability to provide compassionate care. In 2002, researchers at the University of Pennsylvania surveyed residents before and after their first year of training. The prevalence of chronic sleep deprivation soared from 9% to 43%. Emotional exhaustion rose from 8.5% to 68%, and measures of empathy dropped 10%-15%.

We can’t say how these changes affected patients, but it’s no stretch to imagine that they were probably harmful to the patient-physician relationship. They were certainly harmful to the residents — the prevalence of depression increased from 4.3% to nearly 30% by year’s end, and burnout leaped from 4% to 55%.

Skeptics about shift limits may point out that both groups in The New England Journal of Medicine study got a similar amount of sleep, when averaged over time. But participants in the group without shift limits were nearly 2.5 times more likely to be dissatisfied with their amount of time for rest and with their overall well-being. They were also more likely to report that patient safety and the quality of their education had suffered as a result of the longer hours.

In 2017, after the publication of an earlier study showing no association between shift length and patient safety, the governing body of graduate medical education backtracked on shift limits. Maximum shift length for first-year residents was increased from 16 to 24 hours, and more shift-to-shift variation was permitted for senior residents, as long as the 80-hour weekly cap was maintained when averaged over four weeks.

It was an important development, according to Asch and his colleagues, because it seemed that educational policy would finally be based on evidence rather than opinion.

Moving toward evidence-based policy in medical education makes sense. After all, as Asch pointed out, we would never approve a new drug without strong evidence supporting its use.

But it’s my view that using these studies to justify further loosening work-hour restrictions doesn’t make sense. This new study provides strong evidence that shorter shifts are just as safe for patients as longer shifts.

Given what we know about the effects of sleep deprivation on emotional capacity and residents’ well-being, why would we relax work limits again without proof that doing so would cause no harm?

Clayton Dalton is a resident physician at Massachusetts General Hospital in Boston.

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Scientists are gearing up a major study to find out whether a drug can silence the gene that causes a devastating illness called Huntington’s disease.

This development follows the discovery that the experimental drug reduced levels of the damaged protein that causes this mind-robbing ailment. The new study will determine whether that drug can also stop progression of the disease.

It is also another sign that drugs built with DNA, or its cellular collaborator RNA, can be powerful tools for tempering diseases that until now have seemed out of reach.

Huntington’s disease is an apt target because it’s caused by a single mutated gene. It also a frightening and devastating disease.

The symptoms “are like having Alzheimer’s, Parkinson’s and ALS [Lou Gehrig’s disease] simultaneously, when it’s in full swing,” says Jeanette Garcia, a 57-year-old advocate in San Jose, Calif.

If one of your parents has Huntington’s disease, there’s a 50-50 chance you will get it, too. About 30,000 people in the United States carry the deadly gene.

Garcia and her nine siblings lost their mother to the disease. They know the terrible odds. When they get together for family reunions and talk turns to Huntington’s, “it is all of a sudden this terrifying prospect we’re all faced with,” she says.

Garcia decided to take the genetic test for this condition in 2008 and found out she had inherited the damaged gene. She’s recently been seeing the first signs of the illness, including involuntary movements, which she noticed when watching a video of herself, “and I went, ‘Holy crap, OK here we go.’ “

But her disease is emerging at what could be a fortunate moment. She’s heading off to a neurologist to see if she would qualify for a study that is generating a lot of excitement.

Last year, drugmaker Roche’s Genentech unit said that an experimental drug sharply reduced the amount of illness-inducing protein measured in people’s spinal fluid. The results of that study, involving 46 patients, were published Monday by the New England Journal of Medicine.

The protein isn’t eliminated entirely with the experimental drug, but animal experiments suggest that reducing it significantly could be enough to stave off symptoms.

The researchers are now about to launch a trial involving 660 volunteers with early symptoms of the disease, to see if the drug, called RG6042, can slow or stop Huntington’s progression.

“It’s so exciting,” Garcia says. “I want to be a part of it.”

This study marks a milestone for Huntington’s disease. More than 25 years ago, a scientist named Nancy Wexler was able to identify the errant gene that causes the disease by painstakingly studying families in a region of Venezuela where the disease is nearly epidemic.

Her finding was one of the early, great successes in tracking down disease genes. But it has taken all the intervening years to develop this promising angle of attack.

One huge advance has been the development of methods to silence a damaged gene, so cells don’t convert those errant instructions into dangerous proteins, such as the one that causes the symptoms of Huntington’s.

Scientists have developed several methods to jam this signal. The Roche drug uses a custom-built piece of genetic material called an antisense oligonucleotide to block the process. Other advanced research projects aimed at Huntington’s and other diseases use a technique called RNA interference to accomplish a similar result.

Another major challenge has been to figure out how to get the drug into the brain. Scientists at Ionis Pharmaceuticals in San Diego figured out how to make that happen with the antisense oligonucleotide targeting Huntington’s.

The answer turned out to be injecting it into spinal fluid, which circulates up and down the spine and into the brain. “The drug could actually transfer quite readily to the brain and then sink into the target brain tissue,” says Dr. Scott Schobel, who heads the research effort on this drug at Roche, which is co-developing the experimental drug with Ionis.

Roche started recruiting patients for this study in January, but halted the trial to redesign it, after discovering the drug didn’t need to be injected as often as they had planned.

“We’re going to get back up and running over the next several weeks to months,” Schobel says.

The study is supposed to follow patients for 25 months, which should be enough time to determine whether people’s symptoms are held in check by the treatment.

George Yohrling, a scientist at the Huntington’s Disease Society of America, says his main concern is whether the experimental drug will penetrate deeply enough into the brain to stop the disease.

If not, he says other treatments under development could succeed in that regard. One strategy is to use viruses to deliver one of these gene-silencing drugs.

“A lot of different approaches are being worked on in different stages of drug discovery across the world,” Yohrling says. “It’s really quite exciting.”

This development follows more than 20 years of boom-and-bust excitement about gene-silencing strategies.

“Initially there was wild enthusiasm,” says Dr. Judy Lieberman, a professor of pediatrics at Harvard Medical School. “There were literally hundreds of biotech companies formed to do that.”

But they quickly hit technical and scientific roadblocks, she says, “and eventually almost all of them about abandoned these efforts.”

As scientists gradually worked their way through these challenges, Huntington’s disease emerged as an appealing target, despite being a rare disease with a far smaller potential market than, for example, a drug for Alzheimer’s disease.

The first antisense oligonucleotide to be approved as a drug by the Food and Drug Administration treats an even rarer condition, called spinal muscular atrophy. And there are now competitive products targeting that disease, thanks in part to the financial incentives drug companies get to develop drugs for “orphan” diseases. (The drugs are also extraordinarily expensive).

Drug developers are also aware that this strategy could be useful for common disorders, such as high cholesterol. That’s an active area for drug development.

Drug companies would jump on an opportunity to develop a drug for Alzheimer’s or autism, Yohrling says, if only they could identify a straightforward target gene to disrupt. That strategy “now makes the ‘undruggable’ druggable,” he says.

But that’s getting ahead of the story. Before the FDA even considers approving a treatment for Huntington’s, Roche will have to demonstrate that its experimental drug is safe and effective.

Garcia is eager to help them make that case, by joining the study if she can, and encouraging others to do the same. She says she can’t even let herself hope that the treatment will work for her. She’s thinking of her four children and six grandchildren.

She has a grandson who was born blind and is also at risk for Huntington’s, she says. “I’m just not going to stop because I don’t want him to have to deal with this.”

You can contact NPR Science Correspondent Richard Harris at rharris@npr.org.

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President Trump called on Republicans and Democrats to pass legislation this year to end surprise medical bills, in remarks made in the White House’s Roosevelt Room Thursday.

“We’re determined to end surprise medical billing for American patients,” Trump said.

Bills like those have been featured in the NPR-Kaiser Health News series launched in February 2018. Two patients whose medical bills were part of the series attended the event.

Austin, Texas, teacher Drew Calver talked about the six-figure bill he received after having a heart attack. “I felt like I was exploited at the most vulnerable time in my life,” he said. His bill was reduced to $332 after the NPR-KHN story was published.

A bipartisan group of senators has been working to come up with a plan for the past several months. The lawmakers said Thursday they hope to have a bill to the president by July.

But will bipartisanship be enough? Even political will might not overcome divisions within the health industry.

Specifically, lawmakers aim to address the often-exorbitant amounts patients are asked to pay out of pocket when they receive care at health facilities that are part of their insurance network but are treated by out-of-network practitioners. Legislators are also looking to address bills for emergency care at a facility that doesn’t have a contract with patients’ insurers.

“We’re getting really close to an approach that we’ll be able to unveil pretty soon,” Sen. Maggie Hassan, D-N.H., told reporters on a conference call Thursday with Sen. Bill Cassidy, R-La.

And it’s not just politicians and patients: Out-of-network doctors, insurance companies and hospital groups say they want the problem for consumers fixed, too.

Despite that broad agreement, a hurdle remains. Insurers and health care providers each oppose the other side’s preferred solution to end surprise bills. That conflict makes it almost impossible for lawmakers to come up with a fix that won’t leave one of the influential groups unhappy.

“It’s a different axis than the partisan [conflicts] we’re used to,” said Loren Adler, who has been studying the surprise-bill problem for the USC-Brookings Schaeffer Initiative for Health Policy. The fight over how to fix it is less likely “to break down between Republicans and Democrats and more likely to break down to where the money is” and which group will have to take less of it.

“I don’t see a coalescence around a solution,” said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents for-profit facilities.

The divide is wide, despite the overall interest in protecting consumers.

“What we’d most like to see is clarity for the patients,” said Bob Kneeley, a senior vice president for Envision Healthcare, which employs physicians to staff a variety of hospital departments, such as emergency rooms, neonatal units and anesthesiology. “This is a system that’s just not working well for the patient, and we need to establish some appropriate guardrails.”

“We want this to be solved. We know it needs federal legislation,” agreed Molly Smith, a vice president at the American Hospital Association. She said hospitals believe that patients should “not have to be involved in any process if there’s a dispute between the payer and the provider.”

States have been working on the problem for several years. Nine now have programs aimed at protecting patients from surprise bills. But state laws cannot reach those with employer-provided insurance — more than half of all Americans —because those plans are regulated by a federal law called the Employee Retirement Income Security Act. That means only Congress can fix it for everyone.

Patients and groups that represent them say the problem is more urgent than ever.

“We are talking about situations in which families, despite enrolling in health insurance, paying premiums, doing their homework and trying to work within the system are being left with completely unanticipated and sometimes financially devastating bills,” Frederick Isasi, executive director of the consumer group Families USA, told a House education and labor subcommittee hearing in April. “This is inexcusable behavior on the part of hospitals, doctors and insurers. They each know — or should know — that patients have no real way to understand the financial trap they have just walked into.”

Dr. Paul Davis, whose daughter received a bill for a $17,850 for a urine test after back surgery, also spoke at the White House Thursday: “The situation is terrible. It is a national disgrace and I think a lot of people would support me on that,” Davis told a reporter. Their story was the first in the Bill of the Month project.

Still, it’s not clear where compromise might be found.

By and large, doctors favor some sort of negotiated-fee system when there is a dispute about a bill, such as binding arbitration, in which an independent third party makes the ultimate payment decision.

“That’s consistent with what’s working in some states,” said Envision’s Kneeley.

Among those frequently cited by doctor groups is New York, which has one of the strongest state laws on surprise billing. There patients are not required to pay more than they would for an in-network doctor or hospital. For the remaining bill, an independent arbitrator settles any dispute between the provider and insurer.

But the insurance industry worries about that approach. “Our larger concern with arbitration is that it still relies on bill charges,” said Adam Beck, a vice president for America’s Health Insurance Plans, an insurance industry trade group. And insurers think those charges are too high.

A senior administration official also said on Thursday that the administration does not favor the arbitration approach either.

Insurers — and many consumer groups — “believe if you have a clear benchmark pegged to reasonable rates, that will really solve this problem,” Beck said, because insurers would be more likely to cover charges they found more in line with what they consider reasonable.

A “benchmark” payment might correspond to what Medicare pays for the same service, for instance.

But doctors don’t like that idea one bit. “Even if [the benchmark] is on the high side, it’s still rate-setting,” said Kneeley.

Hospitals don’t like it, either.

“We can’t get behind any sort of rate-setting in statute,” said Smith of the AHA. “We have too many concerns about getting that wrong.” For example, she said, if the rate is set too low, hospitals might have trouble finding doctors willing to provide care.

Meanwhile, insurers and hospitals want to ban out-of-network providers from billing patients for whatever part of the charge the insurer won’t cover, a practice called “balance billing.”

Such bans are anathema to doctors, who instead believe insurers bear responsibility for doctors not being in their networks because they “don’t have an incentive to offer fair rates,” said Kneeley. Although insurers often feel they must contract with specific high-profile hospitals, he explained, the doctors who work there are often “invisible providers.”

Addressing the underlying causes of high health costs, however, will be difficult, said Adler of USC-Brookings.

Doctors want to be paid more than insurers typically offer, he said, which is why some do not join insurance networks. And insurers “want the problems [with surprise bills to patients] to go away.” The question for them, he said, is, “How much are insurers willing to pay to have their patients not get surprise bills?”

In the end, a settlement that eliminates surprise bills but builds the excess into everyone’s premiums doesn’t truly address health care’s spending problem.

“I think there’s a good chance it gets solved,” Adler said, and that lawmakers will eventually agree on a plan. “But I’m pessimistic it gets solved in a way” that deals with health care’s high costs.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

KHN’s Fred Schulte contributed to this report.

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When health care workers feel they have been forced to do something they disagree with on moral or religious grounds, they can file complaints with the Department of Health and Human Services’ Office for Civil Rights. Some high-profile cases have involved nurses who objected to providing abortion services.

For a decade, the agency got an average of one of these complaints of conscience violations each year. The complaints can include doctors, nurses or other health care workers who feel a hospital or clinic that receives federal funds has discriminated against them because of their moral position. Groups of health care providers also can file complaints.

Last year, the number of complaints jumped to 343.

That increase was cited by the Office of Civil Rights as one reason for issuing a new rule designed to protect conscience rights, unveiled publicly last week. HHS estimates that implementing and enforcing the rule will cost taxpayers $312 million in its first year.

But why did the number of complaints increase?

HHS declined to offer any specifics on the 343 complaints, such as where they were from or what might be behind the sudden increase over past years.

The Office for Civil Rights handles three types of complaints: violations of the Health Insurance Portability and Accountability Act, the law that protects the privacy and security of health information; violations of civil rights related to discrimination based on race, sex, national origin, disability and age; and violations of conscience rights.

Roger Severino, the office’s director, has made clear that protecting religious freedom is his priority and that his office is “open for business,” as he said to reporters while announcing the new rule.

In fact, he created the Division of Conscience and Religious Freedom in January 2018.

“For too long, governments big and small have treated conscience claims with hostility instead of protection,” Severino said in announcing the new division. “But change is coming, and it begins here and now.”

That signaling from Severino may have helped generate the increase in complaints, says Dr. David Stevens, CEO of the Christian Medical & Dental Associations. “Now that there’s an actual office opened and it’s well-publicized that it’s available, people are contacting them,” he says.

The Christian Medical & Dental Associations, based in Bristol, Tenn., represents about 19,000 health care workers.

“We’re happy to provide compassionate and quality care for anybody that walks in the door as long as we don’t become morally complicit in something that violates our conscience,” he says. As examples, he mentioned abortion, physician-assisted suicide and gender transitioning.

One reason given for the new rule is that it will help keep health workers from leaving the field. It cites data from a 2009 survey from the Christian Medical & Dental Associations that found 82% of its members say they would “limit the scope of their practice if conscience rules were not in place.”

Stevens thinks complaints are increasing because the issues underlying conscience violations are growing. “I think there’s a lot more antagonism towards people of faith,” he says.

He also thinks there are pent-up concerns from before the Trump administration, when nurses and doctors with issues felt like the Office of Civil Rights wouldn’t do anything with their complaints. “The big issue in the past has not been having laws. The big issue was having them enforced,” he says.

Former Director of the Office for Civil Rights Jocelyn Samuels takes issue with that characterization. She was Severino’s predecessor from 2014 to 2017. “It is wholly inaccurate to say that we abdicated our responsibility to enforce these laws,” she says.

Samuels, who now directs the Williams Institute at the UCLA School of Law, notes the average of one complaint a year filed under the provider conscience laws wasn’t just in the Obama administration — there were only 10 complaints in the decade from 2005 to 2015.

“I think that the number of complaints that were filed during the Bush and Obama administrations is some indication about the relative scope of the problem of religious refusals,” she says.

And she points out that those complaints that the office did receive were “dwarfed by the number of complaints filed under another law.”

“When I was the director of OCR we were receiving somewhere upwards of 20,000 complaints under HIPAA and, in addition, we were receiving several thousand civil rights complaints every year,” Samuels says.

She agrees that the office’s publicity around the priority of enforcing provider conscience laws is likely behind the increase in complaints. But rather than welcome that outreach as Stevens does, she worries that it may give health care workers the impression that they can deny any care that offends their religious or moral beliefs.

“So, for example, an orthopedist cannot refuse to set the leg of an LGBTQ patient because the orthopedist disapproves of that person’s sexual orientation or gender identity,” she says. “The provider conscience laws are very narrowly drafted to authorize medical providers to refuse certain types of care under certain funding streams that HHS provides.”

She theorizes that the number of complaints is likely to keep going up because the office has telegraphed that it is expanding the conduct that is covered under these laws.

As NPR reported last week, the new rule offers protection to health care workers who have an “articulable connection to furthering a procedure,” meaning even doing tasks that are indirectly related to a procedure. The rule explains: “Scheduling an abortion or preparing a room and the instruments for an abortion are necessary parts of the process of providing an abortion, and it is reasonable to consider performing these actions as constituting ‘assistance.’ “

“By expanding the scope of protected conduct, you are almost by definition creating a situation in which there could be more allegations of violations,” Samuels says.

When asked about the nature of the 343 complaints and why the number may have jumped from previous years, a spokesperson from HHS declined to provide specifics, saying that the office “does not discuss the substance of open complaints or investigations.”

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The Trump administration moved forward on Wednesday with its plan to lower prescription drug prices by requiring drugmakers to display the list price “in a legible textual statement at the end of the advertisement.”

Secretary of Health and Human Services Alex Azar said today that when it comes to changing prescription drug prices, “putting prices in TV ads may be the most significant single step any administration has ever taken.” But patient advocates are not convinced it will have an immediate impact on drug pricing.

The rule would apply to prescriptions that cost more than $35 per month or courses of treatment, which are covered by Medicare. The rule is very specific, requiring that the price be displayed, “for sufficient duration and in a size and style of font that allows the information to be read easily.”

Industry groups have fought this move since it was announced in October. They adopted voluntary rules, that would have directed ad viewers to a website with more detailed cost information. Today, in a statement, the Pharmaceutical Research and Manufacturers of America (PhRMA) wrote that the list price is confusing since that’s not what most people pay.

The rule addresses that by requiring an additional statement that reads, “If you have health insurance that covers drugs, your cost may be different.”

PhRMA also said that the rule raises “First Amendment and statutory concerns.”

Court challenges may be coming. The legal authority given by the White House is based on the laws that require Medicare and Medicaid to be run in a cost-effective manner, according to the rule.

Rachel Sachs, an associate professor of law at Washington University in St. Louis and an expert in drug-pricing regulation, told NPR and Kaiser Health News in October that could be a weak legal argument since most drugs are marketed to the broader public, not just Medicare and Medicaid beneficiaries.

Consumer and patient advocates generally hailed the move as a step towards greater price transparency, but questioned whether it would do much to lower high prices.

“We don’t believe that disclosing list prices will shame drug corporations into lowering list prices,” says Ben Wakana, executive director of Patients for Affordable Drug Prices. “Drug companies have been shamed about their price increases for years. They appear to be completely comfortable with the shame as long as it is bringing them in the billions of dollars a year that they make from their outrageous prices.”

He gives the government credit for trying to do something on health prices, noting “taking action on this issue is hard.” But he thinks some of the administration’s other ideas to lower prices — announced in a plan released last May — might have a bigger impact.

Critics have pointed out the government’s plan for enforcing the rule is weak, as NPR reported last fall. The plan for enforcement involves competitors policing each other by bringing legal action against competitors who aren’t compliant, Azar said in Wednesday’s press briefing. He calls it “a quite effective mechanism of enforcement.”

Azar defended the government’s authority to issue the new rule. “This is not without precedent,” he told reporters. “We have for over 50 years required that car manufacturers and car dealers post the sticker price of cars on the windows of their cars and be transparent about — even though there are negotiations and everything else — because it’s a starting point that’s an important part of consumer fairness.”

The car-buying analogy doesn’t work very well for drugs, notes Adrienne Faerber, a lecturer at the Dartmouth Institute for Health Policy and Clinical Practice.

“When you go to the car dealer and you see that sticker price and you can negotiate a better price that can fit your budget directly with the car dealership,” she explains. But, she says, drug prices are negotiated through layers of middlemen: “So you don’t get to negotiate based on these prices like you would with a car.”

In other words, car shoppers have a lot more choices that sick patients do, and a lot more bargaining power.

Faerber says certainly displaying the list price won’t “magically flip a switch and cut a percentage or two off of the total drug costs.” But she says it will be interesting to see how patients react to high list prices on their TV screens.

“Consumers are going to start wondering what are people getting for that money,” she says.

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The 50-something man with a shaved head and brown eyes was unresponsive when the paramedics wheeled him into the emergency room. His pockets were empty: He had no wallet, no cellphone and not a single scrap of paper that might reveal his identity to the nurses and doctors working to save his life. His body lacked any distinguishing scars or tattoos.

Almost two years after he was hit by a car on busy Santa Monica Boulevard in January 2017 and was transported to Los Angeles County+USC Medical Center with a devastating brain injury, no one had come looking for him or reported him missing. The man died in the hospital, still a John Doe.

Hospital staffs sometimes must play detective when an unidentified patient arrives for care. Establishing identity helps avoid the treatment risks that come with not knowing a patient’s medical history. The workers also strive to find next of kin to help make medical decisions.

“We’re looking for a surrogate decision-maker, a person who can help us,” says Jan Crary, supervising clinical social worker at LA County+USC, whose team is frequently called on to identify unidentified patients.

The hospital also needs a name to collect payment from private insurance or government health programs such as Medicaid or Medicare.

But federal privacy laws can make uncovering a patient’s identity challenging for staff members at hospitals nationwide.

At LA County+USC, social workers pick through personal bags and clothing, search the contacts of an unlocked cellphone for names of family members or friends and scour receipts or crumpled pieces of paper for any trace of a patient’s identity. They quiz the paramedics who brought in the patient or the dispatchers who took the call.

They also make note of any tattoos and piercings and even try to track down dental records. It’s more difficult to check fingerprints because that’s done through law enforcement, which will get involved only if the case has a criminal aspect, Crary says.

Unidentified patients are often pedestrians or cyclists who left their IDs at home and were struck by vehicles, says Crary. They might also be people with severe cognitive impairment, such as Alzheimer’s disease, patients in a psychotic state or drug users who have overdosed. The hardest patients to identify are ones who are socially isolated, including homeless people — whose admissions to hospitals have grown sharply in recent years.

In the last three years, the number of patients who arrived unidentified at LA County+USC ticked up from 1,131 in 2016 to 1,176 in 2018, according to data provided by the hospital.

If a patient remains unidentified for too long, staff at the hospital will make up an ID, usually beginning with the letter “M” or “F” for gender, followed by a number and a random name, Crary says.

Other hospitals resort to similar tactics to ease billing and treatment. In Nevada, hospitals have an electronic system that assigns unidentified patients a “trauma alias,” says Christopher Lake, executive director of community resilience at the Nevada Hospital Association.

The deadly mass shooting at a Las Vegas concert in October 2017 presented a challenge for local hospitals that sought to identify the victims. Most concertgoers were wearing wristbands with scannable chips that contained their names and credit card numbers so they could buy beer and souvenirs.

On the night of the shooting, the final day of a three-day event, many patrons were so comfortable with the wristbands that they carried no wallets or purses.

More than 800 people were injured that night and rushed to numerous hospitals, none of which were equipped with the devices to scan the wristbands.

Staff at the hospitals worked to identify patients by their tattoos, scars or other distinguishing features, as well as photographs on social media, says Lake. But it was a struggle, especially for smaller hospitals, he says.

The Health Insurance Portability and Accountability Act, a federal law intended to ensure the privacy of personal medical data, can sometimes make an identification more arduous because a hospital may not want to release information on unidentified patients to people inquiring about missing persons.

In 2016, a man with Alzheimer’s disease was admitted to a New York hospital through the emergency department as an unidentified patient and assigned the name “Trauma XXX.”

The police and family members inquired about him at the hospital several times but were told he was not there. After a week — as hundreds of friends, family members and law enforcement officials searched for the man — a doctor who worked at the hospital saw a news story about him on television and realized he was the hospital’s unidentified patient.

Hospital officials later told the man’s son that because he had not explicitly asked for “Trauma XXX,” they could not give him information that might have helped him identify his father.

Prompted by that mix-up, the New York State Missing Persons Clearinghouse drafted a set of guidelines for hospital administrators who receive information requests about missing people from the police or family members. The new guidelines include about two dozen steps for hospitals to follow, including notifying the front desk, entering detailed physical descriptions into a database, taking DNA samples and monitoring emails and faxes about missing people.

California guidelines stipulate that if a patient is unidentified and cognitively incapacitated, “the hospital may disclose only the minimum necessary information that is directly relevant to locating a patient’s next-of-kin, if doing so is in the best interest of the patient.”

At LA County+USC, most John Does are quickly identified: They either regain consciousness or, as in a majority of cases, friends or relatives call asking about them, Crary says.

Still, the hospital does not always succeed. From 2016 to 2018, 10 John and Jane Does remained unidentified during their stays (of varying lengths of time) at LA County+USC. Some died at the hospital; others went to nursing homes with made-up names.

But Crary says she and her team pursue every avenue in search of an identity.

Once, an unidentified and distinguished-looking older man with a neatly trimmed beard was rushed into the emergency room, unable to speak and delirious with what was later diagnosed as encephalitis.

Suspecting the well-groomed man likely had a loved one who had reported him missing, Crary checked with police stations in the area. She learned, instead, that this John Doe was wanted in several states for sexual assault.

“It is a case that I will never forget,” Crary says. “The truth is that I am more elated when we are able to identify a patient and locate family for a beautiful reunification, rather than finding a felon.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN is not affiliated with Kaiser Permanente.

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It’s early morning in an operating theater at Providence Hospital in Portland, Ore. A middle-aged woman lies on the operating table, wrapped in blankets. Surgeons are about to cut out a cancerous growth in her stomach.

But first, anesthesiologist Brian Chesebro puts her under by placing a mask over her face.

“Now I’m breathing for her with this mask,” he says. “And I’m delivering sevoflurane to her through this breathing circuit.”

Sevoflurane is one of the most commonly used anesthesiology gases. The other big one is desflurane. There are others, too, like nitrous oxide, commonly known as laughing gas.

Whatever gas patients get, they breathe it in — but only about 5% is actually metabolized. The rest is exhaled. And to make sure the gas doesn’t knock out anyone else in the operating room, it’s sucked into a ventilation system.

And then? It’s vented up and out through the roof, to mingle with other greenhouse gases.

These two gases are actually fairly similar medically; sevoflurane needs to be more carefully monitored and titrated in some patients, but that’s not difficult, Chesebro says.

Generally, unless there’s a reason in a particular case to use one over the other, anesthesiologists simply tend to pick one of the two gases and stick with it. Few understand that one — desflurane — is much worse for the environment.

And that bothered Chesebro. He grew up on a ranch in Montana that focused on sustainability. “Part of growing up on a ranch is taking care of the land and being a good steward,” he says.

Now he lives in the city with his three kids and has gradually started to worry about their environmental future. “When I look around and I see stewardship on display today, it’s discouraging,” he says. “I got depressed for a while, and so I hit the pause button on myself and said, ‘Well, what’s the very best that I can do?’ “

He spent hours of his own time researching anesthesiology gases. And he learned desflurane is 20 times as powerful in trapping heat in Earth’s atmosphere as sevoflurane. It also lasts for 14 years in the atmosphere, whereas sevoflurane breaks down in just one year.

Opening a big black notebook, filled with diagrams and tiny writing, he shows how he computed the amount of each gas the doctors in his group practice used. Then he shared their carbon footprint with them.

“All I’m doing is showing them their data,” Chesebro says. “It’s not really combative. It’s demonstrative. Ha, ha ha.”

One of the doctors he shared his analysis with was Michael Hartmeyer, who works at the Oregon Anesthesiology Group with Chesebro. “I wish I had known earlier,” Hartmeyer says. “I would have changed my practice a long time ago.”

Hartmeyer says he was stunned when Chesebro explained that his use of desflurane was the greenhouse gas equivalent of driving a fleet of 12 humvees for the duration of each surgical procedure. It’s “only” half a hummer if he uses sevoflurane. Hartmeyer notes that outside the operating room he drives a Prius.

“You try to be good,” he says. “You take shorter showers or [don’t] leave lights on, or whatever else. But you know there’s always more that we could probably do. But this was, far and away, a relatively easy thing that I could do that made a huge impact.”

The anesthesiology carts that get brought into operating theaters tend to have a row of gases to choose from. So Hartmeyer was able to switch pretty much overnight.

Other anesthesiologists made the switch, too. And it didn’t hurt that sevoflurane is considerably cheaper.

Hartmeyer’s change saved his hospital $13,000 a year.

When Chesebro shared his findings with the anesthesia departments at all eight Providence Health hospitals in Oregon, they prioritized the use of sevoflurane. They now save about $500,000 per year.

Providence’s chief executive, Lisa Vance, says the hospital system didn’t change its use of the gas because of the money. It changed because the World Health Organization now says climate change is the No. 1 public health issue of the 21st century — and because of Chesebro.

Vance said Chesebro teared up in front of 2,000 people when talking about the gas, his children and the Lorax from Dr. Seuss. “Unless someone like you cares a whole awful lot, nothing’s going to get better — it’s not,” says Vance, quoting the book.

Jodi Sherman, an associate professor of anesthesiology at Yale School of Medicine, calls Chesebro’s efforts remarkable and important.

She says several hospitals around the country have tried to make this shift, but with mixed results. Some just gave anesthesiologists the information, and not much changed. Other hospitals took desflurane away, but that left many anesthesiologists feeling disrespected and angry.

She thinks Chesebro succeeded because he chose to persuade his colleagues — using data. He showed doctors their choice of gas, plotted against their greenhouse impact. And it helped that he showed them over and over, so doctors could compare their progress with that of their peers.

“Providing ongoing reports to providers is the best way for this movement to catch on and grow,” she says. It can reinforce over time, she adds, not just what their carbon footprint is, but also what progress they’re making.

Sherman says efforts such as Chesebro’s are sorely needed because the U.S. health sector is responsible for about 10% of the nation’s greenhouse gases. “We clinicians are very much focused on taking care of the patient in front of us,” she says. “We tend to not think about what’s happening to the community health, public health — because we’re so focused on the patient in front of us.”

In an emailed statement, Baxter International, the manufacturer of the anesthesia gas, says it is important to provide a range of options for patients. The firm also says inhaled anesthetics have a climate impact of 0.01% of fossil fuels.

“The overall impact of anesthetic agents on global warming is low, relative to other societal contributors, especially when you consider the critical role these products have in performing safe surgical procedures,” the statement reads.

It’s a fair point, Chesebro says, but he has a counterargument.

“Well, if it’s there, it’s bad. And if I can reduce my life’s footprint by a factor of six … why wouldn’t you do it?”

The surgery Chesebro was involved in that morning at Providence was a success. Chesebro estimates that by using sevoflurane on his patient, the same greenhouse gases were produced as in a 40-mile drive across the Portland region.

If he had used desflurane instead, he says, it would have been like driving the more than 1,200 miles from Seattle to San Diego.

Now Chesebro’s hospital bosses are hoping other doctors will follow his lead, research their own pet peeve, and maybe solve a problem no one’s thinking about.

This story is part of NPR’s reporting partnership with Oregon Public Broadcasting and Kaiser Health News, which is an independent journalism program of the Kaiser Family Foundation and not affiliated with Kaiser Permanente.

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Scientists who recently announced an experimental genetic test that can help predict obesity got immediate pushback from other researchers, who wonder whether it is really useful.

The story behind this back-and-forth is, at its core, a question of when it’s worth diving deep into DNA databanks when there’s no obvious way to put that information into use.

The basic facts are not in dispute. Human behavior and our obesity-promoting environment have led to a surge in this condition over the past few decades. Today about 40% of American adults are obese and even more are overweight.

But genetics also plays an important role. People inherit genes that make them more or less likely to become seriously overweight.

While some diseases (like Huntington’s and Tay-Sachs) are caused by a single gene gone awry, that’s certainly not the case for common conditions, including obesity. Instead, thousands of genes apparently play a role in increasing obesity risk.

Many of those gene variants contribute a minuscule risk. Sekar Kathiresan, a cardiologist at Harvard and a geneticist at the Broad Institute, set out to see whether he and his team could find a bunch of these genetic variants and add up their effects. The goal was to identify genetic patterns that put people at the highest risk.

This genetic information “could explain why somebody’s so big, why they have so much trouble keeping their weight down,” Kathiresan says.

His team identified more than 2 million DNA variants of potential interest. He figures most of those variants are irrelevant, but his hunch is, hidden somewhere in there are a few thousand changes that each contribute at least a tiny bit to a person’s risk of developing obesity.

No single gene can do much to move the needle. But he says the composite result, called a polygenic risk score, is still potentially useful. Those with the highest risk scores were more likely to be severely obese (with a body mass index over 40). In fact, 43% of the people with the highest genetic scores were obese.

But the score is far from perfect. For instance, 17% of the people with the highest scores had normal body weights.

The team, with lead author Amit Khera, published its results in the journal Cell.

“The impact of the genetics — and this was a huge surprise to us as well — starts very early in life, in the preschool years, around the age of 3,” Kathiresan says.

That finding suggests prevention efforts are more likely to succeed if they also start in childhood. Kathiresan has a more philosophical takeaway from his work as well.

“I hope this work will hopefully destigmatize obesity and make it very similar to every other disease, which is a combination of both lifestyle and genetics.”

A lot of elaborate genetic analysis is behind the study, which involved more than 300,000 individuals. But the broad conclusions aren’t new.

Scientists already knew genetic risk factors can contribute significantly to obesity. And other studies show that obese children are at high risk for becoming obese adults.

Epidemiologist Cecile Janssens, a professor at Emory University, doesn’t think much of this strategy of adding up the tiny risks from millions of genetic variants to come up with a cumulative risk score.

“In all fairness, we don’t know whether all of these variants really matter,” she says. When asked about the value of doing a study like this, she says, “I have no clue.”

“It is not really answering a very relevant question from the biological perspective, and not really answering a very relevant question from a clinical perspective,” she says.

This type of analysis doesn’t reveal anything about the individual genes that are contributing to obesity, which means you can’t use it to understand the underlying biology. If obesity were a rare disease, a test like this could be useful to identify people at elevated risk. But since it affects 40% of Americans, Janssens says prevention efforts should include everybody.

She is among a group of scientists informally rebelling against the gene-centric way of looking at disease. It’s frustrating for them to see so much money poured into this kind of genetics work, rather than into efforts to change the environment and the behaviors that contribute to diseases like obesity.

Janssens also says that, despite the daunting effort involved in studying 2 million genetic variants, the resulting score still doesn’t explain even 10% of the variation the scientists observed in body mass index. (Kathiresan, who couches his conclusions differently, says the score explains about a quarter of the genetic risk.)

Scientists doing this kind of work hope that data like these, when presented to individuals, will prompt them to change their behavior.

Alas, that’s not supported by scientific reviews.

“This kind of personalized risk information has little [or] no impact on people’s actual behavior,” says Theresa Marteau, who directs the Behaviour and Health Research Unit at the University of Cambridge.

In fact, researchers have worried that when people learn that they are at high genetic risk for diseases like obesity, people would become fatalistic and stop trying to change their behaviors. Fortunately, Marteau says “in a review, we didn’t find any evidence for that.” It seems they just ignore the information.

Ewan Birney, who heads the European Bioinformatics Institute, has been watching this debate play out over the years. Birney agrees with the critics who say obesity isn’t the ideal disease for this kind of analysis.

“One needs to do more than just be able to show a strong statistical association,” he says. “One really needs to show that you can then use that to do an intervention.”

Birney also is wary of making too much of this information because it’s based primarily on data from the UK Biobank, as well as U.S. samples, in which racial minorities aren’t well represented.

There are other instances where these polygenic risk scores can be useful, he says. For example, a score that identifies people at high risk for heart disease identifies people who get the most benefit from cholesterol-lowering drugs called statins. (But it’s unclear whether it would be beneficial to give statins to people who score high on this test but wouldn’t ordinarily be identified as candidates for this medication).

Using a different method of analysis, called a genome-wide association study, scientists have identified more than 140 genes that can slightly increase the risk of obesity. Though their individual influence is small, they do provide clues about the biology of the disease.

For example, one of the relatively potent variants “actually relates to calorie-seeking behaviors,” says Ali Torkamani, who is director of genome informatics at the Scripps Research Translational Institute. Other variants are, unsurprisingly, related to the function of fat cells.

It’s also possible that a careful probe of the genes – rather than the abstract risk score – could identify genetic variants that actually reduce a person’s risk of obesity. A paper in the same issue of Cell as the one that featured work from Kathiresan’s group points in that direction.

While genes influence a person’s risk of obesity, the epidemic in this country is obviously far more extensive than simply people at high risk. And Torkamani notes that the risk score isn’t destiny. “It’s just a probability,” he says. “And you know, when you flip a coin sometimes it comes up heads and sometimes it comes up tails.”

You can contact NPR Science Correspondent Richard Harris at rharris@npr.org.

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