Category Archives: Occupational Health

Researchers call for more study on Agent Orange effects on vets and their kids.


'Ranch_Hand'_run agent orange By Mike Hixenbaugh, The Virginian-Pilot, and Charles Ornstein, ProPublica

More than two decades of studying Agent Orange exposure hasn’t produced a solid understanding of how the toxic herbicide has harmed Vietnam War veterans and possibly their children, according to a report released Thursday.

Additional research is long overdue, the report said, but the federal government hasn’t done it.

Those are among the conclusions of a committee of researchers that, since 1991, has been charged by Congress with reviewing all available research into the effects of Agent Orange, which the U.S. military sprayed by the millions of gallons in Vietnam to kill forests and destroy enemy cover.

Over the years, the biennial reports produced by the committee have identified numerous illnesses linked to the herbicide, in some cases leading the Department of Veterans Affairs to extend disability compensation to thousands more veterans.

But in its tenth and final Agent Orange report 2014 with most Vietnam vets now well into their 60s or older 2014 the committee concluded there’s still much to learn and not enough research underway, especially related to potential health consequences for the children and grandchildren of veterans who were exposed.

“Although progress has been made in understanding the health effects of exposure to the chemicals,” the committee members wrote near the end of the 1,115-page report, there are still “significant gaps in our knowledge.” Continue reading


Learn about toxic chemicals released in your community


Your Right to Know: Learn about toxic chemicals released in your community

From the Washington Department of Ecology

Each year, facilities in Washington and across the country report on the toxic chemicals they release into our air, land, water, or send off site for disposal.

Hanford cleanup accounted for 62% of Washington’s total land releases.

These reports are part of the national Toxics Release Inventory, or TRI, which requires over 20,000 facilities across the country to report on releases of 675 different toxic chemicals.

Those 675 chemicals were chosen because they cause cancer, harmful health effects, or harm our environment. The TRI list includes familiar chemicals like mercury, lead and zinc.

It also covers more obscure chemicals like pyridine, which is used to dissolve substances or to make pesticides, adhesives, food flavorings, dyes and other products.

TRI was created under federal Community Right-to-Know laws. It’s your right to know what chemicals you may be exposed to, so the U.S. Environmental Protection Agency and the Washington Department of Ecology make the data available for you to search. This year marks the 30th anniversary of TRI.

EPA says that TRI data is intended to help communities: Continue reading


Fall prevention essential to preserving health of older adults


Kim, Alice 09 colorBy Alice Kim, MD
Virginia Mason Issaquah Medical Center
Contributing Writer

If you are an older adult a simple thing can change your life, like tripping on uneven pavement or slipping on a slick surface. If you fall, you could break a bone, like thousands of older men and women do every year. Although a broken bone might not sound bad, it could prompt more serious health issues.

Many things can cause a fall. Your eyesight, hearing and reflexes might not be as sharp as they were when you were younger. Diabetes, heart disease or problems with your thyroid, nerves, feet or blood vessels can affect your balance. In addition, some medications can cause you to feel dizzy or sleepy and make you more likely to fall.


Virginia Mason physical therapists working with a patient on gait and stability.

However, it’s important to not allow a fear of falling keep you from being active. Doing things like gathering with friends, gardening, walking or going to the local senior center helps you stay healthy. The good news is there are simple ways to prevent most falls.

Do the right things

If you take care of your overall health, you may be able to lower your chances of falling. Most of the time, falls and accidents don’t just happen. Here are a few tips intended to help you avoid falls and broken bones:

  • Stay physically active. Plan an individualized exercise program that works for you. Regular exercise improves muscle health and makes you stronger. It also helps keep your joints, tendons and ligaments flexible. Mild weight-bearing activities – such as walking or climbing stairs – can help slow bone loss from osteoporosis.

Continue reading


Pre-hab: Rehabilitation before cancer treatment


prehab-570By Michelle Andrews

Cancer patients who do rehabilitation before they begin treatment may recover more quickly from surgery, chemotherapy or radiation, some cancer specialists say.

But insurance coverage for cancer “prehabilitation,” as it’s called, can be spotty, especially if the aim is to prevent problems rather than treat existing ones.

It seems intuitive that people’s health during and after invasive surgery or a toxic course of chemo or radiation can be improved by being as physically and psychologically fit as possible going into it. But research to examine the impact of prehab is in the beginning stages.

Early research suggests prehab may improve people’s ability to tolerate cancer treatment and return to normal physical functioning more quickly. 

Prehabilitation is commonly associated with orthopedic operations such as knee and hip replacements or cardiac procedures.

Now there’s growing interest in using prehab in cancer care as well to prepare for treatment and minimize some of the long-term physical impairments that often result from treatment, such as heart and balance problems.

“It’s really the philosophy of rehab, rebranded,” says Dr. Samman Shahpar, a physiatrist at the Rehabilitation Institute of Chicago. Continue reading


Depression take its toll in the workplace, study


RED # 18355 64-NA-193By Lisa Gillespie

For every dollar spent on treating depression, almost five dollars is spent on the treatment and workplace costs of related medical conditions like back and chest pain, sleep disorders and migraines – placing a greater financial burden on businesses and the health care system, according to new research measuring the economic impact of depression.

“The fact that they’re finding such greater costs with all these different [related conditions] underscores how the fragmented system is not helpful for our economy because people with mental illness are not getting the rounded health care they need,” said Lynn Bufka, assistant executive director of practice research and policy at the American Psychological Association, who was not affiliated with the study.

The average worker who had major depression disorder lost the productivity of about 32 workdays a year due to what’s known as “presenteeism.” That is a term for when an employee is at work but not completing daily tasks and responsibilities.

Among the study’s findings was that the total cost to the U.S. economy of major depressive disorder – a condition that results in having persistent depressive episodes – rose from $173.2 billion in 2005 to $210 billion in 2010, a 21.5 percent increase.

About half of that is for direct treatment and suicide-related services, but the rest is workplace costs. The rise is partially accounted for by the increase in population, but also because depression is being diagnosed and treated more often.

The incidence of major depressive disorder rose during this time period from 6.4 percent of the population to 6.8 percent.

In addition, some of this growth might have been caused by the nation’s 2008 economic downturn and tight job market, factors that combined to make it harder for those suffering from depression to retain their jobs and even more difficult for those with this condition who are job seekers to find work, according to Paul Greenberg, a study author and director of health economics at the Analysis Group, a consulting firm in Boston.

Meanwhile, the study also examined how depression plays out in the workplace.

Mental health experts and economists have long known that someone’s depression can have a significant cost on the workplace, Greenberg said.

For example, the study found that the average worker who had major depression disorder lost the productivity of about 32 workdays a year due to what’s known as “presenteeism.” That is a term for when an employee is at work but not completing daily tasks and responsibilities.

Experts say that, though this loss in productivity highlights the economic toll mental health issues have on the work place, small and medium-sized employers may not have the knowledge or tools to improve the situation. Continue reading


Ballet stretches her body’s limits, insurance brings peace of mind


By Heidi de Marco
KHN Staff Writer


Allynne Noelle has had two metatarsal stress fractures, a torn foot ligament, and two broken ribs. Yet, the 32-year-old ballerina considers herself pretty lucky.

Allynne Noelle 3 300Noelle says not to be fooled by the graceful movements on stage − ballet is a full-contact sport.

“As beautiful as the art form of ballet is, it’s extremely demanding on the body,” said Noelle, a principal dancer with the Los Angeles ballet. “It works every single muscle and fiber.”

The annual injury rates at ballet companies run between 67 and 95 percent.

The annual injury rates at ballet companies run between 67 and 95 percent, according to a study by the American Journal of Sports Medicine.  But ballerinas and their male counterparts often dance through the pain.

“You’re kind of raised with the idea that you’re stronger than any pain you feel,” said Noelle, who once danced with a 103-degree fever that led to her hospitalization with pneumonia. Continue reading


App lets you determine your neighborhood’s radon risk


Screen Shot 2014-01-21 at 11.28.29From the Washington State Department of Health

Olympia, January 21, 2014 — Washington residents now have a new online map to check and see if their neighborhood has a geological risk for the cancer-causing gas, radon, using a new state app. The new app is offered by the state Department of Health’s Washington Tracking Network.

Some areas of the state, such as Spokane and Clark counties, are well-known for having higher levels of radon, but the new online map shows that there are some areas around the Puget Sound such as Pierce and King counties that might come as a surprise.  Continue reading


Cancer rehab begins to bridge a gap for patients



By Rachel Gotbaum

This story was produced in collaboration with NPR

It was her own experience with debilitating side effects after cancer treatment that led Dr. Julie Silver to realize there is a huge gap in care that keeps cancer patients from getting rehabilitation services.

Silver was 38 in 2003 when she was diagnosed with breast cancer. Even though she is a physician, she was shocked at the toll chemotherapy and radiation took on her body. Silver was dealing with extreme fatigue, weakness and pain.

“I was really, really sick, sicker than I ever imagined,” says Silver, who is an assistant professor at Harvard Medical School. “I did some exercise testing and I tested out as a woman in my 60s. So I had aged three decades in a matter of months through cancer treatment.”

Silver went to her oncology team for help. They told her to go home and heal. “The conversation should have been, ‘We’re going send you to cancer rehab to help you get stronger,’” she says. But that’s not what happened, and after Silver came to realize that her experience was typical, she set out to change the system for other patients.

In 2009 she started a program designed to offer cancer survivors rehabilitation therapy after treatment. It’s called STAR and is now offered in almost all 50 states. The program is growing, as is research showing that many of the quality-of-life problems cancer survivors have are physical and can be helped with rehab.

But even with the awareness of its benefits growing, there is still a disconnect for patients.

“Patients are getting stuck, and they don’t know where to go,” says Dr. Rebecca Lansky, a rehabilitation specialist at the University of Massachusetts Medical Center. She says the focus on cancer care is on treatment and that cancer patients suffering from major side effects often fall through the cracks. She recalls one patient who struggled with the side effects of tongue cancer treatment.

“He had radiation to the whole jaw and neck so he couldn’t open up his mouth for six months,” Lansky said. “He had a feeding tube, and he kept going to his oncologist saying, ‘How can I get better? What I can do? He finally got referred to me and we are now opening up his jaw six months after he has been unable to move.”

Dr. Rebecca Lansky examines a patient (Photo by Rachel Gotbaum/For KHN)

Dr. Rebecca Lansky examines a patient (Photo by Rachel Gotbaum/For KHN)

A 2008 study of breast cancer patients in the Journal of Clinical Oncology found that 90 percent of the patients needed rehab but only about one third were getting the therapy.

“I’ve seen cases where someone has had a lot of pain, and they’ve done scans and it’s not a malignancy and maybe they have done exploratory surgery to see what is happening and not really finding much except a lot of scar tissue,” says physical therapist Jennifer Goyette, a STAR trained therapist who works with cancer patients in Worcester, Massachusetts. “I am able to get them a lot of relief and a lot of times patients don’t need to have further intervention. They don’t want to be on the narcotics for the pain management. They would rather come here.”

One of Goyette’s clients is 56-year-old cancer survivor Deborah Leonard. For two years after her treatment for early stage breast cancer, Leonard had swelling, pain and a large mass in her breast –which was not cancer.

“Clearly I didn’t have that before the surgery, because the tumor was so small and this was much bigger, and it just kept getting bigger,” says Leonard. “By nighttime my breast was extremely swollen and very painful.”

At first doctors thought Leonard might have an infection and gave her antibiotics. When that didn’t work they did another surgery to remove scar tissue. But the problem returned. Her doctors were suggesting a third surgery when Leonard finally found Goyette.

After three sessions with Goyette doing what is called lymphatic drainage, Leonard felt much better. Goyette uses manual pressure to clear Leonard’s lymphatic system, allowing the build up of fluid causing Leonard’s pain and swelling to subside.

“I had a 6-inch mass that is now down to half its size,” says Leonard.

“I’m sleeping at night, I have energy again. More people need to know about this because you don’t have to be a martyr and grin and bear it. This works.”

The issues are different for every type of cancer – head and neck cancer patients may need swallowing and speech therapy; blood cancer patients may need therapy similar to cardiac rehab to rebuild their strength and stamina; and patients treated for colon cancer can get help from physical therapists with back pain and abdominal swelling.

Most insurers do cover rehab for cancer patients, but sometimes patients must battle to get more than the standard 9 to 12 sessions covered. Another barrier to care is that too few oncologists and cancer surgeons refer their patients to rehab.

The Commission on Cancer, the arm of the American College of Surgeons that accredits cancer programs in U.S. hospitals, recently announced new requirements aimed at improving care for survivors of cancer including better access to rehabilitation therapy.

This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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More than 24,000 Snohomish County residents earn food worker certification online


At signA record 24,000 Snohomish County residents earned a food worker card through online training in 2012, compared to less than 5,000 who earned their cards in a classroom, Snohomish County health officials report.

A food worker card is required for anyone who:

  • Works with unpackaged food, such as in a restaurant or bar
  • Touches food equipment, such as washing dishes
  • Works at any surface where people put unwrapped food, including grocery store cashiers

The county began to offer the food worker card classes online in the spring of last year. The online course takes about one hour to go through the curriculum and take the test.

The popularity of the online course has reduced the need for in-person classes, officials said, so the Snohomish Health District plans to reduce the number of in-person classes to four a month in English and to one a month in Spanish next year. .

Starting January 1, Health District will offer four classes a month in English and one in Spanish at the Snohomish Health District auditorium in the Rucker Building, 3020 Rucker Ave., Everett.

  • The in-person classes in English will be offered the first and third Thursday of each month at 10 a.m. and 2:30 p.m.
  • The in-person classes in Spanish will be offered the first Tuesday of each month at 10 a.m.
  • In-person classes will no longer be offered in Lynnwood.

The online training program also provides instruction in Korean, Russian, Mandarin, Cantonese, Vietnamese, Cambodian and Closed Caption

The cost of the training and test for a food worker card remains at $10.

Food worker cards are good for three years and are valid anywhere in Washington state.

The Health District accepts cash only for the in-person classes, and Visa or MasterCard only for online classes.

Find details at

To learn more about food safety classes and the food safety program, visit, keyword search “Food Class.” Optionally, call 425.339.5260 to hear a list of class dates.

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$100-dollar bill inside a capsule

Workers’ poor health costs employers $344 billion, study finds


By Julie Appleby

Health costs aren’t just about how much employers pay to provide health insurance: Workers’ poor health costs employers $344 billion annually in lost productivity and absenteeism, a research group estimates.

“Employers haven’t looked at the impact of health on absence from work or on performance while at work,” says Thomas Parry of the Integrated Benefits Institute, a nonprofit group that includes employers and benefit firms among its members.

Improving workers’ health through wellness programs and other efforts, Parry says, will pay off in the short term with improved productivity and fewer days off to illness. Long range, it may also slow rising medical costs if workers’ health improves.

The institute used its own data, along with data from the Bureau of Labor Statistics, to come up with the estimate.  Of that total, $227 billion are costs associated with workers taking days off because they are sick or showing up at work and underperforming.

An additional $117 billion is associated with wage replacement, including worker’s compensation costs and disability payments.

Those costs add up to more than the $232 billion Parry says private employers spend on medical coverage for their workers each year.

“To focus only on costs is missing the boat,” he says. “Unless we think about a healthier workforce, we will never crack this nut.”

The value of wellness and disease prevention programs has been widely debated, but many analysts think such programs reduce spending over time. An increasing percent of employers are tying financial incentives, such as insurance discounts, to employees actively participating in wellness efforts. Some even require them to meet specific medical guidelines for such things as cholesterol, blood pressure or weight.

To slow their cost growth, many employers have also raised deductibles.  Supporters of high-deductible plans say workers will act as better consumers of health care if they’re paying more out of their own pocket. Parry says that might be true, but the flip side is that some workers pay also put off needed care.

“And that may have productivity consequences,” he says.

This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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office workers - Square

Workplace clinics expand focus beyond injuries and preventive care


By Michelle Andrews

On-site workplace clinics used to be primarily focused on patching up people who got injured on the job. Then companies added primary care and started emphasizing preventive screenings and other “wellness” services.

Now, some big employers are beefing up their clinic offerings further with a host of add-ons, including physical therapy, dental and vision exams, mental health counseling and even acupuncture and massage.

The new services may not always improve a company’s bottom line. But they’re a convenient perk for busy employees and can help maintain employee productivity by reducing absences.

In addition, in competitive industries such as technology and financial services, such benefits can help retain employees and attract new ones, experts say.

In 2011, 31 percent of employers with 500 or more workers had on-site clinics, and another 9 percent said they were considering them, according to the annual survey of employer health plans by human resources consultant Mercer.

“It’s a matter of providing enhanced access and making it easier for workers to get enhanced services,” says Bruce Hochstadt, a Mercer consultant.

When Linda Wolohan’s doctor prescribed physical therapy last December to treat a bulging disk in her back, she opted to use a physical therapist at the Valley Forge, Pa., headquarters of her employer, Vanguard, rather than one near her home an hour away.

“It was convenient,” says Wolohan, 54, who works in the mutual fund company’s public relations department. “Getting to a physical therapist near home was hard to schedule.”

Wolohan paid $10 a session, a slightly lower co-payment than if she had used a physical therapist in the community.

More From This Series: Insuring Your Health

Obstetrics And Dentistry

Like most companies that provide on-site clinics, Vanguard is self-insured, meaning the company pays its employees’ health-care claims directly.

Given the high volume of employee physical therapy claims, it made sense financially to provide the service in-house, says Julie Clark, who oversees the clinic, the company gym and other wellness services.

The company has three part-time physical therapists at the clinic, which opened last year. The clinic staff, which also includes a doctor, a nurse practitioner and a couple of nurses, is employed by CHS Health Services, a Reston, Va.-based company that staffs and runs 115 on-site health clinics in 32 states.

Employees’ costs vary. Some employers provide clinic services free. Discounted co-payments such as the one Wolohan paid are common, experts say.

“They want to encourage employees to take advantage of the services on-site,” says Ed McNamara, vice president of sales and marketing at CHS. “It’s a productivity savings and an employee-benefit savings.”

Workers at American Express facilities in Phoenix and Salt Lake City have access to dental services at a van that parks at each of the facilities. In addition to dental exams and cleanings, employees can get fillings and crowns, among other treatments. Services are free for employees enrolled in the company dental plan.

American Express varies the on-site services it offers based on employee needs, says David Kasiarz, senior vice president for global compensation and benefits. The company may provide an OB/GYN at a call center with a mostly female workforce, for example, or a dermatologist in Florida and Phoenix, where skin cancer is more common than in other areas.

On the coasts, especially in Silicon Valley and Southern California, a growing number of companies have added acupuncture, massage therapy and chiropractic services to their clinic offerings, experts say.

“The companies that tend to do it see it as a retention tool,” says Ha Tu, a senior researcher at the Center for Studying Health System Change, who co-authored a study about workplace clinics. “They’re perks, as opposed to offering massage therapy, for example, and expecting direct payoff.”

Mental Health Care

Employers are also paying more attention to mental health issues. Some are adding services at their on-site clinics.

In other cases, they’re linking the employee assistance program, which provides short-term counseling and mental health referrals, with the clinics, says Julie Stone, a senior consultant with benefits consultant Towers Watson.

Services can take many forms. At Prudential Financial, health-care providers at the company’s eight clinics began noticing employee stress from the financial crisis and recession a few years ago. So the company made budget coaches available by phone.

“The financial situation was affecting their health,” says Myrtho Montes, who manages all the company’s on-site health programs.

KHN wants to hear from you: Contact Kaiser Health News
This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Shopping Bag

Can retailers revamp primary care?


By Julie Appleby
KHN Staff Writer

In-store medical clinics like those at Walmart – having established a beachhead with relatively healthy patients looking for convenient, low-cost care for simple problems – are eyeing a bigger prize, the millions of Americans with costly illnesses such as diabetes and heart disease.

Just as Walmart and other retailers shook up the prescription drug business by offering $4 generic drugs, the industry now aims to apply its negotiating and marketing clout to tackle problems that vex consumers and the health sector: unpredictable costs, a lack of primary care doctors and inefficient management of chronic illnesses, whose costs drive the majority of health care spending.

“It’s sad that the existing health care establishment has not figured out a way to make primary care affordable and accessible,” says Jerry Avorn, a professor of medicine at Harvard.  “We should not be surprised if someone outside of our world comes in and does it for us.”

Last week, Walmart’s ambition to become the nation’s largest provider of primary health care services became known when a confidential document the giant retailer sent to some of its strategic partners leaked out.

The request for information sought partners who could help Walmart in a variety of areas, including monitoring patients with diabetes, asthma, high blood pressure, heart disease, obesity and other conditions.

Walmart backed away from parts of its own document, saying it did not intend to build a “nationally integrated, low cost primary care platform.” Indeed, it is hard to imagine what a national platform would look like given the wide variation of state laws governing health care delivery.

 The Association of American Medical Colleges estimates a shortfall of 21,000 primary care doctors by 2015.

But clearly, Walmart and other retailers are looking for ways to expand services at their in-store clinics.

Already, CVS Caremark, the largest operator of in-store clinics with nearly 550, and Walgreens have set up programs aimed at helping diabetics monitor and control their condition, which includes counseling chats with pharmacists. Weight loss programs and counseling are on tap at some retail clinics. Truck drivers can pull their 18-wheelers into the parking lots of more than 600 such in-store centers nationwide to get their mandatory federal health exams.

“There are real savings to containing the cost of the chronically ill in this country,” says Helena Foulkes of CVS/Caremark, which offers in-person and telephone conversations with pharmacists to diabetic patients enrolled in its “Pharmacy Advisor” program. Some employers also send workers to the firm’s MinuteClinics for blood tests and other health screenings. “More and more of clients are actively looking for wellness programs and they see retail clinics as one element.”

In part, the clinics see a pure business opportunity based on consumer convenience and cost savings, which they can market to the public, employers, insurers and hospitals. Costs are roughly 30 percent to 40 percent less than similar care at a doctor’s office and 80 percent cheaper than at an emergency room, according to a study in published this year in the American Journal of Managed Care.

That’s attractive to insurers. Use of retail clinics among patients with insurance rose tenfold from 2007 to 2009, the study found, with clinic visits representing about 7 percent of all medical visits for 11 common acute conditions: “If these trends continue, health plans will see a dramatic increase in retail clinic utilization … particularly among, young, healthy and higher income patients living close to retail clinics,” the study concluded.

Still, while less expensive than going to an emergency room or doctor’s office on a per-visit basis, “if more people seek care, that could increase health care spending,” says one of the co-authors of the study, RAND researcher and medical professor Ateev Mehrotra of the University of Pittsburgh School of Medicine.

The majority of retail clinics are in the South and Midwest and are likely to be in areas with lower overall poverty.

The California Healthcare Foundation found the No. 1 thing consumers liked about the in-store clinics was predictability: the cost of the service was clear ahead of time.

“That contrasts with most people’s experience of health care, where if you walk into a doctor’s office or an urgent care clinic, you have no idea what the charge will be,” says Mark Smith, president and CEO of the foundation.

Interest in clinics is also spurred by the federal health law, which, among other things, will create incentives for small businesses to offer wellness programs for workers.

“An employer with 50 to 250 employees can’t afford to bring in a company to do corporate wellness,” but it could partner with a retail clinic and send employees there for blood tests, nutrition counseling or diabetes management, says Stewart Levy, president of Health Promotion Solutions in Newtown, Pa., a consulting firm that is working with the retail clinic industry.

The growth of retail clinics – both in sheer numbers and the scope of services they offer – is one of several avenues being pursued to revamp primary care, which is facing a shortage of physicians. The Association of American Medical Colleges estimates a shortfall of 21,000 primary care doctors by 2015.

Done right, supporters say, expanding services through retail clinics could provide better access for many patients and lower costs, and provide an outlet for an expected jump in demand for care in 2014, when millions more Americans get insurance through the federal health law.

But obstacles remain. Will retail clinics be able to translate their success with simple acute problems to a more long-range and intensive monitoring of complex conditions? Will employers and consumers embrace the idea? Will clinics become components of new, integrated collaborations between doctors, hospitals and insurers?

“Asthma and diabetes are not something you get one time and get fixed,” says health care consultant Ian Morrison, who follows trends in the industry. “How effective will they be in managing that over the long term?”

While studies have shown that retail clinics provide similar – or even better – quality care for simple conditions such as sore throats, researchers haven’t yet looked at their ability to do more complex monitoring of patients, often called disease management.

Data is mixed on the success of such programs and some have been shown not to save money. Recently, a study of eight disease management firms that used nurse-based call centers failed to save Medicare money.

Another challenge is the wide variety of laws governing medical centers. Some states, including New York and California, prevent clinics (or hospitals) from directly employing physicians, nurse practitioners or physician assistants.

Other states cap the number of nurses each doctor can oversee. Efforts to expand nurses’ or physician assistants’ ability to practice autonomously are often fought by state medical associations.

“It’s interesting that I can go from Washington D.C., where I can be certified to take care of patients autonomously, to Georgia, where I can do very little because I have to have a supervisor who is a physician overseeing what I do,” says Ken Miller, an associate dean in the school of nursing at Catholic University and a past president of the American College of Nurse Practitioners.

While a few centers operated by retailers have doctors on site, the vast majority of staff are nurse practitioners or physician assistants. According to the Convenient Care Association, the industry’s trade group,there are more than 5,000 nurse practitioners working in the clinics, making up 95 percent of the clinicians.

If more patients with chronic illnesses can be seen in settings like retail clinics, where they can stop by on the way home from work or on the weekends, Miller and others say they may be more likely to take their medications, monitor their blood sugars and take other actions to prevent a worsening of their disease.

“If you have a stable diabetic, why should that person be going in to see a physician when a nurse practitioner can manage care of that patient?” he asks.

Primary care doctors fear retail clinics will skim off the healthiest patients, leaving them with more complex or older patients, with no corresponding increase in reimbursement from insurers or the government. They also worry that the expansion of retail clinics into caring for patients with chronic illnesses will further fragment the care such patients receive.

In a statement, the American Academy of Family Physicians says a better answer for such patients is “the development of a health care system based on strong, team-based … care.”

For their part, the clinic industry says it can be an ally for overworked doctors. In the future, clinics could use nurse practitioners and physician assistants to do triage, particularly on the least complex patients,  so doctors could “use their training and skill to focus on patients with long term needs,” says Caroline Ridgway, policy and communications director at the retail clinic industry’s trade group.

But unless payment incentives are changed to reward quality over volume – and laws changed so nurse practitioners and physician assistants can provide more direct care in all states, there will be an increasing burden on primary care doctors as more Americans become insured, she says.

“Insuring 30 million more people isn’t going to matter if they don’t have anywhere to go,” says Ridgway.

The majority of retail clinics are in the South and Midwest, according to a 2010 RAND Study. They’re more likely to be in areas with lower overall poverty and only 12.5 percent were in medically underserved areas, the RAND report said, although 21 percent of the U.S. population lives in such areas.

“The research did not support the claim by some champions.. that these clinics are improving access to care for the medically underserved: retail clinics are more likely to be located in relatively affluent sections of large urban areas,” the report concluded.

Still, about 35 percent of clinic patients are either uninsured or have high deductible insurance plans that put them on the hook for hundreds, if not thousands, in out-of-pocket costs, says Tine Hansen-Turton,  executive director of the Convenient Care Association.

“We are seeing people who are vulnerable,” she says.

For much of their brief history, retail clinics have focused their services on a narrow menu, mainly treatments for acute conditions, such as strep throat or ear infections, vaccinations, and physical exams needed for summer camp or other programs.

But retail clinics are moving beyond just a simple menu of services in part because “it wasn’t a financially sustainable model to be restricted to those things,” says Smith at the California HealthCare Foundation.

Now, the medical community is seeing what other industries have experienced: an interloper gaining a foothold in a market niche, then expanding. “Think about Toyota, they didn’t start off by competing with Cadillac and BMW. They started with cheap little cars but got better and better over time,” Smith says.

PHOTO CREDIT: Michael Lorenzo

This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Full-body x-ray scan of a woman

TSA to conduct new study of safety of airport x-ray body scanners


Full-body x-ray scan of a womanby Michael Grabell
ProPublica, Nov. 2, 2011, 5:40 p.m.

The head of the Transportation Security Administration testified today that the agency will perform a new, independent study on the safety of X-ray body scanners after lawmakers raised questions about a ProPublica investigation at a Senate hearing on aviation security.

The story, researched in conjunction with the PBS NewsHour, reported that while the radiation emitted from the machines is extremely low, scientific studies have concluded that they could still increase the risk of cancer.

It also reported that the Food and Drug Administration went against the advice of a 1998 expert panel, which recommended the agency set a mandatory federal safety standard for the machines.

Several members of that panel said they were concerned about widespread use of X-ray scanners, including in airports.

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The TSA uses two types of body scanners to search for explosives — an X-ray machine that uses ionizing radiation, a form of energy that has been shown to damage DNA, and a millimeter-wave machine that uses radiofrequency technology, which has not been linked to cancer.

Sen. Susan Collins, the top Republican on the homeland security committee, recommended that the Department of Homeland Security independently evaluate the health effects of the X-ray scanners and “establish a goal of using radiation-free screening technology.”

Questioned about the story by Sen. Joe Lieberman, TSA Administrator John Pistole said that the agency has already conducted several independent studies showing that the radiation is equivalent to the dose received in about three minutes of flying at typical cruising altitude.

“But that being said, I am concerned that there is a perception that they are not as safe as they could be,” Pistole said. “And since we are using a different technology, that being the millimeter-wave scanner, that does not have that same perspective, I will take that back and we will conduct an independent study to address that.”

In recent years, the TSA has commissioned tests of the X-ray machines, also known as backscatters, by the Food and Drug Administration and the Johns Hopkins University Applied Physics Laboratory. In addition, survey teams from the Army Public Health Command visit airports to check the machines. The TSA says the results have all confirmed that the backscatters don’t pose a significant risk to public health.

But David Brenner, director of Columbia University’s Center for Radiological Research, said in a recent interview that while the dose is low, the chances of someone getting cancer increase as TSA puts millions of airline passengers through the machines.

“Why would we want to put ourselves in this uncertain situation where potentially we’re going to have some cancer cases?” he asked. “It makes me think, really, why don’t we use millimeter waves when we don’t have so much uncertainty?”

Robin Kane, the TSA’s assistant administrator for screening technology, told ProPublica and PBS that the health risk is small compared to the security benefit. Having both technologies is important, he added, to improve detection capabilities and find the most cost-effective solution.

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Mildew from a wooden soap dish - Photo by Bob Baylock

Removing mold helps reduce asthma and respiratory infections — study


Mildew from a wooden soap dish - Photo by Bob Baylock

By Glenda Fauntleroy, Contributing Writer
Health Behavior News Service

A new evidence review finds that ridding homes and offices of mold and dampness can help reduce respiratory infections and troubling symptoms for asthma sufferers across the globe; however, the best way to eliminate the mold remains unclear.

Mold is one of the most important environmental triggers of symptoms such as coughing and wheezing, according to National Institute of Environmental Health Sciences.

“Mold is found in many homes with basements, in apartments and walkouts that are partially or fully below ground, and in buildings that have been flooded or have poor humidity control,” said Peter Thorne, head of the occupational and environmental health department at the University of Iowa. “Homes and office buildings alike have problems.”

But does “remediating” or relieving homes, offices and schools of dampness and mold make a big difference? Lead reviewer Riitta Sauni at the Finnish Institute of Occupational Health in Tampere, Finland, said that results are mixed.

PHOTO: Bob Baylock under Creative Commons license

Key Points:

  • Ridding homes and office buildings of mold can reduce the incidence of respiratory illness and decrease asthma-related symptoms, a new Cochrane review finds.
  • While removing mold from offices and homes can reduce coughing and wheezing, the best method for mold removal remains to be determined.
  • Mold can be costly to remove from buildings, which can be re-infected even after cleaning and fungicide treatments.

“We were happy to find evidence that remediation of mold-damaged houses decreased the severity and amount of symptoms in patients with asthma and respiratory infections,” Sauni said. “Unfortunately, we did not find evidence that remeditation could prevent these diseases.”

The review appears in the September issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

Remediation of mold and dampness requires total or partial renovation of a building, or cleaning with a fungicide or bleach solution. Sauni and her team looked at eight studies with 6,538 participants who had their homes, schools or workplaces remediated by a mixture of these methods.

The reviewers say that because the available studies did not offer high-quality evidence and sample sizes were small, “drawing hard conclusions was difficult.”

Nonetheless, the review found that when compared to doing nothing at all, repairing houses decreased asthma-related symptoms as well as the amount of respiratory infections in adults.

Remediation also decreased the number of acute care visits in children and students’ visits to physicians for common colds.

In one South Wales study, for instance, 115 members of the group who had their homes remediated with the complete removal of visible mold, a fungicide treatment and installation of a fan, were more likely to see improvement in their respiratory symptoms for six and 12 months afterwards, compared to those in the control group whose homes were not cleaned.

The reviewers, however, could not determine which method of remediation was superior to significantly improving asthma symptoms.

“The studies have shown that after cleaning and fungicide treatment, a large number of the buildings were soon re-infected with molds, and also a partially remediated office building had to be repaired more thoroughly,” Sauni said, adding that mold removal can be costly.

“Sometimes, if the structures are damaged widely, the easiest and most cost-effective possibility is to pull down the damp building and build a new one,” she said.

The reviewers concluded that better research is necessary to give evidence of improved outcomes.

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.


Online Video: Breakthroughs in Spine Surgery


UWTV is offering the Ninth Annual Harborview Spine Symposium: Breakthroughs in Spine Surgery.

Learn about care and recovery from complicated spinal cord injuries, with case studies and in-depth research. From vertebroplasty to disc replacement, this series delivers the most recent developments in spine treatment from national experts as well as doctors at with UW Medicine.

To view: