Globe floating in air

Cancer’s impact in developing world goes unrecognized – panel


Cancer’s impact on the developing world goes largely unrecognized and unaddressed, panelists said at a Seattle World Affairs Council event held Wednesday night at the Fred Hutchinson Cancer Research Center.

While there is a tendency to think of infectious diseases like HIV/AIDS when we think about global health, said Dr. Lawrence Corey, president and director of the Hutchinson Center and a leading HIV expert, cancer takes far more lives in the developing world than HIV.

In fact, of the 7.6 million cancer deaths estimated to occur worldwide each year, 65 percent occur in middle- and low-income countries, Dr. Corey noted.

Indeed, the risk of developing cancer for a person living in the developing world is roughly the same as that of someone living in the developed world, Dr. Corey said. “Just like in the U.S., it is unlikely that a family (in the developing world) is untouched by cancer.”

Many of the leading cancers are the same as those seen in the developed world, lung cancer, particularly among men, and breast cancer among women, Corey said.

But, in addition, there is a high rate of cancer due to infectious agents: liver cancer, due to hepatitis B and C infections; stomach cancer, due to infection by the bacteria Helicobacter pylori; and cervical cancer due to infection with the human papilloma virus (HPV), Dr. Corey said.

HIV infection, too, is a major factor behind the rising cancer rates seen among young people in countries like South Africa, Dr. Corey said. These HIV-related cancers include: cervical, anal and liver cancer; Kaposi’s sarcoma; and lymphomas.

So in addition to tackling issues like smoking and promoting screening for breast and cervical cancers, addressing these infectious agents with vaccines and treatment is needed to reduce cancer rates in the developing world, Dr. Corey said.

Two panelists, Amal Khaleef, a care nurse specialist on the West Bank, and Dr. Saud Al Kharusi, an oncologist and acting head of the National Oncology Center at the Royal Hospital in Oman, agreed that too often patients in their countries do not seek care until their diseases is far advanced.

Part of the problem is the stigma associated with cancer, they said. Cancer is not discussed, so public awareness about the benefits of screening and treatment is low, Khaleef said. “They call it ‘that’ disease; they can’t even say its name,” she said.

The fourth panelist, Dr. Yermek Akhmetov, head of the Nuclear Medicine and Radiology Center at the Republican Diagnostic Center in Kazakhstan said his country had made some progress in raising cancer awareness using public education programs developed by international organizations. Still, it is hard to reach people in his largely rural country, he said.

Despite the challenges, the world’s experience with fighting HIV/AIDS, shows that difficult diseases like cancer can be tackled even in resource-poor nations in the developing world, Dr. Corey said.

HIV/AIDS treatment regimens, which require screening, frequent monitoring and daily medications, are just as demanding as the treatment regimens for many cancers, he noted.

“HIV has shown you can treat chronic diseases in the developing world,” Dr. Corey said.

To learn more:

  • Read the article the Hutchinson Center’s Quest magazine about an effort to tackle infection-related cancers in Uganda.
  • Visit the World Affairs Council’s website.

Most primary care physicians don’t address patients’ weight


By Valerie DeBenedette, Contributing Writer
Health Behavior News Service

Fewer than half of primary care physicians for adults talk to their patients about diet, exercise and weight management consistently, while pediatricians are somewhat more likely to do so, according to two new studies.

These findings come from two National Cancer Institute surveys of family physicians, internists, obstetrician/gynecologists and pediatricians. Participants reported how often they advised patients on diet, exercise and weight control; how often they tracked patient weight or assessed their body mass index (BMI); and how often they referred patients for further management of their weight.

The differences in weight-related counseling among medical specialties stood out, said Ashley Wilder Smith, Ph.D., program director in the Applied Research Program at the National Cancer Institute, and lead author of the studies. ”Obstetrician/gynecologists were much less likely to be participating in a number of areas of counseling. That was a surprise, especially considering the focus on overweight and pregnancy.”

Both studies appear online and in the July issue of the American Journal of Preventive Medicine. One study evaluated the responses of physicians who treat adults and the other those who treat children.

In the pediatric study, about 61 percent of all primary care physicians treating children, either family physicians or pediatricians, regularly assessed obesity using the BMI percentiles of their patients, although almost all measured height and weight regularly.

However, Smith said, pediatricians were more likely than family physicians to assess BMI–74 percent compared with 53 percent–and to provide behavioral counseling to patients and their parents.

Pediatricians were much more likely to consult on all areas of weight control than family physicians.

Tracking BMI is one of the National Institutes of Health guidelines for all physicians.

In treating children, pediatricians were much more likely to consult on all areas of weight control than family physicians, Smith said. “But family physicians held together as a specialty on the separate surveys. Those treating adults had strikingly similar findings to those treating children.”

“We found that physicians were more likely to counsel on physical activity than on diet or weight control, and more likely to counsel on diet than on weight control,” Smith said. “Though I was surprised that physicians discussed physical activity the most, in retrospect, I think diet is a more complicated behavior. The messages are a bit more difficult to deliver.”

Part of the problem could be the limited time that physicians have with patients during the usual office visit and the attitude that this is not enough time to address weight issues.

“But it is doable,” said Thomas McKnight, M.D. “Most people do not believe it is.” McKnight is a family physician with the U.S. Air Force at Hurlburt Field, in Florida.

McKnight said that patients need to hear the message that they can lose weight several times before they might be ready to act on it. He hands out a brochure about weight management to his patients with weight issues. “Four out of five times that brochure goes in the trash. But then when they are ready, they come for a weight management appointment.”

The situation has improved since the surveys took place in 2008, said Sandra Hassink, M.D., chairperson of the Obesity Leadership Work Group of the American Academy of Pediatrics. Weight management recommendations have escalated in pediatrics even since then, she said. A recent poster at an AAP meeting reported that 88 percent of pediatricians are calculating BMI for their patients, she said. “This is still a work in progress and we are escalating the push to have all pediatricians do this.”

The AAP has created tools for pediatricians, such as flip charts, to help incorporate diet, exercise and weight management into their practices for patients at all age levels, Hassink said. The message must be given to the whole family, she added. “Many parents are taking the message in for themselves as well.”

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.


Campaign urges Hispanics to talk with their doctor


By Carolyn M. Clancy, M.D.

Hispanics are less likely to see a doctor or other health professionals regularly than other ethnics groups. The data from the Agency for Healthcare Research and Quality is startling. Half (47 percent) of adult Hispanics reported that they did not see a doctor in 2008, compared with 29 percent of adults in other ethnic groups.

Why is there such a gap? One reason is the lack of health insurance. One in three, or 33 percent, of Hispanics under age 65 did not have health insurance coverage in 2009, according to the Centers for Disease Control and Prevention.

Another is language. Nearly half (49 percent) of Hispanics who are not comfortable speaking English do not have a regular source of health care, compared to two-thirds (63 percent) who are fluent in English, according to AHRQ data.

Our recent report on disparities in health care also found that, compared with whites, the proportion of Hispanics who said they had poor communication with their health providers is growing. And the percentage of Hispanics who regularly get important screening tests to check for diabetes or cancer is not improving.

However, Hispanics do seek out information on their care, but research shows that that they are more likely to consult other people—even casual acquaintances—instead of a doctor when they have health concerns.

To address these problems, AHRQ and the Ad Council have created a new Spanish language campaign called Conoce las Preguntas, or Know the Questions. Through TV, radio, print and Web ads, the new campaign encourages Hispanics to get more involved in their health care and to talk with their doctors.

For example, one ad shows a middle-aged man with a backache asking for treatment advice from his barber, a woman in a Laundromat, and a friend at the gym. Each offers different—and sometimes conflicting—remedies: use heat to relieve the ache, use cold, and exercise. Finally, in the last part of the ad, the man asks his doctor what he should do about his aching back.

The PSAs also offer tips to help Hispanics prepare for medical appointments by thinking about questions to ask during doctors’ visits. Additional tips include talking to the doctor about all symptoms, habits, and treatments; making sure you understand what your doctor tells you; and following instructions about medicines or follow-up visits.

The PSAs direct audiences to visit AHRQ’s Spanish-language Web site at for important health information.

This is only one effort to improve health and health care for Hispanics. Federal health clinics offer a range of health services, even if patients don’t have health insurance. They provide checkups, treatments if you’re sick, care for pregnant women, and immunizations for children. These clinics are located in most cities and in many rural areas. Select to find one in your area.

Today, many hospitals, doctor’s offices and pharmacies have staff who speak Spanish fluently. And many Web sites for patients, such as AHRQ’s and, offer information in Spanish.

AHRQ and the Ad Council’s new campaign support the Department of Health and Human Services’ (HHS) Action Plan to Reduce Racial and Ethnic Health Disparities. This represents HHS’ first strategic plan to reduce health disparities among racial and ethnic minorities in the United States.

Making our health system better will happen only when everyone can reap the benefits of good medical information and timely care.

I’m Dr. Carolyn Clancy and that’s my opinion on how to navigate the health system.


Agency for Healthcare Research and Quality

Conozca Las Preguntas (Know the Questions)
Available at:

2010 National Healthcare Quality & Disparities Reports
Available at: and

AHRQ News and Numbers: Problems with English Help Block Many Hispanics from Medical Care
Available at:

U. S. Department of Health and Human Services

Espanol: Su guia a la informacion confiable de la salud
Available at:

HHS Action Plan to Reduce Racial and Ethnic Health Disparities
Available at:

HHS Office of Minority Health

Hispanic/Latino Profile: The Office of Minority Health
Available at:

Centers for Disease Control and Prevention

FastStats: Health of Hispanic or Latino Population
Available at:

Health Resources and Services Administration

Find a Health Center at:

Current as of June 2011

Internet Citation:

New Public Service Campaign Urges Hispanics To Talk With Their Doctor. Navigating the Health Care System: Advice Columns from Dr. Carolyn Clancy, June 7, 2011. Agency for Healthcare Research and Quality, Rockville, MD.

Photo of Vierdrie

Insurer cuts premiums as industry prepares for new health reform rules


Photo of Vierdrie

It turns out that pigs do fly. Last month, insurer Aetna received approval from Connecticut regulators of its request to reduce premiums on individual policies by an average 10 percent, starting in September. Yes, you read that right: reduce the premium.

The decrease, which affects 15,000 consumers will save those policyholders $259 annually, on average.

“I think it’s the shape of things to come,” Timothy Jost, a law professor at Washington and Lee University and a consumer representative to the National Association of Insurance Commissioners, says of Aetna’s move.

Under the health-care overhaul, insurers beginning this year must spend at least 80 percent of the premium dollars they collect on medical claims or quality improvement efforts.

Administrative expenses and profits are limited to 20 percent or less of what they collect. Those that don’t meet these new “medical loss ratio” standards have to refund the extra premiums collected to consumers. (In insurance lingo, medical claims paid are considered “losses.”)

“[It] has to do with making sure consumers are getting value for their premium dollar,” Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities, says of the new provisions.

While Aetna’s move may not be unprecedented, it is also not the norm. “It certainly is possible” that premiums have been reduced on occasion for particular individuals or groups, says Robert Zirkelbach, a spokesman for America’s Health Insurance Plans. But if so, the trade group’s data, which track average premiums, don’t show it. “Premiums are going up every year,” he says.

Aetna LogoSince 2005, the average family health insurance premium has increased 27 percent, according to the Kaiser Family Foundation’s annual employer health benefit survey. (KHN is an editorially independent program of the foundation.)

Premiums are based on a number of factors, including claims, the price of medical goods and services, and regulatory requirements. As the economy continues to struggle, consumers have cut back on their use of medical services. The request for a rate decrease in Connecticut reflects this lower-than-anticipated use, says Aetna spokesman Mohit Ghose.

That’s where the medical loss ratio, or MLR, requirement comes into play, say health-policy experts. “If you have an insurer whose costs are leveling off and it continues to increase premiums, then there’s going to be a day of reckoning,” says Jost. “They’ll have to pay a big rebate.” By lowering premiums now, Aetna avoids this eventuality.

The Obama administration estimates that starting in 2012 the MLR provisions may result in as many as 9 million people being eligible for rebates totaling $1.4 billion; in the individual market, where people who don’t get insurance through their workplace can purchase coverage, the average rebate could be $164 per person.

Elsa Obuchowski would like to be one of them. The Norwalk, Conn., resident, who is a freelance textbook editor, pays $520 a month for a UnitedHealthcare policy with a $2,500 deductible. This year, Obuchowski’s increase was 4.5 percent, but in previous years it’s been as high as 14 percent, she says. Even though her own premium won’t be affected by Aetna’s move, she’s heartened by it. “It sounds very hopeful,” she says.

More From This Series: Insuring Your Health

Under the health law, insurers in the individual and small-group market must have a medical loss ratio of least 80 percent; in the large-group market, the figure is 85 percent. Self-insured companies, which pay employee medical claims directly, are exempt from the requirement.

The law permits states to request an adjustment to the MLR requirements for up to three years if meeting the standard might destabilize their individual markets, causing insurers to pull out and resulting in fewer options for consumers. To date, three states have been granted adjustments; nine other states and Guam have requested them.

Insurance industry representatives say the law’s focus on the MLR doesn’t address the rising costs of hospitalization, drugs and other medical care, and their effects on premiums. “Simply capping administrative costs and reviewing premiums doesn’t get at the main drivers of health-care costs and thus health insurance premiums,” says Zirkelbach.

In 2010, Aetna’s individual policies had a medical loss ratio of 54.3 percent, according to the Connecticut Insurance Department’s document approving the rate decrease. Aetna attributes the low MLR to people who signed up for coverage but didn’t use it. “In the case of 2010, we saw lower utilization than we expected across the board,” says Ghose.

Medical loss ratios are often lower in the individual market than they are for large groups, says Lueck. Reasons vary: Individual plans can deny coverage to people who aren’t healthy; in addition, the policies tend to have higher deductibles and less-comprehensive benefits. Both factors can result in fewer, smaller claims, putting downward pressure on the medical loss ratio.

In addition, insurers sometimes have high administrative expenses, and not only because they have to review and approve people for coverage in the individual market. Jost says a review of commissions paid to brokers found that insurers sometimes paid them as much as 40 percent of the first year’s premiums. “That’s more than they spend on drugs, and far more than on primary
care,” he says.

“If you ask the consumer, ‘Do you think more should be spent on pharmaceutical costs or on agents and brokers?’ what do you think they’ll say?” asks Jost.


Local Insurance Resources:

We want 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.


Open for Questions: 30 Years of AIDS


Last week mark the 30th anniversary of the first report of the disease that became known as HIV/AIDs Surgeon General Dr. Regina Benjamin, Director of the White House Office of National AIDS Policy Jeffrey Crowley and Director of the Division of AIDS at the National Institute of Allergy and Infectious Diseases, NIH, Dr. Carl Dieffenbach took questions about the epidemic from an online audience.

To learn more:

  • Visit
  • Read the original MMWR report of the first cases of the disease.
  • Visit the CDC’s “basic information” webpage on HIV/AIDS.
  • To find a local HIV testing site go here.

Other local and national resources:


European E. coli outbreak linked to bean sprouts


German health authorities have linked the E. coli outbreak that has killed 22 and sickened 1,700 people across Europe to locally grown bean sprouts, the European press is reporting today.

The strain — Escherichia coli O104:H4 (STEC O104:H4) –produces a toxin that can cause severe, bloody diarrhea and kidney failure, a condition called hemolytic uremic syndrome, or HUS.

The U.S. Centers for Disease Control and Prevention (CDC) is investigating three suspected cases of E. coli infections linked to the outbreak in Europe. All had recently travelled to Hamburg, Germany, the CDC said.

“Any person with recent travel to Germany with signs or symptoms of STEC infection or HUS, should seek medical care and let the medical provider know about the outbreak of STEC infections in Germany and the importance of being tested,” the CDC warns.

To learn more read these sprout FAQs from

Do sprouts carry a risk of illness?

Like any fresh produce that is consumed raw or lightly cooked, sprouts carry a risk of foodborne illness. Unlike other fresh produce, seeds and beans need warm and humid conditions to sprout and grow. These conditions are also ideal for the growth of bacteria, including Salmonella, Listeria, and E. coli.

Have sprouts been associated with outbreaks of foodborne illness?

Since 1996, there have been at least 30 reported outbreaks of foodborne illness associated with different types of raw and lightly cooked sprouts. Most of these outbreaks were caused by Salmonella and E. coli.

What is the source of the bacteria?

In outbreaks associated with sprouts, the seed is typically the source of the bacteria. There are a number of approved techniques to kill harmful bacteria that may be present on seeds and even tests for seeds during sprouting. But, no treatment is guaranteed to eliminate all harmful bacteria.

Are homegrown sprouts safer?

Not necessarily. If just a few harmful bacteria are present in or on the seed, the bacteria can grow to high levels during sprouting, even under sanitary conditions at home.

What can industry do to enhance the safety of sprouts?

In 1999, the FDA provided the sprout industry with guidance on reducing the risk of contamination of sprouts by harmful bacteria. The FDA and other Federal and state agencies continue to work with industry on detecting and reducing contamination and keeping contaminated sprouts out of the marketplace.

What can consumers do to reduce the risk of illness?

  • Children, the elderly, pregnant women, and persons with weakened immune systems should avoid eating raw sprouts of any kind (including alfalfa, clover, radish, and mung bean sprouts).
  • Cook sprouts thoroughly to reduce the risk of illness. Cooking kills the harmful bacteria.
  • Request that raw sprouts not be added to your food. If you purchase a sandwich or salad at a restaurant or delicatessen, check to make sure that raw sprouts have not been added.

General Information

To learn more about the E. Coli outbreak in Europe:

  • Visit Germany’s Robert Koch Institute which posts updates in English.
  • Visit Public Health – Seattle & King County’s information page on E. coli, which includes information in Chinese, Korean, Russian, Spanish, Somali and Vietnamese.
HIV virons (green) budding from a white cell -- Photo: C. Goldsmith/CDC

View: 30 years of AIDS


HIV virons (green) budding from an infected white cell -- Photo: C. Goldsmith/CDC

By Dr. Anthony S. Fauci and Gregory K. Folkers, M.S., M.P.H.

Dr. Anthony S. Fauci is director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health. Gregory K. Folkers, M.S., M.P.H, is Dr. Fauci’s Chief of Staff.

30 years ago the CDC reported the first cases of AIDS

Thirty years ago, the first five cases of what is now known as the acquired immune deficiency syndrome were reported in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

The amount of knowledge gained since then has been extraordinary, and the pace at which research findings have been translated into lifesaving treatments and tools of prevention is unprecedented, although much remains to be done with regard to delivering the fruits of this research to the people who need them most.

The discovery of the human immunodeficiency virus as the cause of AIDS in 1983-84 was followed by an understanding of how HIV leads to AIDS; the natural history and epidemiology of the disease; the creation of a diagnostic blood test; and the development over the years of more than 30 antiretroviral drugs.

The approval of the first protease inhibitors in 1995-1996 paved the way for powerful, multi-drug antiretroviral therapy. The many combination regimens now available using different classes of antiretroviral drugs have dramatically improved the quality of life and extended the life expectancy of people with HIV.

An HIV-infected person properly treated with this combination therapy, and provided other needed care and services, now can expect to live for decades after being diagnosed.

Antiretroviral treatment regimens also can prevent HIV infection. When given to pregnant HIV-infected women and their newborns, these drugs have been enormously successful in preventing mother-to-child transmission of HIV.

Moreover, just three weeks ago, a rigorous, controlled clinical trial conducted in nine countries confirmed another potent way to apply treatment as prevention.

The study results were striking: Among more than 1,700 heterosexual couples in which one partner was HIV-infected and the other was not, starting combination antiretroviral therapy immediately in the infected partner when blood tests indicate his or her immune system is still strong resulted in a 96 percent reduction in HIV transmission to the uninfected partner, compared with deferring treatment until the same tests showed the immune system to be weaker.

Of the 1.1 million people living with HIV in the United States, approximately 20 percent are unaware of their infection.

This recent report confirms that combination therapy not only benefits the infected individual but also can reduce the risk of transmitting the virus to others.

By confirming that this type of therapy can do double duty as treatment and prevention, this study has energized the medical, public health and activist communities.

In addition to its role in protecting babies from infection, “treatment as prevention” to block sexual transmission now can be added to our toolkit of proven HIV prevention interventions, which also includes behavioral modification, condom distribution, the provision of clean needles and syringes to injection drug users, medically supervised adult male circumcision, and other approaches.

Meanwhile, other recent progress in HIV research gives us hope that we soon will have additional prevention tools. Notably, a once-a-day pill combining two antiretroviral drugs was shown to reduce the risk of HIV acquisition in men who have sex with men, and an antiretroviral-based, vaginally-applied gel did the same for heterosexual women.

Although a protective HIV vaccine remains elusive, we are encouraged by the recent demonstration that a vaccine tested in Thailand provided modest protection against HIV. Researchers now are examining blood samples and data from the Thai trial to determine how the vaccine prevented HIV infections, information that will help guide efforts to improve on those results.

Scientists also are pursuing many other research avenues, including structure-based vaccine design. With this approach, researchers characterize in exquisite detail key molecules on the HIV virus and use these structures to design new components for next-generation HIV vaccine candidates.

Entering the fourth decade of HIV/AIDS, our task is to build on these advances and deliver scientifically validated interventions to everyone who needs them, in the United States and abroad. Six in ten HIV-infected people in developing countries who need combination antiretroviral therapy are not receiving it, which puts their health and that of their sexual partners at risk.

Domestically, access to treatment and care also is not optimal. A recent analysis estimated that of the 1.1 million people living with HIV in the United States, approximately 20 percent are unaware of their infection. And within the entire group of infected people, only about 19 percent have a viral load that has been driven to undetectable levels by combination therapy.

Both at home and globally, greater numbers of HIV-infected individuals need to be identified early in the course of their disease through expanded voluntary HIV testing programs and linkage to appropriate care and antiretroviral treatment.

In addition, prevention programs using proven tools must be dramatically “scaled up,” refined, improved and made more cost-effective. At the same time, we must continue to develop additional effective prevention strategies.

We also must find innovative approaches to curing HIV/AIDS by eradicating or permanently suppressing the virus in infected people, thereby eliminating the need for lifelong antiretroviral therapy.

In this regard, important new research is being undertaken by the National Institutes of Health and other organizations.

In addition, a robust research effort is critical to address the malignancies, cardiovascular and metabolic complications, and premature aging associated with long-term HIV disease and/or antiretroviral therapy.

Despite these challenges and the huge burden of this modern-day plague, we now look at the fight against HIV/AIDS – and our chances of prevailing – with considerably more optimism than we previously have felt. With the medical and public health tools now or soon-to-be available, controlling and ending the global HIV/AIDS pandemic are feasible goals.

Unfortunately, we are in a difficult situation of considerable global constraints on resources to support this goal. Every effort must be made to efficiently apply existing resources so that proven interventions are delivered in the most cost-effective manner.

In addition, public-sector, commercial and philanthropic commitments to HIV/AIDS research and implementation of proven findings must be sustained and strengthened with the investment of additional resources to ensure that HIV treatment and prevention services are universally available to the people who need them, wherever they live.

With a global commitment, we can control and ultimately end the HIV/AIDS pandemic. On this commemoration of the 30-year anniversary, let us recommit ourselves to that goal.

To learn more:

  • Read the original MMWR report.
  • Visit the CDC’s “basic information” webpage on HIV/AIDS.
  • To find a local HIV testing site go here.

Other local and national resources:

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.

E. coli -- Photo: Janice Haney Carr/CDC

Three cases of E. coli infection in the U.S. linked to European outbreak


E. coli -- Photo: Janice Haney Carr/CDC

The U.S. Centers for Disease Control and Prevention (CDC) is investigating three suspected cases of E. coli infections linked to the outbreak in Europe.

All had recently travelled to Hamburg, Germany, the agency reports.

The E. coli strain — Escherichia coli O104:H4 (STEC O104:H4) –produces a toxin that can cause severe, bloody diarrhea and kidney failure, a condition called hemolytic uremic syndrome, or HUS.

The outbreak was centered in Germany, which as for May 31, has seen 470 patients with HUS with nine deaths, the CDC said.

“Any person with recent travel to Germany with signs or symptoms of STEC infection or HUS, should seek medical care and let the medical provider know about the outbreak of STEC infections in Germany and the importance of being tested,” the CDC warns.

To learn more read the CDC update below:

CDC Statement on Outbreak of STEC O104:H4 infections in Germany

CDC is following a large outbreak of Shiga toxin-producing E. coli O104, or STEC O104, infections currently going on in Germany.

As of May 31, 2011, the Robert Koch Institute (RKI), Germany’s disease control and prevention agency, has confirmed six deaths and 373 patients with hemolytic uremic syndrome, or (HUS) (kidney failure), a life-threatening complication of E. coli infections.

To date, no confirmed cases of STEC O104 infections have been reported in U.S. travelers to Europe. Two cases of HUS in the United States have been reported in persons with recent travel to Hamburg, Germany.

CDC is working with state health departments to learn more about these two cases and to identify others. CDC has been in contact with the German public health authorities at RKI. We have alerted state health departments in the United States of the ongoing outbreak.

We have also requested that they report to CDC any cases in which people have either HUS or Shiga toxin-positive diarrheal illness, with illness onset during or after travel to Germany since April 1, 2011.

The strain of STEC causing illness, STEC O104:H4, is very rare. CDC is not aware of any cases of STEC O104:H4 infection ever being reported in United States.

Any person with recent travel to Germany with signs or symptoms of STEC infection or HUS, should seek medical care and let the medical provider know about the outbreak of STEC infections in Germany and the importance of being tested.

Symptoms of STEC infection include severe stomach cramps, diarrhea, which is often bloody, and vomiting. If there is fever, it usually is not very high.

Most people get better within 5–7 days, but some patients go on to develop HUS—usually about a week after the diarrhea starts. Symptoms of HUS include decreased frequency of urination, feeling very tired, and losing pink color to skin and membranes due to anemia.

CDC is not aware that a specific food has been confirmed as the source of the infections. Travelers to Germany should be aware that the German public health authorities have recommended against eating raw lettuce, tomatoes or cucumbers, particularly in the northern states of Germany (Hamburg, Bremen, Lower Saxony, Schleswig Holstein).

We have no information that any of these suspected foods have been shipped from Europe to the United States at this time. The US Department of Defense has been notified of this outbreak because of the presence of U.S. military bases in Germany. We are not aware of any cases among U.S. military personnel.

Here are answers to frequently asked questions:

Would this be the largest E. coli outbreak ever in the world?

We are still learning more about the overall size of this outbreak. The number of HUS cases involved indicates that the outbreak is very large.

Tell us about this rare strain and are we testing for it here?

A very rare strain of Shiga toxin-producing E. coli, or STEC has been reported from some patients in the outbreak. This strain, E. coli O104:H4 has never been seen in the United States, and CDC is only aware of few reports of this strain from other countries.

Although it is rare, the United States’ public health surveillance systems are designed to be able to identify this, and other rare STEC strains, in ill people. However, the ability to detect STEC infections through surveillance depends on proper diagnostic testing of patients presenting with symptoms suggestive of STEC.

In 2009, CDC published recommendations for the diagnosis of STEC infections by clinical laboratories. The illness that it causes is similar to that caused by E. coli O157:H7 which is also a Shiga toxin-producing E. coli and the one most commonly identified in the United States.

Could people travel from Germany and spread it here?

STEC infections can be spread from person to person. The best defense is careful, thorough hand washing. Persons returning from Germany who have diarrhea should be sure to wash hands well with soap and warm water after using the bathroom, and should not prepare food for others while they are ill.

People who are in contact with ill people who recently visited Germany should also follow basic hygiene practices carefully, including washing their hands thoroughly before eating or drinking and after caring for an ill person.

Why so many sick people?

It is too early to know why this is such a large outbreak. The large size may have to do with contamination of a popular food item. However, to our knowledge a specific food vehicle has yet to be confirmed. It is also possible that the unusual strain is particularly likely to cause HUS.

surgeons performing surgery in operating room

Medicaid to stop paying for hospital mistakes


By Phil Galewitz
KHN Staff Writer

Medicaid will stop paying for about two dozen “never events” in hospitals, such as operations on the wrong body part and certain surgical-site infections, federal officials said today.

Currently, about 21 states have such a nonpayment policy. The 2010 federal health law, in effect, expands the ban nationwide. The rule published today gives states until July 2012 to implement it.

Medicaid is a joint state-federal program for the poor and disabled. Under the rule, Medicaid funds can’t be used to pay doctors and hospitals for services that “result from certain preventable health care-acquired illnesses or injuries,” the officials said.

A similar regulation has been in place for Medicare, the federal health program for the elderly, since 2008.

“These steps will encourage health professionals and hospitals to reduce preventable infections, and eliminate serious medical errors,” said Donald Berwick, administrator of the Centers for Medicare and Medicaid Services. “As we reduce the frequency of these conditions, we will improve care for patients and bring down costs at the same time.”

Some physician groups have concerns about the new policy. “Simply not paying for complications or conditions, that, while extremely regrettable, are not entirely preventable, is a blunt approach that is not effective or wise for patients or the Medicare or Medicaid program,” Dr. Michael Maves, CEO of the American Medical Association, said in written comments to CMS in March.

He said the medical association has “grave concerns” about states extending the non-payment policy beyond the conditions considered by Medicare. The American Hospital Association expressed similar reservations.

Responsing to complaints from hospitals, CMS gave states additional time — until July 2012 — to implement the new policy.

Cindy Mann, deputy director of CMS and director of Medicaid, said the rule gives states the option to expand the nonpayment policy to health care settings besides hospitals and to add other types of “never events.”

She said the policy would help improve patient care and drive down costs in the $364 billion program. “All (health care) payers are looking to gain better value for the dollars they spend and Medicaid is no different,” she said.

But the costs savings from the change is relatively modest. According to the proposed rule, Medicaid would save about $35 million over the next five years from stopping pay for such medical mistakes. Medicare has saved about $20 million a year under its policy.

“It’s a welcome first step into the national debate on quality,” said Matt Salo, executive director of the National Association of Medicaid Directors. “Clearly many states have already moved ahead, although that should never be taken as rationale for forcing the rest of them to do … well, anything. But improving quality in a coordinated fashion between Medicare and Medicaid is important.”

This is list of preventable conditions that Medicaid will no longer pay for:

Foreign Object Retained After Surgery

Air Embolism

Blood Incompatibility

Stage III and IV Pressure Ulcers

Falls and Trauma

  • Fractures
  • Dislocations
  • Intracranial Injuries
  • Crushing Injuries
  • Burns
  • Electric Shock

Catheter-Associated Urinary Tract Infection (UTI)

Vascular Catheter-Associated Infection

Manifestations of Poor Glycemic Control

  • Diabetic Ketoacidosis
  • Nonketotic Hyperosmolar Coma
  • Hypoglycemic Coma
  • Secondary Diabetes with Ketoacidosis
  • Secondary Diabetes with Hyperosmolarity

Surgical Site Infection Following:

Coronary Artery Bypass Graft (CABG) – Mediastinitis

Bariatric Surgery

  • Laparoscopic Gastric Bypass
  • Gastroenterostomy
  • Laparoscopic Gastric Restrictive Surgery

Orthopedic Procedures

  • Spine
  • Neck
  • Shoulder
  • Elbow

Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Total Knee Replacement or Hip Replacement – with pediatric and obstetric exceptions

Surgery on the wrong patient, wrong surgery on a patient, and wrong site surgery

Source: CMS


Contact Phil Galewitz:

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.

red-headed boy winces as he gets a shot

State kindergarten vaccination rates below national targets — CDC


Children in Washington State are entering kindergarten with one of the lowest vaccination rates in the nation, well below national targets, the U.S. Centers for Disease Control and Prevention (CDC) reported Thursday.

According to the new report, kindergarten coverage in Washington State for required vaccines (including polio, whooping cough, measles, hepatitis B, and chickenpox) ranged from 88 percent to 93 percent, below the state and national goal of  95 percent or higher for all vaccines.

One reason for Washington’s poor showing, health officials said, is that the state’s high vaccine exemption rate, with 6.2 percent of children entering kindergarten having been opted out of one or more vaccines by their parents — the highest exemption rate in the nation.

Other states with high opt-out rates were Oregon (5.4 percent) and Vermont (5.8 percent).

All told, vaccine exemptions were obtained for 5,015 kindergarteners in Washington State.

Until this year, obtaining an exemption in Washington state was relatively easy. All a parent or guardian had to do is sign a certificate to exempt a child from one or more vaccines and the child could enter school unvaccinated.

According to the CDC, almost all of the exemptions in Washington were for non-medical reasons, such as philosophical or religious objections to vaccinations.

Concern over the state’s low vaccination rate and recent outbreaks of vaccine-preventable diseases such as pertussis and measles prompted the State Legislature to pass a new law to make obtaining an exemption a bit harder.

Under new rules that go into effect July 22, parents or guardians who want to exempt their child from school or child care immunization requirements must first get information from a licensed health care provider about the benefits and risks of vaccinations.

The health provider must then sign a form or letter confirming that the parent got this information and the form must be turned in to the school or child care.

Washington state health officials hope the new requirements will encourage more parents to have their children fully immunized and reduce the number of “convenience” exemptions, when parents turn in the exemption form rather than spend time gathering up the child’s immunization records.

The Washington State Department of Health notes:

  • All recommended vaccines for kids under 19 are provided at no cost through the state’s Childhood Vaccine Program. Health care providers can charge an office visit or administration fee; this may be waived for those who are unable to pay.
  • School nurses have access to Washington’s CHILD Profile Immunization Registry and can help parents turn in complete and accurate immunization records.

To learn more:

  • For help finding a health care provider or an immunization clinic, contact the local health agency ( in your community or call the Family Health Hotline at 1-800-322-2588.

Watchful waiting: When treatment can wait


By Amy Sutton
Contributing Writer, Health Behavior News Service

In today’s fast-paced world, waiting — whether it’s at the doctor’s office, in line at the grocery store or for an Internet connection — is rarely considered a good thing.

But when it comes to certain medical conditions, delaying treatment while regularly monitoring the progress of disease — a strategy doctors refer to as “watchful waiting,” active surveillance or expectant management — may benefit some patients more than a rush to pharmaceutical or surgical options.

Patients want to know what they’re waiting for, says urologic oncologist E. David Crawford, MD, chairman of the Prostate Conditions Education Council and associate director of the University of Colorado Comprehensive Cancer Center.

The purpose is to watch in order to see whether a condition progresses. That way, patients and physicians know what kind of threat a disorder poses and they can make a better decision about how urgently treatment is needed. Some people might never need treatment, for instance with a slow-growing cancer. Other people can delay treatment for months or years.

Precancerous conditions may also be monitored with active surveillance. One example is ductal carcinoma in situ (DCIS), or abnormal changes in the ducts of the breast. DCIS may eventually progress into an invasive form of cancer, but most cases do not, so some physicians promote regular monitoring to avoid or delay the side effects of breast surgery, chemotherapy or radiation.

Syd Ball

Often, active surveillance is associated with cancer treatment, particularly cancers that may progress slowly. There’s evidence that active surveillance offers particular benefit for prostate cancer, follicular lymphoma, myeloma and chronic lymphocytic leukemia. Ovarian, endometrial and uterine cancer might also warrant active surveillance at some point during treatment.

When Syd Ball, a nuclear engineer from Tennessee, was diagnosed with prostate cancer, he chose active surveillance over immediate surgery or radiation therapy.

“When I was diagnosed, it did shake me up,” Ball said. “Once I talked to the doctor, and got the statistics about my chances, then I felt there was no question about what to do. Being an engineer, if you give me the risk statistics on it, I’ll tend to believe that the best course of action is based on what my chances are.”

Watchful waiting allowed Ball and his physician to get a better idea of his risk — whether his cancer was growing and how quickly. If the cancer grew quickly, then he knew he should start treatment. If not, he could wait. Ball was not looking forward to possible treatment side effects that could interfere with his quality of life and wanted to delay or avoid them if possible.

The concept of active surveillance isn’t limited to cancer treatment. It occurs across a variety of medical conditions. Pediatricians or family doctors may recommend watchful waiting for children with ear infections, since many resolve without treatment from antibiotics.

Physicians who treat chronic lower back pain might employ watchful waiting, monitoring patients regularly instead of immediately performing surgery to see if symptoms resolve on their own or whether stress management, strengthening exercises and other strategies effectively manage pain.

The physicians of couples trying to conceive a child sometimes suggest watchful waiting for a period of time before starting infertility tests and treatments, because most healthy partners conceive within a year without added intervention.

Women with endometriosis whose pain isn’t severe, who do not want to have children or who are approaching menopause may choose active surveillance, rather than deal with the side effects of surgery or hormonal treatments. And women with ovarian cysts who have mild or no symptoms might be advised to delay active treatments until symptoms become severe, because surgery carries the risk of infection and bowel and bladder damage.

What Happens While You Wait?

Though it’s a common misconception among patients, watchful waiting isn’t just ignoring the disease or disorder, hoping it will go away. “Active surveillance is a term that defines the fact that it’s not just wishful waiting or delayed treatment,” Crawford says. Physicians actively monitor the situation, and if needed, will jump in and begin active treatment, he says.

If you and your physician agree that active surveillance is a good idea, you’ll need regular checkups, and, depending on your condition, medical testing, such as blood tests, biopsies or imaging scans like MRIs or CAT scans, will be part of your regular monitoring. For conditions like chronic back pain, your doctor may recommend you make changes to your dietary habits, exercise regimen or lifestyle.

“We don’t want to let things fall through the cracks. With active surveillance, frequently we would be following patients as often as you would when they are on treatment, checking tumor markers and monitoring for new problems or symptoms they might have,” says Deborah Armstrong, MD, an associate professor of both oncology and of gynecology and obstetrics at the Johns Hopkins University School of Medicine. “It is different from someone who is at the end of their treatment options. It’s not ‘Should I try this?’ That’s a different concept. The concept of watchful waiting is that you do plan that you will be starting treatment but you’re going to delay it.”

The length of time active surveillance is recommended varies from person to person and is based on a variety of factors, including your age and general health, how severe your symptoms are, how quickly the disease progresses and the risks of delay. Physicians may monitor some patients, such as Syd Ball, for more than a decade without changing course. In other cases, active surveillance may take place for only for a few months ─ or in the case of ear infections, a few days ─ before having to move on to active treatment.

Nikkie Hartmann

Nikkie Hartmann, a public relations professional from Chicago, came to the process of active surveillance after more than a decade of battling papillary thyroid cancer. Hartmann, given a cancer diagnosis during her freshman year of college, underwent total thyroid removal surgery, as well as radioactive iodine treatments.

Though her blood tests still show elevated levels of cancer markers, the side effects of the radioactive iodine treatments and lymph node biopsies have proved uncomfortable and time consuming ─ and the active surveillance offers a break from the treatments while keeping an eye on her disease.

“The doctor didn’t use the phrase watchful waiting or active surveillance, but he said ‘watch and wait,’” Hartmann said. Though she’s still monitored with blood tests and will require additional diagnostic testing and possible treatments if she chooses to have children, within the last year Hartmann and her doctors have adopted an active surveillance stance that delays radioactive iodine treatments and lymph node biopsies for now.

Knowing the side effects that biopsies and radioactive iodine treatments can cause, Hartmann says that she’s at peace with the decision. “I was relieved when they told me that they recommended watching and waiting,” Hartmann said.

Asking About Watchful Waiting

Has your doctor recommended active surveillance? Here are some questions to ask as you consider your options:

  • What is the expected course of the disease?
  • If I wait, will the disease be harder to treat later?
  • What types of monitoring will I receive while under active surveillance? How often?
  • At what point would you recommend I move from active surveillance to treatment?=
  • Are there therapies or activities I can do to slow or halt the course of the disease?

Waiting Isn’t for Everyone

Active surveillance is not without risks, however. For some types of cancer, for example, there’s a risk that the cancer may be harder to control if treatment is delayed. Doctors do not recommend active surveillance for fast-growing, aggressive or late-stage treatable cancers.

For other conditions, such as chronic back pain or endometriosis, there’s the risk that painful symptoms may worsen during active surveillance, eroding quality of life and making it difficult to work.

Though active surveillance offers a delay in the physical symptoms caused by treatment, the emotional issues associated with this choice prove difficult for some patients to handle.

“A lot of difficulty comes from the historical context of how we’ve treated cancer,” said Jamie Studts, Ph.D., a psychologist who treats oncology patients and an associate professor at the University of Kentucky College of Medicine. “The idea is very foreign to people that you have cancer in your body and you’re not doing anything to get it out.”

It takes a significant discussion and a decision-making process shared between doctor and patient to understand the pros and cons and how that can be the best way to manage their care at a particular time, Studts says.

“The other problem is the perception of potential rationing of care,” Studts adds. Particularly if people don’t have resources, they could feel like they’re being mistreated or undertreated or not treated fairly if active surveillance is suggested.

But Dr. Armstrong offers reassurance that active surveillance doesn’t mean less face time with your physician: “I spend as much time with these patients as with patients I’m treating. At every point we say, ‘If we see this, we are going to do this. Let’s see what the disease looks like, then we’ll decide if we need to do treatment.’”

For some people, the anxiety of watchful waiting cannot be overcome, Armstrong said. Regardless of the statistics and the doctor’s recommendation, patients who could benefit from active surveillance sometimes insist on and receive treatment instead.

In addition, the influence of a family member or partner who doesn’t fully support active surveillance may erode a person’s initial decision to use it, Dr. Studts says.

Making the Decision

“Watchful waiting may allow people to have a good quality of life and have the tumor completely arrested. Take diabetes. You don’t cure diabetes, you manage it. With cancer, maybe we don’t have to get it all, maybe we can arrest it or stop it so it doesn’t spread or doesn’t affect major organ systems,” Studts said.

So how do you decide whether active surveillance is for you?

The starting point for making the decision is a trusting relationship with your physician, Armstrong says. “This is a situation where patients have to have trust in the physician, trust that the physician is doing the right thing. It’s easier to treat someone than it is to do watchful waiting. The main issue is that people need to be comfortable with the concept and their doctor is doing the right thing,” Armstrong says.

“Trust your gut if it doesn’t feel right and get a second opinion. You have to be your own advocate, and if you don’t feel comfortable, get more information,” Hartmann says.

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.

PCIP clean

Feds cut fees, requirements for high-risk health insurance pools


By Phil Galewitz
KHN Staff Writer

Trying to spur enrollment in a key new benefit of the 2010 health law, the Obama administration announced today it is slashing premiums for new high-risk insurance plans and no longer requiring applicants to submit a rejection letter from private insurers.

Since the plans were introduced in most states last summer, enrollment has fallen far short of expectations; only about 18,000 people have signed up. The Congressional Budget Office had estimated that as many as 4 million uninsured Americans would be eligible and that 200,000 would be enrolled by 2013. The government set aside $5 billion to fund the plans.

Twenty-seven states run their own plans; the federal government operates them in 23 states and the District of Columbia. The changes, which occur July 1, affect only federally run plans.

The plans are intended to serve as a bridge to help people with medical conditions until insurance market reforms required by the law are implemented in 2014. At that time, insurers will no longer be able to deny coverage or charge higher rates for people with pre-existing conditions, a major benefit of the law.

To learn more about Pre-existing Condition Programs:

  • Visit the Centers for Medicare and Medicaid Service’s Pre-Existing Condition Insurance Plan webpage.
  • Visit Washington State’s Pre-Existing Condition Insurance Plan webpage.

To be eligible for the plans, applicants have to be uninsured for at least six months and have a pre-existing condition.

In the states where the plans are run by the federal government, applicants will no longer have to prove they were denied coverage by an insurance company. Instead, they can provide a doctor’s letter stating that they have a medical condition. At least a dozen state-run plans do not ask for a denial letter from an insurer.

The premiums will drop as much as 40 percent in 17 states plus the District where the federally administered plans operates, the administration estimates.

These decreases will help bring premiums closer to the rates in each state’s individual insurance market. In the six states where high-risk plan premiums were already similar to what healthy people pay for individual plans, premiums will remain the same.

States that will see a 40 percent drop in premiums are Alabama, Arizona, Delaware, Florida, Kentucky and Virginia. In other states, premium reductions range from 2.1 percent in Mississippi to 38.3 percent in Minnesota.

In Florida, where 770 people have enrolled, a person 55 and over who subscribes to the so-called standard plan will see his or her monthly premium for the standard plan fall by $150 to $376.

To further generate interest in the plans, HHS this fall will begin paying insurance agents and brokers for signing up people.

“These changes will decrease costs and help insure more Americans,” said Health and Human Services Secretary Kathleen Sebelius.

One critic of the program again took the administration to task.

“It seems a fairly safe assumption that today’s announcement is an effort to jump-start a program that has not come close to meeting expectations,” said a spokesman for Rep. Fred Upton, R-Mich., chairman of the Energy and Commerce Committee. “However, additional information is needed to determine the ramifications of this change – both for taxpayers and Americans with pre-existing conditions who may or may not benefit from this program.”

The administration released a chart showing changes to premiums in states with federally administered plans.

To learn more about Pre-existing Condition Programs:

  • Visit the Centers for Medicare and Medicaid Service’s Pre-Existing Condition Insurance Plan webpage.
  • Visit Washington State’s Pre-Existing Condition Insurance Plan webpage.
  • Visit for information about the latest changes.

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.


In the news: Seattle hospital building boom, hospital costs and doctors shift left


New medical centers ‘not your father’s hospital’ — Seattle Times

Seattle Times health reporter Carol Ostrom profiles Swedish’s new Issaquah hospital in an article about the boom in hospital expansion in and around Seattle.

Ostrom says the new Swedish facility turns the “concept of hospital on its head, putting food and spa and wellness products up front, and rooms — literally and figuratively — out back.”

She writes:

Behind the radical new design for Swedish/Issaquah is a concept of hospital that’s evolving to be less foreboding fortress on the hill and more community center.

The changes, driven in part by competition for patients with good insurance, emphasize outpatient services, giving prime space to medical offices and centers that provide chemotherapy and radiology.

Ostrom goes on to outline other medical building projects in the area, often costly projects that worry some health economists.

For architects, maybe. For health-care economics experts, it’s a little scary.

“The history of hospital construction and expansions like this is that they generally add to the ever-rising costs of health care,” said Aaron Katz, principal lecturer in Health Services and Global Health at UW’s School of Public Health.

To learn more:

Sign for an emergency room.Medicare to reward hospitals that are efficient, punish those that aren’t

In today’s New York Times, Robert Pear reports on Medicare’s plan “to establish ‘Medicare spending per beneficiary’ as a new measure of hospital performance, just like the mortality rate for heart attack patients and the infection rate for surgery patients.”

He writes:

Hospitals could be held accountable not only for the cost of the care they provide, but also for the cost of services performed by doctors and other health care providers in the 90 days after a Medicare patient leaves the hospital.

This plan has drawn fire from hospitals, which say they have little control over services provided after a patient’s discharge — and, in many cases, do not even know about them. More generally, they are apprehensive about Medicare’s plans to reward and penalize hospitals based on untested measures of efficiency that include spending per beneficiary.

To learn more:

Are doctors becoming more leftwing?

Doctors have traditionally been conservative. Most were male, owned their own practices and tended to favor lower taxes and less government regulations.

But that’s changing, writes New York Times reporter Gardiner Harris, as more and more doctors give up private practices and take salaried jobs in hospitals.

Harris writes:

There are no national surveys that track doctors’ political leanings, but as more doctors move from business owner to shift worker, their historic alliance with the Republican Party is weakening from Maine as well as South Dakota, Arizona and Oregon, according to doctors’ advocates in those and other states.

That change could have a profound effect on the nation’s health care debate. Indeed, after opposing almost every major health overhaul proposal for nearly a century, the American Medical Association supported President Obama’s legislation last year because the new law would provide health insurance to the vast majority of the nation’s uninsured, improve competition and choice in insurance, and promote prevention and wellness, the group said.

To learn more:

Swedish's Issaquah Emergency Department

Emergency care, but not at a hospital


By Michelle Andrews

Swedish's Issaquah Emergency Department

Emergency departments are struggling to keep up with demand, serving a growing number of people at the same time that their numbers are shrinking.

One increasingly popular option to improve access to services is the freestanding emergency department, a facility that, as its name suggests, isn’t physically located with a hospital.

Services at these facilities get high marks, but questions remain about whether they’re the best choice for some serious medical problems, such as heart attacks.

And some policy experts say the facilities may not be serving the people who need them most.

Since 1990, the number of hospital-based emergency departments has declined by 27 percent, according to a study published in the Journal of the American Medical Association in May. Meanwhile, the number of visits to hospital emergency departments has been on the rise, increasing 30 percent — to 123 million — between 1998 and 2008 alone, the study found.

Freestanding emergency departments originally emerged to serve people in rural areas where access to emergency care was scarce.

But in recent years, freestanding EDs have often been cropping up in fast-growing suburban areas where the need isn’t always as clear.

“It seems that now they’re being aimed at populations that do have a fair amount of access to health care already,” says Emily Carrier, a senior health researcher at the Center for Studying Health System Change, who is also an emergency physician.

Experts say that, in an effort to muscle in on a competing hospital’s ED and siphon off some of its patients, health care systems sometimes build freestanding EDs even if there are already adequate emergency services nearby.

Whatever the reason, they’re on the rise: In 2009, there were 241 freestanding emergency departments, 65 percent more than there were just five years ago, when there were 146 such facilities, according to the American Hospital Association. They’re located in at least 16 states, according to a study for the California Healthcare Foundation.

Care That’s Close By

One Saturday evening when Phil Dyer was puttering around the garden of his home in Issaquah, a Seattle suburb, he felt his heart begin to race, and his throat constricted so much that he could barely breathe.

His wife drove him to the emergency department, a freestanding facility two miles away that’s operated by Swedish Medical Center, a health care system with four acute care hospitals and three freestanding EDs.

Whisked directly into an exam room, the doctor checked him over and determined he was probably having an allergic reaction to a bug bite. He gave Dyer, 58, a shot of epinephrine and sent him home. The whole process took less than an hour.

Before the Issaquah ED was built a few years ago, the nearest emergency department was at a hospital about 12 miles away, says Dyer. Having emergency care so close is “reassuring,” he says. “It was always disconcerting that we had to go so far [before].”

More From This Series: Insuring Your Health

Unlike urgent care centers, which are limited in their hours and services, freestanding EDs are generally open 24/7 and are capable of handling most emergencies, say experts.

Generally operated by larger health care systems, they’re staffed by emergency physicians and nurses, and typically have lab and radiology services on site. They can stabilize and provide initial treatment to patients with a wide range of emergent problems.

They often have arrangements with local emergency medical services personnel to deliver patients elsewhere who need services not available at the facility. “If they diagnose you as having a heart attack, they’re going to bypass our freestanding ER and go straight to the cath lab at the hospital,” says Dr. John Milne, vice president for medical affairs at Swedish Health System, referring to a catheterization lab, where hospital personnel can insert a cardiac catheter to diagnose and treat heart problems.

While it’s certainly important to know where the nearest emergency department is, there’s no easy way for consumers to know what specific services are available there. If someone is facing a true emergency, let the pros sort out where you need to go, say experts. “If you’re having chest pain, you really ought to call 911,” says Dr. Sandra Schneider, president of the American College of Emergency Physicians.

Many times, however, the situation is not so dire. A third of patients who visit the emergency department have problems that are considered non-urgent or semi-urgent, according to the Centers for Disease Control and Prevention.

In those instances, patients would be better off visiting an urgent care center or their primary care provider, if they could get an appointment (a big if, in many cases). That would likely save patients a pricey copayment for an ED visit and would also be a more cost-effective use of health care resources overall, since insurers pay a lot more for emergency department care than they do for a visit to an urgent care center or a primary care provider.

Hospitals, meanwhile, market their freestanding EDs for their convenience and short wait times. And indeed, since acutely ill patients are often diverted to hospital-based emergency departments for care, it’s not surprising that waits are generally much shorter at freestanding facilities, where door-to-discharge times may be 90 minutes or less, compared with 180 minutes for hospital EDs. Whether a shorter wait results in actual health benefits isn’t always clear, however, say experts.

“There are some data showing that long wait times are a problem for some medical conditions,” says HSC’s Carrier. “But it’s not necessarily clear that consumers will see improved health if they don’t have to drive an extra five minutes.”

KaiserHeatlhNews wants 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.


Seattle ranks in top 10 most fit cities


The Seattle metropolitan area, which includes Tacoma and Bellevue, is the 8th most fit city in the U.S., according to a new report by the American College of Sports Medicine.

In the report, called the Annual Fitness Index, the College ranks cities on a variety of measures including the preventive health behaviors of its citizens, levels of chronic diseases, access to healthcare, and community resources and policies that support physical activity.

Photo by Bufferchuck

Compared to national averages, Seattle residents were more likely to to have exercised, to have eaten five servings of fruit and vegetables per day, and to have walked, biked or taken public transportation to work.

And Seattle residents were also less likely to smoke, 13.3 percent vs. a national average of 17.9 percent.

Like other top ranked cities, the Seattle region tended to be better off with a higher median household income, lower percentage of households below the poverty level, and fewer unemployed.

The area also has more primary care providers per capita than average metropolitan area in the study, lower rates of diabetes, asthma, and coronary artery disease.

Where the region fell short, the report finds, was in access to amenities that can promote physical activity, having fewer acres of parkland, golf courses, recreation centers and pool per capita than average.

Overall, the region scored 66.5 out of a possible 100, placing it in 8th place. Minneapolis, Minnesota came in first, well ahead of Seattle, with a score of 77.2. Oklahoma City, Oklahoma came in last with a score of 24.6.

Top ten:

1. Minneapolis, MN
2. Washington, D.C.
3. Boston, MA
4. Portland, OR
5. Denver, CO
6. San Francisco, CA
7. Hartford, CT
8. Seattle, WA
9. Virginia Beach, VA
10. Sacramento, CA

    Bottom five:

    46. Detroit, MI
    47. Birmingham, AL
    48. Memphis, TN
    49. Louisville, KY
    50. Oklahoma, OK
    Photos by Bufferchuck via Flickr:
    To learn more:
    • Read the report, which is available with other material, on the American College of Sports Medicine’s website.