By PAUL LEVY

At a seminar last night at the Center for Public Leadership at Harvard’s Kennedy School, one of the students asked a question along the lines of, “How do you know when you have done too much with regard to transparency?” My answer was that the question presupposed the wrong approach to transparency, that it was being driven by the CEO without proper attention to the efficacy and appropriateness of what was being measured and disclosed. Instead, I suggested that it should be driven by the leadership of the organization, but based on metrics that were viewed as useful and appropriate by the clinical staff. In such an instance, transparency serves the function laid out by IHI’s Jim Conway, as summarized here in an article discussing the BIDMC experience:

[P]ublic reporting created what management guru Peter Senge calls creative tension, a key in getting an organization to change. Announcing a daring vision â€" the elimination of patient harm â€" combined with honestly publicizing the problems, fuels improvement, he said.

I expressed the concern last night that the general recalcitrance of the medical profession about engaging transparency will inevitably lead to fiats about disclosure from government regulatory agencies. The problem with those fiats is that they will be grossly constructed and force hospitals and doctors to focus on the wrong things, in a manner not consistent with widely established principles of process improvement. (See, for example, this approach in Maryland.)

Now comes the Veterans Administration, proving the case with panache! You may recall my complimentary post on the VA back in January. Thomas Burton’s article this week in the Wall Street Journal â€" “Data Spur Changes in VA Care” â€" documents this in more detail. Some excerpts:

Hospitals serving U.S. military veterans are moving fast to improve care after the government opened a trove of performance dataâ€"including surgical death ratesâ€"to the public.

The information was released at the urging of VA Secretary Eric K. Shinseki. Among other things, it presents hospitals’ rates of infection from the use of ventilators and intravenous lines, and of readmissions due to medical complications. The details have been adjusted to account for patients’ ages and relative frailty.

“Why would we not want our performance to be public? It’s good for VA’s leaders and managers, good for our work force, and most importantly, it is good for the veterans we serve,” Mr. Shinseki said in an emailed statement.

At VA hospitals in Oklahoma City and Salem, Va., the rate of pneumonia acquired by patients on ventilators was shown last fall to be significantly higher than the national VA average. The Salem hospital says a relatively low number of patients on ventilators skewed its infection rate higher, but staff members at both facilities say the numbers prompted action.

Seeing the data helped, says the Salem hospital’s chief of surgery, Gary Collin, because “you can become kind of complacent.”

In contrast, notes the article:

This unusually comprehensive sort of consumer information on medical outcomes remains largely hidden from the tens of millions of Americans outside the VA system, including many of those in the federal Medicare system.

And, as I reported last month,

A November 2010 report from the Health and Human Services inspector general concluded that one in seven Medicare patients is harmed by medical care, nearly half of those avoidably.

Conway is right. Senge is right. The veterans have figured out how to start winning the war for patient safety and quality and process improvement. The rest of the profession is in retreat and is letting the wrong people design the battle plan.

Filed Under: THCB

Tagged: BIDMC, Kennedy School of Government, Quality, Transparency, VA Medical System Mar 31, 2011

Human body utilizes the iron (to produce hemoglobin for carrying oxygen) from food supply and to some extent reuses the iron that is released after red blood cells break down. If an individual consumes less than required amount of iron per day or losing iron from body due to any reason, iron deficiency anemia can result. Common causes of iron deficiency anemia include lack of adequate iron in food, loss of blood (chronic or acute loss), pregnancy and inability to absorb iron.

Lack of adequate iron in food:

This is one of the most important as well as common cause of iron deficiency anemia. This is particularly important in underdeveloped countries, where diet may be generally poor in iron. Only approximately 5-10% of iron we eat is absorbed normally (although the absorption may be higher in iron deficiency anemia). The rest of the iron we eat is wasted.

Pure vegetarians are at higher risk of iron deficiency anemia, as vegetables are generally poorer in iron content and also less percentage of iron is absorbed from vegetable origin. Pure vegetarians need to plan their diet properly so the low absorption rate can be compensated appropriately. Foods of animal sources are generally rich in iron and also higher percentage is easily absorbed and individuals have less risk of iron deficiency anemia, if they consume food from animal sources.

Milk, including breast milk is poor source of iron and infants after weaning need iron rich foods for preventing iron deficiency anemia.

Loss of blood:

Loss of blood is the most common cause of iron deficiency anemia in developed countries. Because, hemoglobin is present in the red blood cells and blood loss due to any reason, there is loss of red blood cells and loss of hemoglobin as a result. Blood loss may be acute (due to injury as in road traffic accidents) or chronic (e.g. bleeding from gastrointestinal ulcer, heavy blood loss during menstruation in women, tumor of kidney, bladder etc.). In developing countries worm infestation is a common cause of chronic blood loss, as worms living in the intestine survive on blood and also there is bleeding from the site of sucking of blood in intestine.

Pregnancy:

During pregnancy there is increased demand for iron due to growing fetus as well as due to increase in blood volume. If the iron intake is not increased appropriately/adequately there may be iron deficiency anemia. Iron supplementation should be done routinely during pregnancy to prevent iron deficiency anemia, which is common during pregnancy.

Inability to absorb iron:

In certain medical condition there may be inability (or inadequate amount is absorbed) to absorb iron from intestine, such as Crohn’s disease or celiac disease. Iron absorption may also hamper in case of surgical removal of a part of small intestine to treat ulcer or cancer. Uses of medications which reduce gastric acid secretion also reduce iron absorption.

Related posts:

What are the Symptoms of Iron Deficiency Anemia?

What Complications may Arise due to Gluten Free Diet?

Factors that alter Energy/Nutrients Need

Causes of Chronic Diarrhea

Prevention of Specific Kidney Stones

Calcium Consumption and Osteoporosis

Chronic Disease, Physical Activity and Osteoporosis

Treatment of Chronic Diarrhea

Estrogen Status and Osteoporosis

Common Concerns & Their Solution during Pregnancy

Playing music in the band is good for kids, but maybe not so much if that clarinet is a cesspool of bacteria and fungi.

Enlarge Kenneth C. Zirkel/iStockphoto.com Kenneth C. Zirkel/iStockphoto.com

That's the provocative suggestion from the Oklahoma State University for Health Sciences, where researchers found germs galore growing on brass and wind instruments that were used in high school band programs.

The researchers in Oklahoma City swabbed 13 brass and wind instruments, then rubbed the swabs on petri dishes and waited to see what would grow. They found 295 different bacteria as well as yeasts and molds. The parts that musicians put in their mouths were more contaminated than the rest of the instruments, and the two clarinets showed more contamination than the other instruments. The results were published in the latest issue of General Dentistry.

OK, that's gross. But does having bacteria in your bassoon really pose a health risk?

 

Yes, says Thomas Glass, a dentist and professor at Oklahoma State who was lead author of the study. In the past he has tested for pathogens on toothbrushes, dentures, and athletic mouthguards. So he wasn't too surprised to find gunk growing on band instruments. "The bacteria can produce local infections in the mouth, in the gastrointestinal tract, and in the respiratory tract," Glass tells Shots. Molds can cause allergic reactions, and skin infections are a risk, too, he says.

Glass's study didn't look to see if the high schoolers who played these grubby instruments had health problems. And there's precious little evidence of rampant infections associated with practicing "Stars and Stripes Forever."

But a few pulmonologists have reported patients coming in with lung problems. A letter from 1988 in the journal Chest told the tale of a 67-year-old saxophone player with a cough and shortness of breath. He was diagnosed with hypersensitivity pulmonitis from candida, and it turned out the saxophone mouthpiece was contaminated with that fungus. The symptoms disappeared after the musician started washing the instrument's mouthpiece with soap and water.

More recently, a 48-year-old French saxophonist with inflamed lungs from a moldy saxophone also got a write-up in Chest. In the same issue last September, a pulmonologist at the University of Connecticut Health Center reported on a 35-year-old professional trombone player who had been suffering from a cough and shortness of breath for 15 years. Those symptoms cleared up when the musician started cleaning his instrument with rubbing alcohol.

Now, we have to point out that the General Dentistry study was sponsored by Dr. Lorenzo Lepore founder of Encore Etc., Inc. It turns out that Lepore is a dentist, and Encore Etc., Inc. is a company he founded to sterilize musical instruments.

When Shots asked Glass if he saw a conflict of interest in that funding, particularly when he recommends sterilizing instruments with ethylene oxide, the method used by Encore Etc., Glass said:

We are independent of any conflict of interest. All we have to do in the article is say how we're funded. That has no impact on us in terms of our findings.

Ethylene oxide is used to sterilize medical instruments, and it does a very good job. It's also pretty toxic to humans. So we don't think that you're going to be cleaning your mellophone at home with this stuff.

Glass does say that instrument cleaning products available at music stores are probably enough to keep the microbes at bay. (Thanks to the magic of the Internet, Shots just learned how to give a trombone a nice bath. All you need is ish soap, a bathtub, and fluffy towels.)

Shots can't help but ask if the good doctor isn't being a wee bit alarmist. "Alarmist? We worry about that, we always worry about being alarmist," he tells us. "It's not going to hurt anybody to break down their instrument once a week and clean it." That, he says, is preventive health.

"Playing a musical instrument has a certain level of hazard," Glass says. "You can minimize the hazard by being fastidious."

By VINCE KURAITIS

Health care lobbyists and advocates are bracing for six pages of the health care reform law to explode into more than 1,000 pages of federal regulations when the Department of Health and Human Services releases its long-delayed accountable care organization rules this week. Politico

What should you be looking for as you snuggle by the fireplace this weekend reading the draft ACO regs?

Rob Lazerow writes a helpful article listing 5 Things to Watch in the Medicare Shared Savings Program Proposed Rule. His list of five key design issues includes:

How will patients be assigned to ACOs?

To what cost benchmark will ACOs be compared?

How will bonuses be calculated and paid?

For which quality metrics will ACOs be responsible?

What is the application process?

I’d like to add a sixth  item â€" which actually would be #1 on my list.

As I’ve previously written, IMHO the central issue around ACOs is:

Are (hospitals and doctors) viewing ACOs as a way to truly develop patient centric, collaborative care or as a means toward consolidating market power against payers? We really don’t know.

So here’s item #6:

6. What incentives and safeguards will assure that ACOs are focused on coordinating and integrating clinical care vs. consolidating market power?

Here are some specifics I’ll be looking for:

• How meaningful are guidelines, metrics and thresholds that define and specify elements of clinical integration?

• Are doctors and hospitals incentivized to provide value? How will this be measured?

• Will there be explicit safe harbors clarifying anti-trust and other regulatory issues? Will there be allowances for meaningful collaboration among providers? Will there be penalties for collusion leading to higher prices?

• Are the ACO Shared Savings regs designed to be an end point financing/delivery model or a first step in a transition toward shifting some downside risk to care providers (e.g., bundled payments or episodic payments)? There’s a danger that this initial Medicare shared savings ACO approach could become the worst of both worlds:

  • retaining the perverse incentives of current fee-for-service payment while adding potential for bonuses

  • not providing sufficient long-term incentives for care providers to change systems and workflow to improve patient care.

• Will there be specific requirements for ACO information technology?

• …and others (please add your comments).

Vince Kuraitis JD, MBA, is a health care consultant and primary author of the e-CareManagement blog where this post first appeared.

Filed Under: THCB

Tagged: ACOs, Vince Kuraitis Mar 30, 2011

While surfing the net I came across a term called “cell phone elbow”. Frankly I have heard terms such as tennis elbow, but cell phone elbow I have never heard before. So I decided to find more details about the disease and found it to be actually “cubital tunnel syndrome” in medical term. I thought I should write some information regarding cell phone elbow (and why it is called so) or cubital tunnel syndrome, as cell phone use is so common these days.

Cell phone elbow is the second most common nerve compression syndrome in upper extremities, after carpal tunnel syndrome. The disease commonly occurs among users of cell phones, especially for long duration. During talking, when a cell phone user holds the phone to their ears they stretch a nerve (the ulnar nerve) which provides nerve supply to smaller fingers (ring finger and little fingers of hands). If the user use cell phone for long duration it can compress the ulnar nerve as well as reduce (and may even choke) blood supply to the nerve, which can be harmful to the nerve.

What are the symptoms of cell phone elbow?

The symptoms of cell phone elbow include tingling, numbness, aching and burning in the ring finger (the half adjacent to little finger side to be precise) and little finger of the affected hand and forearm. The affected hand becomes weak and the patient may even find it difficult to perform certain easy tasks such as opening jars and bottles, writing, typing or playing instruments.

How cell phone elbow is diagnosed?

The diagnosis is mainly clinical, by thorough history and clinical examination.

What is the treatment for cell phone elbow?

The most important advice is to switch hands when you notice symptoms of cell phone elbow or use of hands free device can be of great help. Switching hands while talking on cell phone for prolonged period can reduce the constant compression and prevent development of the syndrome. Sometimes patients may require anti-inflammatory medication and some severe cases may require surgical treatment to decompress the ulnar nerve.

The prognosis is generally good even in severe cases who present late. But overall recovery is much better, who presents early and if symptoms are not severe.

Other causes of cell phone elbow:

There are other causes of cell phone elbow, other than long use of cell phones. Sleeping in elbow flexed position can also cause nerve compression and cell phone elbow or cubital tunnel syndrome. Any condition which cause constant or long duration of flexion of elbow can cause cell phone elbow. Treatment of cell phone elbow depends to some extent on the cause of the syndrome e.g. cell phone elbow due to extension of elbow during sleep is treated by wrapping a pad or towel around elbow during sleep to prevent flexion.

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Hey, KV Phamaceuticals, that new, $1,500-a-dose drug of yours is about to get some competition!

The Food and Drug Administration said in an unusual statement that it's quite all right for pharmacists to go ahead and make their own version of the medicine, given by injection to help some women avoid preterm delivery of their babies. Many of them had been doing that for years anyway and charged $20 or less per dose.

But KV, based in St. Louis, pursued formal approval of the medicine, hydroxyprogesterone caproate, to avoid premature deliveries. Starting this month, KV began selling it as Makena at a price of $1,500 a shot. For women who need the drug, given weekly for about 20 weeks, the tab would come to around $30,000, as the Washington Post reported the other day. The price hike led to a backlash from just about everyone except KV shareholders.

Now the FDA has cleared the air about whether pharmacists can make the medicine. The agency's answer boils down to an emphatic yes.

 

Pharmacists have a lot of latitude to make their own medicines to order. Before big drug companies came on the scene with drugs made in mass quantities, pharmacists spent a lot of time mixing medicines and prepare the right doses. The practice, called compounding, is still around, and these days specialized pharmacies still produce made-to-order medicines prescribed by doctors.

The FDA can crack down on compounding pharmacists when there's trouble, as it did a few years ago over custom-made hormone therapies for symptoms of menopause. But generally, the agency gives pharmacists a wide berth.

Today, the agency says it's aware that KV has been telling pharmacists FDA "will no longer exercise enforcement discretion with regard to compounded versions of Makena." (Read one of the letters online here.) To which the FDA responded, bluntly, "This is not correct."

In fact, the agency went out of its way to encourage pharmacists to get into the game, as long as they can produce the Makena substitute properly:

In order to support access to this important drug, at this time and under this unique situation, FDA does not intend to take enforcement action against pharmacies that compound hydroxyprogesterone caproate based on a valid prescription for an individually identified patient unless the compounded products are unsafe, of substandard quality, or are not being compounded in accordance with appropriate standards for compounding sterile products. As always, FDA may at any time revisit a decision to exercise enforcement discretion.

So the heat is on KV. I contacted a company spokeswoman for a comment, which wasn't immediately available.

Update: KV's Ther-Rx unit issued a statement this afternoon, saying, in part, that it "takes very seriously the public concerns raised regarding the list price of Makena." The company said it's committed to making sure the medicine is available "at an affordable cost and to all women" who get prescriptions for it. "We are finalizing solutions to the concerns, and will announce them by the end of the week."

Bonus video: For more on the history of compounding and how it works today, check out the FDA video below.

By J.D. KLEINKE

The names in this article have been changed to protect the privacy of all individuals involved.

If every medical specialty has its homily for indoctrinating new members, “a normal pregnancy is a retrospective diagnosis” is the cynical soundbite for obstetrics. It is a patronizing and alarmist statement, meant to distance weary practitioners, terrify patients, silence objections from families, and establish the first defensive perimeter in the legal fortress that defines obstetrical practice in the US.

It is also the perfect, if inadvertent expression of how little obstetricians really know â€" and how limited the specialty is in its ability to test and expand that knowledge â€" thanks in part to the visceral fear inspired in patients by statements like “a normal pregnancy is a retrospective diagnosis.”

This homily serves as the opening taunt to one of the more quietly rebellious obstetrician/gynecologists (OB/GYNs) in my new book, Catching Babies. For reasons I’ll explain momentarily, the book began as an expose of the practice of high-risk obstetrics, but it quickly morphed into a novel, an ensemble drama about the brutalization of OB/GYNs during their residency training.

But tonight, none of that matters. Tonight, life is imitating art; nothing from my years of research on the subject is comforting or even interesting; and I want to cringe every time one of the Kaiser people asks this nervous, expectant uncle if he is “the one who wrote the book about us.”

As I hole up on the labor “deck” with worried expectant parents and juggle emails and callbacks from OB/GYN and certified nurse-midwife (CNM) friends around the country, the horrible truism about the medical mysteries that can hijack a “normal pregnancy” â€" often with devastating capriciousness and cruelty â€" loses the last of its intellectual and literary charm. This is not a cool case in my new book; this is my family.

Hannah’s growth has stalled in the final month of her pregnancy, and she has actually lost a small amount of weight. And even though ultrasound and all available tests indicate no other problems with what, at 39 weeks, is no longer a fetus but a baby boy with an emotionally charged family name, the protocols at Kaiser call for immediate admission and an induction of labor. There could be a problem with the placenta or umbilical cord, and “Baby Sam” â€" as we started calling him months ago â€" might be slowly starving. Or he might just be small. As the homily from internal medicine would have it, Baby Sam has a classic case of “GOK,” or “God Only Knows.”

Which is why I am frantically calling around the country for help, before Hannah gives the final go-ahead for the induction. “GOK” rankles and infuriates me, even if it is honest, even if it is not gussied up for our side of the medical curtain like “idiopathic” â€" a term meant to sound clinically authoritative by physicians who would rather not admit in plain English that they are clueless about what is happening with a patient, i.e., that they have been reduced by the case, literally, to idiots. But not knowing anything about Baby Sam’s status â€" other than he sits at the 7th percentile for fetal weight, he is still active, and his heart rate is normal â€" is especially frustrating, given the freefall Hannah is about to take into the world of cascade birth interventions and potential complications.

My first callback is from Meg, a CNM with 30 years’ experience delivering babies and training other midwives.  “She is right on the edge,” Meg says. “She really could go either way. I would not induce her. I’d have her stop all activity, monitor her closely, and let her deliver naturally.”

A few minutes after we hang up, I get a callback from Tom, Meg’s colleague, also a friend, and a professor of high-risk obstetrics at one of the most celebrated academic medical centers in the country.

“She is right on the edge,” Tom agrees.  “At 39 weeks and 7th percentile, she could go either way. Could be serious IUGR [intrauterine growth restriction] or nothing. And the risks of waiting, though they’re extremely remote, are developmental delay and retardation. I’d go ahead and induce and deliver her.”

Wonderful. IUGR. Developmental delay and retardation. Not an option. I already know what Hannah and her husband are going to do; extremely remote is not remote enough.

An induction, on the other hand, does not guarantee a good outcome either â€" and it is fraught with the potential for bad outcomes that are not all that remote. An induction, or the forcing of labor with drugs and procedures, often triggers downstream interventions, most notably emergency c-sections, which are already done with hair-trigger frequency throughout the US obstetrical care system; these in turn lead to numerous other complications, including the need for more interventions and c-sections in subsequent pregnancies. The blessing and the curse of modern medicine, from the NICU to the oncology unit, is its ability to stimulate its own demand, and obstetrical practice is the quintessence of this cost-curve-sustaining paradox.

The specter of these interventions â€" inflated by expectant families’ primordial fear of arbitrary physical harm to their babies and providers’ primordial fear of arbitrary legal harm to their careers â€" has instituted a permanent game of chicken between pregnant women and the medical establishment. In obstetrics, “defensive medicine” is not just assumed, but actively evoked as part of a normative explanation for medical decisions. I have heard the phrase “we have to do this to cover ourselves legally” uttered to patients with such frequency, it has gone from appallingly crass, to admirably candid, to nearly superfluous.

Whether or not this does explain every dysfunction in obstetrical care, as many would have us believe, medicine does not get any more defensive that this: the inexorable increase in birth interventions has driven a growing number of women away from the medical establishment, off the grid, to home births attended by “lay” or unlicensed midwives. It has spawned a cottage industry of “alternative birthing” activists. And it has inspired language no less ugly than terms like “birth rape” (seriously â€" Google it) to describe what many view as a mangling of womens’ bodies against their will by OB/GYNs held hostage by lawyers who do not ambulance-chase malpractice so much as hearse-chase mal-outcomes â€" many of which are the fault not of any doctor, but of nature, God, or bad luck, depending on your beliefs.

Not that a purely defensive induction of Hannah’s pregnancy would protect anyone at Kaiser from a lawsuit. Tom tells me that as an expert witness he has seen perfect replications of her case present twice and go perfectly wrong in both directions: one patient chose to wait, the baby was disabled, and the family sued and won; the other patient chose to induce, ran the gauntlet of severe birth-related complications, and the family sued â€" and also won. As anyone who has ever had the pleasure of litigation will tell you, its outcomes have more to do with a gothic mix of technical arcana and emotion than anything resembling fairness or truth.  And that is before parading dead or disabled children and devastated families in front of juries without medical training.

The Womb is Not a Study Site

During the long night before Hannah’s actual induction begins, I talk with two more friends, a teaching OB/GYN in Denver and a lay-midwife in rural Oregon. Guess how they vote? The OB/GYN agrees with Tom and recommends, reluctantly, that Hannah go ahead with the induction; the midwife of course recommends getting her and Baby Sam the hell out of the hospital.

“IUGR, placental disorder, developmental delay and retardation,” I remind the midwife. “This is not a family of gamblers.” Like a growing number of women, Hannah has been wanting as natural a childbirth as possible, inside the traditional birthing system. But “7th percentile” sounds tiny, puny, scary; maybe not for weight distribution among a sample packed as tightly as near-term babies, and definitely not to somebody who understands biostatistics and just wrote a book on this very subject; but it sounds terrifyingly small and vulnerable to people who want and expect a healthy baby.

More pacing on the labor deck. What to do, who knows? Perfectly consistent with the absence of definitive data and driven, like patients, by their own temperaments, values and biases, my OB friends say intervene and my midwife friends say do not intervene. So is this a normal pregnancy? Or a family heartbreak in slow motion?? Can’t we have our retrospective diagnosis now???

The smart-ass answer to this entire problem â€" the one I might give on a panel at a health care conference â€" is that we need to study the problem. We could settle this matter within months with a clinical trial: randomly assign 500 women who present with late-term stalled fetal growth to induction versus no induction, stratify by number of weeks of pregnancy and fetal weight, and see what happens.

What would happen, of course, is nothing. No expectant mothers would sign up for the trial, for fear of relinquishing control to randomness; and an absence of subjects would not matter because no hospital’s Institutional Review Board (IRB) would sign up to host the research. I imagine the only folks really interested in seeing anyone undertake such a study would be the plaintiff’s bar, who would line up and count off by ones-and-twos to represent the “victims” on either side of it. But even if, through the twin miracles of fundamental malpractice reform (meaning profound process reform, not just economic futzing) and an emboldened medical research bureaucracy, the study were initiated, it would quickly be terminated for ethical reasons. Many expectant mothers would suffer mildly or moderately bad outcomes, and a small number of babies would suffer catastrophic outcomes â€" something society could no more countenance than my family could for Baby Sam.

Which makes Hannah’s situation not only vexing, but a post-modern American medical classic: what is best for Hannah and Baby Sam, absent the retrospective diagnosis we desperately wish we had, is not what would be best for the overall population. The situation is even more complex when you factor in potential divergences between the needs of an expectant mother and her near-term baby â€" where the mostly male politicians start showing up with their mouths open â€" but we have enough to worry about tonight. For us, right now, Baby Sam comes first; he is Hannah’s baby, not everybody else’s data point. The nominal risks associated with an induction are minuscule compared with the remote but catastrophic risks associated with fetal distress, developmental delay, or the word Tom spared me on the phone but we both know is relevant to IUGR, the one word I dare not utter in Hannah’s labor and delivery room: “stillbirth.”

The induction process begins in the morning.  The Kaiser care team gives Hannah the drug CYTOTEC (misoprostol) â€" the drug used in conjunction with the politically incendiary medication, RU-486, or “abortion pill” â€" hoping this will ripen her cervix and stimulate labor.

Several hours of waiting, worrying, praying, and staring at the fetal heart rate and uterine pressure monitors, and nothing. Hannah’s care team escalates to intravenous injections of PITOCIN (oxytocin).  In clinical shorthand, they are “pitting” her â€" a weirdly apt way to describe throwing one’s body somewhere it does not want to go on its own.

The day wears on, turns into evening, then another day. Hannah’s labor does not progress. She is starting to weary of the process, and she’s hungry; they have put her on a restrictive diet, of course, assuming she will soon go into labor and deliver. When her blood sugar starts dropping, they let her go back on solid food.  Her energy picks up, enough to start arguing that maybe she should just go home and wait.  “Maybe this is a sign that Sam is fine,” she says, “and
he just doesn’t want to be born yet.”

The Kaiser people get wind of our conversation when they walk in to check her IV, and send in the CNM who has just begun her shift.

She runs through the same argument that had brought Hannah in two days earlier.

This time, Hannah argues back.

“Do you know what could happen, if you wait?” the CNM finally says with an impatient sigh. “Your baby â€" he could be â€" stillborn.”

The ugly stench of the word fills the chlorine air of the delivery room, where it hovers, like a dead infant in a shroud, for all of us to behold.

“It’s actually time,” the CNM adds, “to move things along and break your water.”

There is no argument from Hannah or anyone else.

The next stop on the standard tour of birth interventions is the rupturing of Hannah’s membranes, or the amniotic sac that holds and protects Baby Sam. This would be the point of no return, an irreversible procedure that could well result in a massive infection if it did not work in short order, thus guaranteeing the necessity of a c-section.

Why did all of this suddenly feel like a runaway train? It would be causally accurate and certainly easy to blame the American legal system for the collision in our nation’s delivery rooms between what patients want and what protocols demand. But our tort system, with its stupefying processes and swarm of venomous creatures, is not the root cause of the problem.  Rather, it is a symptom of our own denial, of Americans’ entrenched cultural inability â€" shared by this author â€" to accept life on its own occasionally heart-shattering terms. Our medical malpractice system, like much of the post-modern American health care system itself, is a house of broken mirrors for our own worst neuroses as a society; and a big part of these neuroses includes our pathologizing of childbirth, along with our pathologizing of shyness, baldness, the normal effects of aging, dry eyes, twitchy legs, and whatever other little misery we can figure out how to medicate next.

As Americans, we seem hellbent on controlling the uncontrollable; this is why we create so many breathtaking medical technologies and give the world almost all of its breakthroughs in the treatment of cancer, heart disease and other real diseases.  But it is also why we grind up tens of billions of health care dollars every year overtesting, overreacting, and overtreating; why we look for someone with deep pockets to blame when things go wrong anyway; and why we demand and expect to get retribution when nature wants â€" to add insult to our injury â€" simply to take its own difficult course.

Every Baby Tells a Story

In the hours I have to sit around the labor deck thinking back on every detail of Hannah’s pregnancy, I realize that perhaps none of this would have happened if she had not been overtested and overtreated in the first place. When her blood sugars started coming back just on the high side â€" based on a crude test known to generate suspicious results â€" her care team put her on a highly restrictive diet to prevent gestational diabetes. Gestational diabetes, after all, would result in too large a fetus. That intervention certainly worked.

What else would anyone do for their own baby? For every argument for and against Hannah’s dietary reaction, once again the fear of a remote catastrophic outcome outweighed the more likely mildly bad outcomes. These choices are not really rational or irrational, so much as they are differently rational; they are the human calculus of fear and dread winning out over skepticism. From the oversized pre-natal ultrasound clinic at one end of the hospital to the oversized ICU at the other end, patients and their families are driven not by reason, but by faith, fear, guilt, anger, entitlement, and nothing less than what they perceive as the rockbottom meaning of life. And God help anyone who tries to stand in their way, as the hysteria about “death panels” during the health reform debate made garishly clear. With childbirth, all of these forces go into overdrive.

Hannah’s husband and I pace the labor deck.  He reminds me that she is carrying the hopes of an entire family. Baby Sam will be the first child in a new generation, and because of that, he has been tagged by name with nothing less than the legacy of a recently deceased uncle who survived the concentration camps and walked from Poland to Israel. Against a landscape of hope that dramatic â€" and for every family, the landscape is that dramatic â€" it is difficult if not impossible for anyone to think clearly about imperfectly informed medical choices: not the mother, nor the family, nor anyone on a jury.

This is why Catching Babies morphed, almost against my own will, into a novel. In my earlier work about the economic and political conflicts that define the delivery of health care in the US, I kept noticing that the greatest variations in care â€" and deepest cultural angst and antagonisms â€" seemed always to be associated with women’s health: our grossly disproportionate misdiagnosis and undertreatment of heart disease in women; our obsession with breast cancer when lung cancer is far deadlier and far more preventable; the almost criminal variations in hysterectomy rates around the country; the uninformed, blanket imposition of one group’s religious values on all women’s reproductive decisions. What started out as an analysis of the health policy problems unique to obstetric medicine quickly escalated into outright drama, if only because nowhere else in our health care system have I found the needs and obsessions of individual providers on such a direct collision course with the needs and obsessions of patients.

Like Hannah, we all dream of perfect pregnancies and perfect babies, as if they were natural rights. This happy baby dream can be punctured, often in a few messy, terrifying moments, by the harsh and merciless realities of the working OB/GYN’s world â€" a world shaped by an OB/GYN resident’s disproportionate exposure not to happy baby dreams, but to disaster pregnancies among the poorest, unhealthiest, least insured, most vulnerable women in society. The specialty has learned to cope, barely, by muttering homilies about retrospective diagnoses; by learning to hate lawyers like they learn to hate cancer; and by hoping for the best (maybe) but always assuming the worst â€" and treating accordingly. Without sleep, without data, one patient at a time. Who would not find great drama in a medical culture so doomed and dysfunctional, and so utterly driven by the conflict between patient preference and provider prejudice.

But tonight, as I go back to pacing the labor deck alone, none of that matters. And then, a terrible thought: is this somehow my fault?  I’ve spent the past two days in Hannah’s room and the waiting room, exchanging emails about publishing details for Catching Babies. The idea of some perversely cosmic connection sounds totally absurd of course, more than a bit self-aggrandizing, maybe even paranoid. But it is perfectly consistent with the belief, held only half-jokingly by many otherwise perfectly rational OB/GYNs I know, in the existence of  “Call-Gods” â€" mischievous personal deities who preside over pregnancies on nights when they are on call at home or in the hospital, starving for sleep. But this teleology would not sound all that absurd to a billion or so Hindus, many of whom are just as rational and science-minded as a physician awakened to another precipitous delivery at 3 AM, ten minutes after finally falling asleep.

Breaking Hannah’s water finally works. The artificially induced contractions are severe, throwing her from the bed. The pain is too intense, and Hannah finally relents and agrees to an epidural, which will numb her from the midsection down and cut her off from the core sensations of the birthing process. It is the next car on the runaway train of interventions, and she did not want this one either, but the pain from the induced contractions are overwhelming.

Three hours of pushing later, and Baby Sam is born. He is perfect and pink and healthy.

It had been a normal pregnancy.

J.D. Kleinke is a medical economist, author, and health information industry pioneer.  He has helped create four health care information organizations; served on several public and privately-held health care information company boards; and written about health care business and policy for The Wall Street Journal. The names in this article have been changed to protect the privacy of all individuals involved.

Filed Under: THCB

Tagged: Diagnosis, Gynecology, Obstetrics Mar 29, 2011

While surfing the net I came across a term called “cell phone elbow”. Frankly I have heard terms such as tennis elbow, but cell phone elbow I have never heard before. So I decided to find more details about the disease and found it to be actually “cubital tunnel syndrome” in medical term. I thought I should write some information regarding cell phone elbow (and why it is called so) or cubital tunnel syndrome, as cell phone use is so common these days.

Cell phone elbow is the second most common nerve compression syndrome in upper extremities, after carpal tunnel syndrome. The disease commonly occurs among users of cell phones, especially for long duration. During talking, when a cell phone user holds the phone to their ears they stretch a nerve (the ulnar nerve) which provides nerve supply to smaller fingers (ring finger and little fingers of hands). If the user use cell phone for long duration it can compress the ulnar nerve as well as reduce (and may even choke) blood supply to the nerve, which can be harmful to the nerve.

What are the symptoms of cell phone elbow?

The symptoms of cell phone elbow include tingling, numbness, aching and burning in the ring finger (the half adjacent to little finger side to be precise) and little finger of the affected hand and forearm. The affected hand becomes weak and the patient may even find it difficult to perform certain easy tasks such as opening jars and bottles, writing, typing or playing instruments.

How cell phone elbow is diagnosed?

The diagnosis is mainly clinical, by thorough history and clinical examination.

What is the treatment for cell phone elbow?

The most important advice is to switch hands when you notice symptoms of cell phone elbow or use of hands free device can be of great help. Switching hands while talking on cell phone for prolonged period can reduce the constant compression and prevent development of the syndrome. Sometimes patients may require anti-inflammatory medication and some severe cases may require surgical treatment to decompress the ulnar nerve.

The prognosis is generally good even in severe cases who present late. But overall recovery is much better, who presents early and if symptoms are not severe.

Other causes of cell phone elbow:

There are other causes of cell phone elbow, other than long use of cell phones. Sleeping in elbow flexed position can also cause nerve compression and cell phone elbow or cubital tunnel syndrome. Any condition which cause constant or long duration of flexion of elbow can cause cell phone elbow. Treatment of cell phone elbow depends to some extent on the cause of the syndrome e.g. cell phone elbow due to extension of elbow during sleep is treated by wrapping a pad or towel around elbow during sleep to prevent flexion.

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If you've ever thought about going to a meeting of experts advising the Food and Drug Administration on whether to approve a new drug, be prepared to fight your way through the crowd of Wall Street types looking for scraps of information to trade on. The tiniest tidbit can be worth a lot of dough.

Now imagine you could get to the mother lode of FDA info about a drug â€" a computer system that tracks approval applications, including memos that explain what the agency is about to do before it goes public. That would really be valuable!

Well, an FDA chemist named Cheng Yi Liang had access to the database and with the help of his son, Andrew Liang, allegedly used insider information to make profits of more than $2.27 million. In a criminal complaint, the Justice Department alleges the men engaged in securities and wire fraud and a conspiracy to commit the frauds.

 

The pair allegedly began trading on the insider information in November 2007 and continued doing so until this month. The Justice Department says they made money trading in shares of:

• Clinical Data
• Vanda Pharmaceuticals
• Progenics Pharmaceuticals
• Middlebrook Pharmaceuticals
• Momenta Pharmaceuticals

The two men were arrested at their home in Gaithersburg, Md., Tuesday and were arraigned in U.S. District Court in nearby Greenbelt. Seeking comment, Shots called a telephone number listed for their residence. A man answering the phone said no one by the name of Cheng Yi Liang was there.

"Profiting based on sensitive, insider information â€" as Liang is charged with today â€" is not only illegal, but taints the image of thousands of hard-working government employees," said Special Agent in Charge Elton Malone of Health and Human Services-OIG Special Investigations Branch in a statement. "We will continue to insist that federal government employee conduct be held to the highest of standards."

In an internal FDA e-mail, Janet Woodcock, head of the Center for Device Evaluation and Research, wrote to employees today:

As part of the ongoing investigation, federal agents are interviewing a number of other CDER staff and collecting documents and files. The Agency is cooperating fully with law enforcement officials regarding this matter and I encourage any of you who are contacted to cooperate fully as well.

By KIMBERLEY MANNING, MD

On May 19, 1996, I graduated from medical school. And although I look and seem ridiculously youthful (I know, that’s what you were saying) it’s beenâ€"as my patients at Grady like to sayâ€"”a mi-nute” since I was a medical student. This week, for a myriad of reasons, I have been reflecting on how much as changed since I was a medical student.

As a medical educator of both resident physicians and medical students, I get to see this evolution taking place before my very eyes. Some of the changes have definitely been for the better. But real talk? Some of them have probably been for the worse.

Today, I bring you the top ten things that have sho’ nuff changed since I was a medical studentâ€"good, bad, and . . .let’s just say. . .different.

#10. Class.

For most folks who went to medical school in the early to mid-nineties like I did, the first two years were all pre-clinical and all in class.

We didn’t go near any patients until third year. And no, I’m not counting the Physical Diagnosis class that we participated in for the second half of our second year. If I recall correctly, that clinical time was spent either shadowing some busy doctor OR scaring the crap out of yourselves by listening to your Physical Diagnosis partner and making very off diagnoses. (Like the ganglion cyst behind my ear that me and my partner Ernest P. decided was a slow-growing lymphoma. . . um, yeah.)

Anyways. We had class all day, every day Monday through Friday. And what’s interesting is that the culture was that we went to class without fail. Skipping class was not cool. So for that reason, there were very few people in my class who didn’t regularly attend class. Unfortunately, this isn’t so much the case these days.

Verdict:

Not being in class 24 â€" 7 is a good thing. Getting clinical experience early in the game (our students start seeing patients in the first semester of the first year!) is a sho’ nuff great thing. But thinking that you can learn medicine from transcripts, from studying on your couch or in Starbucks without going to the like 2 to 3 hours TOPS of lectures that most medical schools have evolved to having? Wompity womp womp. Thumbs way down, dude. Medical school is not an on-line adventure. Period.

#9

The Internet.

So how ’bout we Xeroxed everything back in the 90’s. Waitâ€"do y’all even know what it means to “Xerox” something? Do people even say that any more? Dang.

Old tests were schlepped around in a big box and shared between friends or at Kinko’s. There was no following the lecture on Power Point or any such thing. You took your butt to class. You busted out your highlighters and rollerball pens, and you took notes. Old school style.

Verdict:

Having the internet for resources, learning and sharing of material is definitely a sho’ nuff good change.

Having one hundred and thirty people intermittently “poking” each other on Facebook during a lecture that you spent twenty hours preparing since they know that the transcript service will have it posted on line later? Boo hisss.

#8 Clinical work.
When I was in medical school, we had this rotation called the “acting internship.” They do still have that now, but a lot has changed since we were in that role. We used to have two fourth year medical students join a team, and somehow that became the equivalent of one intern. We were folded into the call schedule, we wrote notes and orders, and we cross-covered sick patients overnight just like any intern would. And if you weren’t there? Oh, you were definitely missed. And not just missed because you’re niceâ€"but missed because you were literally acting as an intern.

It was terrifying.

These days, the acting interns, or “sub-i” as they are affectionately called, do get to do more than the third year clerksâ€"but as far as being exactly like interns? Uhhhh, not so much. Now it’s not because they don’t want to. But more because there are a lot more laws about who can write notes and orders and all that jive. It also requires more work out of the supervising resident since they have to be there to cosign and make every decision official. In other wordsâ€"more layers between the student and the medical decision making really waters down the experience. And that “being terrified” thing? It’s actually very necessary.

My classmate Jada R. and I were doing an away rotation at a very fancy-schmancy institution during our fourth year. We signed up for what we thought was a month of Ambulatory Pediatrics. SIKE! We arrived and promptly had a big ol’ call schedule grid handed to us with our combined names as the “intern” on one of the teams for that month. It was crazy. What made matters worse was that we had the laziest senior resident of all time covering us who regularly said to us:

“Call me if you need me, but need me if you call me.” (Right before he toodled off to the call room to post up with a tiny portable black and white television.)

Um, yeah. I will never forget the day that we both stood in front of the bed of this acutely ill child and, after doing all that we knew to do, decided to call a code. Us. The medical students. Called a code. And did I mention that this automatically made us the first responders? Lawd. Talk about some tremulous chest compressions. . . .

“First rule in a code: Check your own pulse . . .” ~ The House of God

Verdict:

Senior students getting less autonomy on acting internships? Uhhh, yeah. I’d say the old way was better, as long as the supervision was appropriate. Patient care is kind of like running long distance. The only way to learn to run long distance is to run long distance. Feel me?

#7 The clothes.

When I was a medical student on the wards, we were anatomically different. Seriously. I am pretty sure that no one had a belly button, an upper thigh, or cleavage. If they did, I didn’t know about itâ€"because their ass got sent home by one of the senior faculty long before anyone could catch a glimpse of it.

Verdict:

Clothes for the club should be kept separate from clothes for the clinic. That’s all I’ll say on that.

#6 Cell phones.

I still have no idea how any of us knew how to find each other. My first cell phone was this scary contraption that I bought for emergencies only at the end of my senior year of medical school. Every call was five-trillion dollars per second and, for that reason, no one had your number. Matter of fact, if by chance you did give your closest friend your number, it didn’t matter because you couldn’t afford to answer the phone.

Verdict:

Being able to find each other is a good thing when you’re a med student. Having cell phones sure would have saved a lot of folks from a lot of unnecessary fumbles. A quick text could have alerted you to all sorts of things before they happened:

“Girl, you need to change that short skirt ’cause Dr. Johnson is here today.”

“Aww, damn! I’m too short?”

“Yeah, playa. Don’t forget the stockings in case he’s really tripping.”

“Good lookin’ out!”

Instead, all you could do is wince when such things happened.

#5 Breaks.

The only breaks we ever had were for major holidays connected to Jesus either being born or being resurrected. I’m sayingâ€"I cannot keep up with all the breaks that our students get. Spring breaks, fall breaks, intersessions, discovery periodsâ€"and when I tell you these students make the most of this time away? Baby, I mean it.

I ask the students what they are doing for their break and if often is one or all of the following:

“Vail”
“The Galapagos Islands and Machu Picchu!”
“South Africa.”
“China.”
“Bangkok.”
“Hong Kong.”
“Paris and then maybe Amsterdam for a bit.”
“The Amalfi Coast.”
“St. Tropez.”
“The MOON.”

Um, yeah. I promise you that I am not exaggerating AT ALL. Ohâ€"and if I sound like I’m hating, oh it’s only because I am considering the only place me and my friends went was Chattanooga, Tennessee to the outlet mall. One, because we were broke. Two, because we were broke. And three, because we NEVER had a large enough chunk of time to go anywhere other than Subway for a five dollar footlong between study breaks.

Verdict:

Becoming a doctor can be heavy. Taking time out for breaks and personal enrichment is a good change if you ask me.

#4 The Verbal Filter.

When I was a medical student, we called everyone who was already a doctor “doctor.” We followed directions and showed up where we were supposed to show up and 99% of the time felt so freakin’ happy to be in medical school that we wouldn’t dare not act like it.

So this is probably one of the most disturbing new developments I’ve seen. Now, first, let me give the disclaimer that there are many, many wonderful, insightful, humble, and respectful medical students all across the country. But. There is also a growing culture of disturbingly entitled learners who not only look gift horses in their mouths but kick them in the teeth, too.

I overheard a student say this about a part of their curriculum that they didn’t like:

Student: “This whole part of the curriculum is bullshit and a waste of time.”

Faculty: “Well, it’s mandatory, so if you don’t go, you won’t graduate.”

Student: “Like I really won’t graduate. Yeah right.”

(SCRATCH THE NEEDLE ON THE RECORD)

Wait, huh? Awww, hee-yaaaallll nawww!!!

(Picture me kicking over a chair.)

Are you, like, kidding me? Yeah, now this? This is not something that would have gone down when I was a medical student. This exchange was in the presence of a faculty member. When I think about how much work, how many babysitters get hired, how many spouses get angry, and how many meetings we all go to just to work on the curriculum. . . . .all I can say is this:

Them’s fightin’ words.

Check it: There are goo-gads of studies looking unprofessional attitudes and behaviors in med students and how it all pans out for future disciplinary actions like litigation and state board problems. No shockâ€"even the smart kids who have had professionalism issues are much more likely to find themselves in trouble at some point. And this isn’t just my opinion. This is evidence-based.

Telling a professor to “stick it” by quasi-boycotting a part of the curriculum that they worked hard on or just fussing about that curriculum in the most unproductive way ever is not only entitled and immature, but painfully unprofessional. When I recertified for the Internal Medicine boards last year, I was required to do over twenty something hours worth of question banks, literature searches, surveys and much more. It was horrible. But you know what else it was? Mandatory. Now. If, by chance, someone has asked me my opinion on the whole thing, I would have wanted to say:

“I am a clinician educator. I work with medical students and residents in a teaching hospital every single day. I read. I teach. So forcing me to do fifty five hours worth of homework is like a giant thorn jabbed directly into my side.”

The key word is “wanted.” Just because you are thinking something doesn’t mean you say it. And just because you don’t exactly want to do something that is professionally mandatory, doesn’t mean that you are so special that you get to be the one who doesn’t. Be that the maintenance of certification process. Or just, as my husband the military dude would say, shutting your piehole and doing what you are supposed to doâ€"like participate in a part of your med school curriculum.

Newsflash: That’s life. Especially in medicine.

Verdict:

Some of that old school deference should be recaptured. To those who do “get it”â€" I’m not talking to you. To those who are smirking at this and calling it stupid, here’s my wise words for you: check yourself before your wreck yourself. Oh yeah, and while you’re at it? Do what all of us grown ups and professionals do when we are faced with mandatory hoops that we must but don’t wish to jump through:

Suck. It. Up.

Ugggh!

#3. The Library.

A literature search used to involve waiting twelve thousand years for a librarian to help you find the paper that you located in the antiquated INDEX MEDICUS. There was nothing quick about a lit search back then. And it was PAIN. FULL. Oh and did I mention that since we did not have internet access during my intern year and med school years that our questions were found in big, fat, textbooks. That we carried around in our backpacks. Crazy, I know.

Verdict:

Hallelujah for Pub Med.

#2 The Confusion.

I have to give the medical students these days credit. These kids are scary smart. I recall quite a few times in medical school where I was frozen in terror during a lecture. I’d realize that, after taking three pages of notes, that I had NO IDEA what the professor was talking about. Whatsoever.

But the med students these days? Fuggeddaboudit. They are all over this stuff. They type 100 words per minute and they ask us questions so hard that we immediately question our medical school diplomas. I don’t know if it’s me, but the learners seem smarter than we were. Now, the work ethic seems to be a lot differentâ€"but sheer smarts? They’ve got that.

It’s amazing how well these students can digest information and multitask. They grasp the most complicated concepts all while tweeting a friend, reading the New York Times on their iPads from the back of the room, and balancing their checkbooks at the same time. That part really impresses me.

Verdict:

The future of medicine includes some really bright minds. Which if you ask me, is a GOOD thing.

#1 The Friends and the Fun.

Boy did we have fun in med school. I’m talking a full on blast. We worked hard, yes. But man did we play hard. I made some of the best friends I’ve ever known in med school who remain my closest confidants to this very day. I’d like to think that our crazy duty hours and ridiculous schedules created that in us. I’m even tempted to say that we were WAAAAY closer than these young bucks in medical school these days.

But I can’t.

The good news? It looks like that part hasn’t changed one bit. I’ve witnessed some rich friendships grow out of the the medical school, and even a few love matches to boot. It warms my heart to know that the same ties that were fostered by those all nighters and post-exam parties in the 90’s still live on.

Verdict:

A lot has changed. But some things always remain the same.

Kimberly Manning, MD, is an assistant professor in the Department of Medicine at Grady Memorial Hospital in Atlanta. As both a clinician and educator, she teaches pre-clinical medical students and residents and serves as residency program director for the Transitional Year Residency Program. She blogs regularly at Reflections of a Grady Doctor.

Additional posts on THCB by Kimberly Manning:

Perspective

Filed Under: THCB

Mar 27, 2011

How rotavirus infection is transmitted?

The route of transmission of rotavirus is feco-oral. Contact with contaminated hands, surfaces and objects can transmit the virus and initiate infection and diarrhea. Respiratory route is also considered to transmit the virus from one person to another. The number of rotavirus particle in infected person’s feces is estimated to be more than 10 trillions and the infective dose is only 10-100 virus particles. Presence of such huge numbers of virus and the small size of infective dose required makes it ideal for mass transmission of rotavirus. Another important aspect in high incidence and infectivity of rotavirus is the less effectiveness (may be ineffectiveness) of standard sanitary measures used for elimination of bacteria, virus and parasites. This can be easily understood by the fact that the incidence of rotavirus infection is similar in countries with high as well as low health standards, unless there is mass and routine vaccination program against rotavirus infection. The stability of rotavirus in normal environment also makes the transmission of the virus easy.

How to prevent rotavirus infection?

It is not possible to prevent transmission and infection of rotavirus by improving sanitation and drinking water quality (as standard sanitary measures used for elimination of bacteria, virus and parasites can not eliminate the rotavirus) by providing safe drinking water, the only effective way to prevent rotavirus infection and diarrhea is vaccination. The numbers of rotavirus diarrhea and hospitalization is high despite providing safe drinking water.

The rotavirus vaccine:

At present there are two safe and effective vaccines available against rotavirus A. One is marketed by GlaxoSmithKline with brand name “Rotarix” and the other marketed by Merck with brand name “RotaTeq”. Both vaccines are oral vaccines and approved by USFDA and licensed for use in more than 100 countries. But only few countries (including US) use it as routine vaccination. World Health Organization at present recommends use of rotavirus vaccine in routine national immunization programs, after clinical trial in 2009, which found the vaccine to be safe and effective.

The Rotavirus Vaccine Program aims at reducing infant and child morbidity and mortality in poor countries by making the rotavirus vaccine available in those countries.

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Enlarge Maggie Starbard/NPR

Zach Lester, seen here working in the field of Tree and Leaf Farm, grew the kale, chef Todd Woods cooked it, and Your Health podcast host Rebecca Davis got to eat it.

Maggie Starbard/NPR

Zach Lester, seen here working in the field of Tree and Leaf Farm, grew the kale, chef Todd Woods cooked it, and Your Health podcast host Rebecca Davis got to eat it.

It's been a year since President Obama signed health overhaul legislation into federal law. On this week's podcast we'll learn about the lingering debate over the law as it celebrated its first birthday.

We'll also get an update on the nuclear crisis in Japan, where veggies, milk and water are tainted by radiation. Blogger Scott Hensley stops by to explain how some folks are using "crowdsourcing" to map the extent of radioactive contamination.

Plus, Scott brings us an exclusive interview with the Andrew Witty, CEO of drug giant GlaxoSmithKline. He talks about how the company is working to regain the public's trust and trying to spur development of drugs for neglected diseases.

We also call up Nancy Shute to talk about sex and heart attacks.

And, finally, at the end of the program, we'll follow the route some rainbow kale took from an organic farm in Virginia to a farmers market to one chef's kitchen.

You can find the podcast at the bottom of the page under the podcast heading. To subscribe to the Your Health podcast click here.

By JOSEPH KVEDAR, MD

Of course that is not true, but it seems like that sometimes, doesn’t it?  If you are working to promulgate a solution that promotes health in the context of our current healthcare system, there is no end to the challenges you will face.  Lets think a bit about the various actors, why they should care and why they do not.

I’ll start off with you. No one should care more about your health than you.  But as the behavioral economists remind us, we are not rational beings.  We are more likely to focus on tangible things in the moment rather than long-term uncertain benefits. So we persist in participating in unhealthy behaviors that provide short-term pleasure and lead to downstream sickness.  In addition, we’ve been addled into believing that once we are diagnosed, we are victims and that we can abdicate all responsibility for our care. (see 5-17-2010, Are Individual’s with Chronic Illness More Passive?).  This insidious combination makes it hard to hold ourselves accountable for our own health.  Most times, we’d rather blame the environment, or bad luck, and ask if we can take a convenient pill to make it better.

Next, how about your loved ones?  They are the best targets. In most cases our loved ones (the more current phrase is ‘social network’) can and do affect our health (See Nicholas Christakis’ book Connected and related articles).  It has, however, been challenging to get loved ones to open their wallet to pay for service offerings that improve your health.  In my experience, this is most often because of the same mentality that makes you a passive victim once you get sick.  We feel that society owes a victim.  We all feel like we’ve paid into various insurance programs â€" public and private â€" and that they should be the ones to pay for health-related services, particularly in the setting of chronic illness.  So your loved ones do care, but they have been trained not to open their wallet to support your care.  I can think of a dozen or so business plans I’ve seen over the years where the service to support a chronically ill individual was to be paid for by the “sandwich generation.” There is an appeal to this on the surface, but I haven’t seen one of those businesses scale yet.

What about those insurers then?  They probably care the least.  They see their role as spreading risk over large populations. So they work to recruit and keep healthy people on their rolls.  They work to be as efficient as possible at processing claims and mathematically predicting risk. They only got into the care management business because their customers (employers) demanded it of them.  They invariably vote for commodity or ‘check the box’ solutions.  Keeping cost down is held at a premium compared to improving health. Insurers are hard to engage in a visionary conversation about improving health, even though they’ll admit that in many cases the savings of improving health would accrue to them.

OK, so lets move upstream in the supply chain.  Employers hire insurers to help them with employee benefit health care plans.  Employers are motivated to keep you healthy if for no other reason than you will be a more productive worker if you are healthy.  They even care a bit that your dependents are healthy too, since you’ll be more productive if a sick parent or child doesn’t distract you.  And there is the original reason employers started paying for healthcare in the first place â€" because their benefits packages help them attract a more talented workforce.  The latter has largely been forgotten these past 2-3 years, as we’ve been adrift in a sea of employable people without jobs.  Supply and demand curves to motivate behavior and with such a large supply of workers, benefits are less important. That will change as the economy picks up.

So a high level analysis would conclude that employers are good targets for novel health-improvement interventions.  The challenge is that the direct customer is the human resources professional.  These poor, overworked souls are true generalists. They have to help you invest money in a retirement plan, guide you through how to handle a maternity leave, discipline a difficult employee and, oh yeah, choose your health plan.  Few of them have any training in health so it is natural that they develop trusted relationships with folks at health plans…so they get talked into purchasing check the box, commodity solutions.

Well, for goodness sake, what about your doctor? Your health professionals are there for you.  But they too have perverse incentives.  The most prevalent of these is that they are trained to and get paid well for taking care of sick individuals.  The system does not reward them financially at all for improving health.  They are also big believers in patient accountability and don’t usually buy that victim thing.  So they quickly articulate a treatment plan so they can go on to the next sick person who needs their help.  They expect you, the passive victim, to be proactive about learning everything you need to do to execute that plan and carry it out.  They are not on the same page as society is regarding who is accountable for keeping you healthy. They’d say it’s you, with their help from time to time.

Throughout this piece I have purposefully equated ‘caring’ with ‘spending’.   I suppose this too is controversial, but I think the linkage is fair.  What is the relevance to connected health?  Simply put, connected health interventions promote health over sickness management.  In today’s healthcare marketplace, they’ve been a hard sell.  Most folks I talk to readily agree that connected health as a care model makes sense.  But there is this mystery about ‘who pays?’.  I believe this phenomenon of ‘nobody cares enough about health to pay for it’ helps explain that conundrum.

So it feels a bit like merry-go-round to me, or if you take a more sardonic view, a game of Russian roulette.  So tell me: am I off base?  Who really does care?

Anemia is low (lower than normal) hemoglobin level in blood. Iron deficiency anemia is one of the common forms of anemia, especially in the developing countries where number of causes of iron deficiency anemia exists. In the developed countries iron deficiency anemia is less commonly seen and the causes of iron deficiency in developing countries differ from that of developed countries. Iron deficiency anemia occurs due to lack of adequate number of mature and healthy red cells due to deficient iron. Red blood cells (hemoglobin present in red blood cells) are responsible for carrying oxygen to the tissues. If there is inadequate number of mature (healthy) red cells the oxygenation of tissues suffer and the patient suffering from iron deficiency anemia become weak, and easily get tired.

Iron deficiency anemia occurs due to deficiency of iron (as the name suggests) and due insufficient iron there is less hemoglobin in the red blood cells and as a result the tissue (including heart) oxygenation suffers and the patient become weak, pale and easily fatigued.

What are the symptoms of iron deficiency anemia?

If iron deficiency anemia is mild there may not be any symptoms and the disease may go unnoticed or may be detected only during routine investigation for other medical condition. But if the disease progress the signs and symptoms of iron deficiency anemia become apparent.

The symptoms of iron deficiency anemia includes,

• Pale skin
• Generalized weakness, fatigue, shortness of breath
• Headache, lightheadedness, dizziness
• Cold extremities (hands and feet)
• Brittle nails (clubbing of nails) on long run
• Increased risk of infection, soreness of tongue or inflammation of tongue
• High pulse rate
• Unusual cravings for non-nutritive substances, such as dirt, mud, etc. especially among children.
• Failure to thrive among children.
• Loss of appetite or poor appetite

If you or your children have symptoms suggestive of iron deficiency anemia, you should consult a doctor. Do not start taking iron supplementation on your own, as it may lead to complications.

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Another reassuring fact: The reported radiation dose in Tokyo tap water (210 becquerels) versus the Japanese safety limits (100 becquerels/liter for infants, 300 for adults) is not far from the difference in radiation dose people naturally get if they live in a place like Denver versus a sea-level city such as Los Angeles. That's because the thinner atmosphere in Denver provides less protection against cosmic rays.

The warning that Tokyo's tap water contains twice as much radioactive iodine as allowed for infants strikes a particularly distressing chord.

Infants are especially vulnerable because their cells are dividing faster than at any other time of life, and dividing cells are especially sensitive to radiation damage.

The dilemma is compounded by the fact that bottled water can be hard to get in Tokyo right now. That could make matters desperate for mothers of formula-fed babies. And nursing mothers are undoubtedly wondering if the water they drink raises their babies' risk of cancer. (Answer: It could.)

But Kim Kearfott, an expert on the health effects of radiation, says these young mothers shouldn't panic.

 

"If it were my infant, I would make an effort to secure some water that's clean," says Kearfott, a professor of nuclear engineering and radiological sciences at the University of Michigan. But if she couldn't, she says, "I wouldn't be concerned [about using the tap water] unless this continues over a long time period."

How long? "Half a year," she says.

That's because the radiation dose limit for infants â€" 100 becquerels per liter of water â€" is based on a year's worth of exposure. The radioactivity from iodine-131 in Tokyo's water, due to the emissions of the Fukushima Dai-ichi power plant, is twice that.

So drinking the radioactive tap water for half a year would not exceed the safety standard, she says.

But parents are understandably reluctant to ignore the authorities' advice to stop giving the contaminated water to their babies. Kearfott says there are other ways to reduce the risk.

"Using a charcoal filter would dramatically reduce the amount of iodine-131 in the water, by between 50 and 100 percent," she says. These are the kinds of filters available in many grocery stores.

Another strategy is to draw tap water and keep it in a jug for eight days. That's the half-life of iodine-131, so in that time, half of the radioactivity would be gone â€" and the water would be within the 100-becquerel safety standard. Meanwhile, parents could use bottled water if available, or just use tap water in the knowledge that short-term use isn't likely to cause any harm.

"We would guess that cancer rates would be higher for people living in the Rockies," Kearfott says. "However, we've been unable to detect any increase. There are too many confounding factors, and the risks are much, much too small."

Another thing people should keep in mind is that the cancer risk from very low levels of radiation exposure are really unknown. Our knowledge of that risk is based largely on 60 years of studies of cancer among survivors of the atomic bombs at Hiroshima and Nagasaki.

From that research, the smallest radiation dose that scientists can tie to cancer risk is 100 millisieverts. Below that, the risk is just a guess â€" or rather, an extrapolation based on the somewhat controversial assumption that there's a straight-line relationship between radiation dose and cancer risk.

The radiation dose in a liter of Tokyo tap water right now is equivalent to 1 to 2 millisieverts. That's a tiny fraction (1 to 2 percent) of the lowest cancer threshold that scientists have been able to identify, based largely on the research from Hiroshima and Nagasaki. Some health researchers are calling for monitoring to begin now for any possible longterm health effects from Fukushima.

"We need to stay calm and reasonable," Kearfott says.

By Matthew Holt

The bunting is up, the programs are printed and more than 300 of our best friends are in San Diegoâ€"even last weekend’s foul weather seems to have blown over. Health 2.0 Spring Fling starts today. So if you want to join in the fun, the pre-conference activities kick off around 1pm, with the main event hosting a wonderful series of interviews at 5pm. It’ll run through end of Tuesday and it’s an amazing line-up. We’re getting crowded but there will be a few on site tickets available, or you can register here.

Filed Under: THCB

Mar 21, 2011

Hepatitis is a common medical problem, especially in the developing countries. Hepatitis can be of many types namely infective hepatitis (hepatitis A), hepatitis B, hepatitis C, hepatitis D, hepatitis E and some more, which are very rare. The commonest is hepatitis A or commonly known as infective hepatitis, which is transmitted by feco-oral route i.e. from unsafe drinking water. This disease is common in developing countries due to unavailability of safe drinking water for large number of people in developing countries.

Dietary modifications recommended during hepatitis:

Energy requirements: During hepatitis a high energy diet is advised, to maintain health and to ensure maximum protein utilization. As loss of appetite is a symptom of hepatitis, initially patient may not be able to consume enough food to maintain health. But patient should be encouraged to take more energy dense foods which he/she will be able to take gradually in increasing amount.

Proteins: Protein intake should be high in hepatitis as protein is required for regeneration of liver cells. But in case of severe hepatitis the protein intake should not be very high as the liver may not be able to handle or tolerate the high protein in food. If the liver damage is extensive the protein intake should be lower, sometimes less than normal protein intake.

Carbohydrates: High carbohydrate diet is recommended during hepatitis, as there is increased need of energy. Any source of carbohydrate can be used to provide high energy need.

Fats: The fat consumption should be less in case of hepatitis, as the digestion and absorption of fat is impaired. Fat intake should be reduced and easily digestible fats such as fat from milk, butter, cream, and eggs should be taken more in compared to fats which are difficult to digest like animal fats. But some amount of fat is required to increase the palatability of the food.

Vitamins: The requirement of all vitamins is increased in hepatitis, especially vitamin A, B, C and K. So the diet should be balanced for vitamins and if required vitamin supplementation can be given.

Minerals: The diet of hepatitis should have all the minerals required by us, especially calcium and iron. If diet can not meet the demand of minerals, they can be supplemented.

The objectives of dietary modifications in hepatitis are:

• To provide optimal nutrition for speedy recovery.
• To help in the regeneration of live tissue/liver cells (hepatocytes).
• To prevent further damage to liver cells.
• To provide symptomatic relief.

Related posts:

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Protein Requirement for Us

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Enlarge Ken Shimizu/AFP/Getty Images

A woman feeds her cattle at a farm in Futamata, Fukushima prefecture, March 20, 2011.

Ken Shimizu/AFP/Getty Images

A woman feeds her cattle at a farm in Futamata, Fukushima prefecture, March 20, 2011.

The World Health Organization weighed in Monday on the risk of eating food contaminated by radiation emitted by the still-troubled Fukushima Dai-ichi power plant.

Peter Cordingley, a Manila-based WHO spokesman, told Reuters that the radioactive-food situation is "a lot more serious than anybody thought in the early days, when we thought that this kind of problem can be limited to 20 to 30 kilometers."

At Geneva headquarters, WHO spokesman Gregory Hartl told the Associated Press that Japan must act quickly to keep radioactive food out of the marketplace.

This calls for a reality check.

 

So I had an hour-long chat with Peter Caracappa, a health physicist at Renssealaer Polytechnic Institute in Troy, N.Y. He's been running some calculations on the radioactive iodine-131 and cesium-137 levels being reported in Japanese milk, spinach and drinking water.

Before we get into the details, Caracappa's bottom line is that the risk of ingesting even the most highly contaminated Japanese foodstuffs reported so far is very, very small.

"The long and the short of it is that we're not going to be able to detect any statistically significant change in the cancer rate for anyone as a result of the events in Japan," he told Shots.

To understand why, let's look at how the amounts of radioactivity found in spinach and milk from northern Japan in the past few days relate to two metrics:

• The amount of radiation a U.S. nuclear power plant worker is allowed to get in a year: 50 milliSieverts.
• The amount of radiation it takes to increase your lifetime risk of cancer by 4 percent: 1 Sievert. (A Sievert is a measure of ionizing radiation's effect on human tissue; a milliSievert is a thousandth of a Sievert.)

We started with spinach. Its broad leaves tend to catch whatever radioactive dust is floating around.

Caracappa calculated for me the implications of eating the most radioactive sample of the vegetable reported so far â€" a bunch of spinach grown in the open air near Hitachi, a Japanese city about 70 miles south of the Fukushima power plant. Japanese authorities reported over the weekend that 2.2 pounds of this particular spinach sample contained 54,000 becquerels of radioactive iodine-131. (A becquerel is a measure of radioactivity.)

That spinach reading is by far the highest reported so far.

It takes a million becquerels to reach a nuclear plant worker's annual limit of radioactivity â€" and remember, that's not enough to do any measurable harm, in the short or long term.

Caracappa figures someone would need to eat 41 pounds of that Hitachi spinach to reach the nuclear power plant worker's annual exposure limit. "That's a significant amount of spinach," he allows.

But what about cancer? That's probably what most people worry about when they hear about radioactivity in food. Well, it takes 20 million becquerels to yield a Sievert's worth of exposure; remember, that's what it takes to increase a lifetime cancer risk by 4 percent.

That translates to 820 pounds of spinach â€" more than two pounds a day for a year.

Well, nobody eats spinach every day. But many people drink milk every day. And one lot of milk sampled from the town of Kawamata, 29 miles from the power plant, reportedly contained 1,510 becquerels of radiation per kilogram.

To reach the radiation dose limit for a power plant worker, you'd need to drink 2,922 eight-ounce glasses of milk. To raise your lifetime cancer risk by 4 percent, you'd have to drain more than 58,000 glasses of milk. That would take you 160 years, if you drank one 8-ounce glass a day.

But wait a minute. Consider this:

• Contaminated milk from Fukushima or other areas is not reaching grocery stores.
• The half-life of radioactive iodine â€" as Chernobyl showed, the main isotope-of-worry when it comes to public health effects from contaminated foodstuffs â€" is only eight days. As a rule of thumb, Caracappa says, a radioisotope is gone after 10 half-lives, or 80 days in the case of iodine-131.

So unless the Fukushima Dai-ichi plant keeps releasing iodine-131 at the same rate it did one day last week, it doesn't seem as though there's too much to worry about.

And anyway, Japan exports very, very little milk â€" and, according to its Ministry of Agriculture, Forestry and Fisheries, no spinach at all.

Oh, and what about cesium-137? It's more worrisome, since a given amount takes 300 years to decay away to a non-radioactive form. But the few cesium-137 readings reported from Japanese foodstuffs so far show much lower becquerel levels. And cesium-137 doesn't get dispersed over nearly as wide an area as iodine-131.

By Matthew Holt

The bunting is up, the programs are printed and more than 300 of our best friends are in San Diegoâ€"even last weekend’s foul weather seems to have blown over. Health 2.0 Spring Fling starts today. So if you want to join in the fun, the pre-conference activities kick off around 1pm, with the main event hosting a wonderful series of interviews at 5pm. It’ll run through end of Tuesday and it’s an amazing line-up. We’re getting crowded but there will be a few on site tickets available, or you can register here.

Filed Under: THCB

Mar 21, 2011

Hepatitis is a common medical problem, especially in the developing countries. Hepatitis can be of many types namely infective hepatitis (hepatitis A), hepatitis B, hepatitis C, hepatitis D, hepatitis E and some more, which are very rare. The commonest is hepatitis A or commonly known as infective hepatitis, which is transmitted by feco-oral route i.e. from unsafe drinking water. This disease is common in developing countries due to unavailability of safe drinking water for large number of people in developing countries.

Dietary modifications recommended during hepatitis:

Energy requirements: During hepatitis a high energy diet is advised, to maintain health and to ensure maximum protein utilization. As loss of appetite is a symptom of hepatitis, initially patient may not be able to consume enough food to maintain health. But patient should be encouraged to take more energy dense foods which he/she will be able to take gradually in increasing amount.

Proteins: Protein intake should be high in hepatitis as protein is required for regeneration of liver cells. But in case of severe hepatitis the protein intake should not be very high as the liver may not be able to handle or tolerate the high protein in food. If the liver damage is extensive the protein intake should be lower, sometimes less than normal protein intake.

Carbohydrates: High carbohydrate diet is recommended during hepatitis, as there is increased need of energy. Any source of carbohydrate can be used to provide high energy need.

Fats: The fat consumption should be less in case of hepatitis, as the digestion and absorption of fat is impaired. Fat intake should be reduced and easily digestible fats such as fat from milk, butter, cream, and eggs should be taken more in compared to fats which are difficult to digest like animal fats. But some amount of fat is required to increase the palatability of the food.

Vitamins: The requirement of all vitamins is increased in hepatitis, especially vitamin A, B, C and K. So the diet should be balanced for vitamins and if required vitamin supplementation can be given.

Minerals: The diet of hepatitis should have all the minerals required by us, especially calcium and iron. If diet can not meet the demand of minerals, they can be supplemented.

The objectives of dietary modifications in hepatitis are:

• To provide optimal nutrition for speedy recovery.
• To help in the regeneration of live tissue/liver cells (hepatocytes).
• To prevent further damage to liver cells.
• To provide symptomatic relief.

Related posts:

Dietary Advice for Diarrhea

Dietary Advice during Pregnancy

Protein Requirement for Us

Vitamins and Minerals in Your Diet

Factors that alter Energy/Nutrients Need

Nutrition and Nutrients

Fat, Carbohydrate and Water Requirement

Energy-dense Foods may Trigger Diabetes

Some Dietary Advises on Constipation

What food items to Avoid in Diarrhea

Enlarge Harry Cabluck/AP

A booster seat sits atop a chair in the Texas House of Representatives back in 2009, when a bill was passed requiring their use for kids under 8 years old.

Harry Cabluck/AP

A booster seat sits atop a chair in the Texas House of Representatives back in 2009, when a bill was passed requiring their use for kids under 8 years old.

Don't rush to turn your toddler around in her car seat.

A leading group of pediatricians is advising parents to stick with rear-facing car seats until their children turn 2, or the kids exceed the limits for weight and height in the seats.

Older kids should stay in booster seats until they are between 8 and 12 years old. The key is for kids to be at least 4 feet 9 inches tall, so seat belts are in the proper position to protect them in case of an accident..

An older recommendation by the American Academy of Pediatrics from 2002 had been less emphatic, saying kids should ride facing backward until they turned 1 or hit 20 pounds. So many parents, eager to get on with easier-to-use seats, are quick to get their kids looking out the front windshield as soon as possible. And the kids I know seem happier not staring at upholstery, for that matter.

 

That's not the best bet for safety.

The pediatricians note that auto accidents are the leading cause of death for kids older than 4, causing more than 5,000 deaths in children and young people under the age of 21 each year.

Proper use of child seats can help a lot. The pediatricians cite research that suggest safety seats can reduce the risk of injury 71 percent to 82 percent. The seats can reduce the risk of death by 28 percent compared with kids wearing seat belts alone.

The recommendations, as written for doctors and policymakers, appear in the latest issue of the journal Pediatrics. Parents can find more practical advice on car seats and the new recommendations on the HealthChildren.org website here.

By VANESSA HURLEY

What if I told you that across the country there’s a procedure being performed on pregnant women that makes their newborns more likely to end up sick and in a $3,000-a-day Neonatal Intensive Care Unit (NICU)?

Too outrageous to believe?

It’s true.

Early elective delivery ‚ when labor is induced 3 to 4 weeks early without medical necessity , is on the rise in the U.S. According to a report released in January 2011 by the Leapfrog Group, between 1992 and 2003 the number of these births increased from 19% to 29%. Seven hospitals across the country perform these deliveries on 100% of women without medical necessity, and over thirty others perform them 50% of the time or more.

The American College of Obstetricians and Gynecologists (ACOG) has long recognized the risks associated with inducing labor when it is not medically needed. One retrospective study found that infants born at 37 weeks are nearly 23 times more likely to suffer severe respiratory distress than those born between 39 and 41 weeks. ACOG thinks this is unacceptable.

So why do hospitals do it? Experts see a few possible explanations:

Obstetricians deliver but don’t care for newborns. They move quickly from birth to birth, and lack a complete understanding of the complications associated with early deliveries.

Natural deliveries are difficult to anticipate. Nature can be fickle and tends to ignore the schedules of busy physicians. Patients may simply agree because they see little harm in early deliveries.

There’s yet another incentive worth pondering. It’s prefaced by a big green $, and followed by plenty of zeros. NICUs â€" where many pre-term babies end up â€" are highly profitable for hospitals. John Lantos, a former Chief of General Pediatrics at the University of Chicago, recently wrote in Health Affairs:

The NICU â€" which represented nearly 4 percent of total admissions [for the hospital] – had generated 11 percent of the net revenue. Since most of the academic medical center’s divisions either barely broke even or lost money, that meant that a staggering 69 percent of the net profits of the entire hospital system came from the 4 percent of hospital admissions to the NICU.

In other words, healthy, full-term babies are not nearly as profitable as preemies. The average cost of caring for a premature baby is $41,610 versus just $2,830 for a full term baby. A clear line can be drawn between more early term births and more days spent (and dollars generated) in the NICU. Increasing the numbers of preterm births creates a perceived need for additional NICU beds, thereby increasing the need to fill those beds. A self perpetuating cycle quickly emerges.

Such a cycle can be broken, as illustrated by Intermountain Healthcare. This Utah and Idaho-based health system reported a 30% rate of early induced labor in 2001 before introducing a protocol that explicitly urged doctors to avoid performing early inductions unless medically necessary. At first, some obstetricians didn’t see a problem. Convincing them required bridging the‚ “information gap,” between what doctors thought they knew and the evidence-based reality. When presented with data from their own patient base ‚ which showed a lot of babies in distress ‚ obstetricians fundamentally changed their practice patterns.

By 2004, Intermountain’s rate of early elective deliveries had plummeted to 5%. They have since brought this rate even lower to 2%. A New York Times article on Dr. Brent James, the chief quality officer at Intermountain, noted that Intermountain’s protocol had reduced the number of babies who ended up in the NICU.

Maybe it’s time to start thinking about babies first and changing the way we pay for births. Simply put, as hospitals reduce their early elective deliveries, they’ll see reduced NICU profits. Intermountain is a capitated health system, so there is little incentive to provide unnecessary care. The fee-for-service model of most American medicine still encourages doing more, even when more medicine doesn’t translate to better health. Bundling payments for birth might be one way to discourage hospitals from performing early elective deliveries when they’re not medically necessary. Although bundled payments require risk adjusting to account for the mother’s health, they would serve as a check against doing more than what’s really needed. Early elective deliveries involve more care at a very great cost â€" a baby’s health.

(This post originally appeared on The New Health Dialogue,a blog from New America’s Health Policy Program.)

Vanessa Hurley is an analyst for New America’s Health Policy Program. She earned her bachelor’s degree in English from Dartmouth College. Ms. Hurley also holds a Master of Public Health degree from The Dartmouth Institute for Health Policy and Clinical Practice.

Filed Under: The Insider's Guide to Health Care

Mar 19, 2011