Sobering results for cost-cutting Medicare project

By LINDSEY TANNER, AP Medical Writer Lindsey Tanner, Ap Medical Writer

CHICAGO – An ambitious effort to cut costs and keep aging, sick Medicare patients out of the hospital mostly didn't work, a government-contracted study found. The disappointing results show how tough it is to manage older patients with chronic diseases, who often take multiple prescriptions, see many different doctors and sometimes get conflicting medical advice.

The study showed just how hard it is to change the habits of older patients and their sometimes inflexible doctors. And it points up the challenges the Obama administration will face in trying to reform health care for an aging nation.

Most of the patients had serious, but common, age-related illnesses including diabetes, heart disease and lung disease. Programs were set up at 15 centers around the country. Only two cut the number of times these patients were hospitalized, and those are still in operation. None saved Medicare any money.

The authors of the study called the results "underwhelming." An editorial in the Journal of the American Medical Association, where the study appears Wednesday, used the term "sobering."

"The only way you can really do it is by changing patients' behavior and by changing physicians' behavior, and both things are really hard to do," said study author Randall Brown, a researcher at Mathematica Policy Research Inc., in Princeton, N.J., which was hired to evaluate the programs.

Often, these patients need to stop smoking, or lose weight, exercise more, eat healthier foods — a challenge even for generally healthy people. Those changes are especially tough for sick, older patients who often are set in their ways.

"The same thing with physicians," Brown said. "A lot of them feel like they know how to take care of patients, so why do they need a nurse calling up and asking them why the patient isn't on some certain medication?"

Many patients in the study had more than one chronic disease, a common Medicare scenario. In 2002 alone, half of Medicare patients had been treated for five or more ailments, and they accounted for 75 percent of Medicare spending, the study authors noted.

Seeking ways to reduce those costs and improve care, the Centers for Medicare & Medicaid Services selected 15 proposals for test-site programs in 2002. The sites developed their own programs, enrolling a total of 18,309 fee-for-service Medicare patients through 2006.

About half got the patients got the usual care. The others got more intensive, coordinated care. That often involved nurses who acted as go-betweens, helping doctors give patients clear, appropriate advice; counseling patients on changing bad habits and recognizing worrisome symptoms. The nurses were available on a regular basis by phone or in person to answer patients' questions.

Jim Reid, a 74-year-old retired Pennsylvania welder, was among study patients who got coordinated care.

When he enrolled in 2002 in a test program run by Health Quality Partners, a nonprofit group in Doylestown, Pa., he was obese, had high blood pressure, high cholesterol and pre-diabetes.

But Reid was a rare success story.

He actually took the advice offered in group sessions run by nurses. He learned how to read food labels and avoid salty, calorie-laden foods. He also started exercising, walking with a pedometer and building up to a few miles daily.

Now, he breakfasts on oatmeal or vegetable omelets instead of coffee and doughnuts He's lost almost 60 pounds. His blood pressure and cholesterol have greatly improved and his pre-diabetes is gone.

Sticking with the program "is hard," he acknowledged. "As you get older, you don't want to do it." But he said it has "put an extra 10 years in my life."

Reid credits his success to the personal attention of a nurse coordinator.

"I have to have somebody to own up to," he said.

That close, in-person contact with nurses was also a feature of the project's other more successful, still-operating program, at Mercy Medical Center-North Iowa in Mason City, Iowa.

In both programs, each patient had face-to-face contact an average of about once a month with a nurse. That was far more frequent personal contact than in other programs. Both reduced hospitalizations — 17 percent yearly compared with usual-care patients at Mercy, and by about 20 percent in the Pennsylvania program, but only among its sicker patients. That program worked with Doylestown Hospital and recruited patients from area physicians' offices.

Targeting sicker patients and providing frequent in-person contact show the approach has some benefits and that success with future reform efforts "is possible, but it's not easy," Brown said.

Peter Ashkenaz, a spokesman for the Centers for Medicare & Medicaid Services, said the agency is evaluating the Iowa and Pennsylvania programs to see if their positive results persist.

He said there are other approaches being tested, some that offer incentives to doctors who meet quality benchmarks, or who use electronic health records to improve quality.

But so far, Ashkenaz said, "as the study shows, we have not yet found broad success."

Testicular Cancer Risk Linked To Marijuana Smoking

A new US study suggests there is a link between marijuana use and elevated risk of the most aggressive form of testicular cancer, with frequent and long term users having the highest risk.

The study was the work of researchers from the Fred Hutchinson Cancer Research Center in Seattle, Washington, and other centres in the US and is published early online in the journal Cancer.

The study results show that being a marijuana smoker at the time of diagnosis was linked to a 70 per cent higher risk of testicular cancer. For men who smoked marijuana at least once a week or who had been smoking it since their teens, the risk was about double that of a man who had never smoked it.

The results also showed that the link with marijuana use might only be with the most aggressive, fast growing form of testicular cancer, nonseminoma. This type of cancer usually develops in younger men between the age of 20 and 35, and accounts for approximately 40 per cent of all cases of testicular cancer.

The rate of testicular germ cell tumors (TGCTs) has been growing by about 3 to 6 per cent a year for the last 40 to 60 years in the United States, Canada, Europe, Australia and New Zealand, and coincides with a similar rise in the use of marijuana in North American, Europe and Australia.

There are two types of TGCT: the aggressive, fast growing form, nonseminoma, that generally strikes younger men, and the more common, slower form, that generally strikes men in their 30s and 40s.

Previous studies have already shown that regular and frequent use of marijuana affects the human endocrine and reproductive system, and in men this has been linked with reduced testosterone, lower sperm quality, and impotency. Male infertility and poor semen quality has also been associated with an increased risk of testicular cancer, so the researchers decided to investigate if there was a link between this type of cancer and use of marijuana.

Study author Dr Stephen M Schwartz, an epidemiologist and member of the Public Health Sciences Division at the Hutchinson Center, said in a press statement that:

"Our study is not the first to suggest that some aspect of a man's lifestyle or environment is a risk factor for testicular cancer, but it is the first that has looked at marijuana use."

Known risk factors for testicular cancer include family history of the disease, having undescended testes, and problems with testicular development. There is a widely held theory that the disease starts in the unborn fetus, when fetal germ cells (the ones that go on to make sperm in adulthood) don't grow properly and become vulnerable to becoming cancerous and that this is further exacerbated by male sex hormones later in life.

As senior author Dr Janet R Daling, another epidemiologist and member of the Hutchinson Center's Public Health Sciences Division explained:

"Just as the changing hormonal environment of adolescence and adulthood can trigger undifferentiated fetal germ cells to become cancerous, it has been suggested that puberty is a 'window of opportunity' during which lifestyle or environmental factors also can increase the risk of testicular cancer."

"This is consistent with the study's findings that the elevated risk of nonseminoma-type testicular cancer in particular was associated with marijuana use prior to age 18," she added.

Daling said she first got the idea for the study when she heard a talk eight years ago that showed the brain and the testes both had cellular receptors for tetrahydrocannabinol, or THC, the main psychoactive component of marijuana. Since then, she said, other studies have found other sites for these receptors, which are also located in the heart, uterus, spleen and immune system.

The reproductive system of men naturally produces a cannabinoid-like chemical that is thought to protect against cancer tumors, and Daling, Schwartz and colleagues suggested that perhaps marijuana interferes with this protective process.

For the population-based, case-control study, the researchers interviewed 369 Seattle-Puget Sound-area (in Washington State) men aged 18 to 44 years who were diagnosed with TGCT from January 1999 through January 2006 and asked them about their lifetime use of marijuana. Their responses were compared to the responses of 979 age-matched healthy controls who lived in the same area.

The men were also asked about other lifestyle habits such as smoking and alcohol consumption.

The results showed that even after ruling out the effect of these other lifestyle habits, and other risk factors such as family history of testicular cancer and undescended testes, use of marijuana was significantly and independently linked to higher risk of testicular cancer.

However, the researchers said they do not claim the results are definitive, the link is just a link, and does not prove cause. They want their findings to open a door to further research, as Schwartz explained:

"Our study is the first inkling that marijuana use may be associated with testicular cancer, and we still have a lot of unanswered questions."

One question for example is why is marijuana use linked to only one type of testicular cancer? Schwartz said more studies were needed to examine whether the link appears in other populations, and whether it might be possible to find molecular markers that show the pathways through which the marijuana might be helping testicular cancer to grow.

The researchers' next step is to look at the expression of cannabinoid receptors in both seminomatous and nonseminomatous tumor tissue from the patients in this study and look for genetic variations and signalling molecules that might suggest the underlying mechanism of cancer development.

In the meantime Schwartz said that young men should know that we don't know enough about the long term effect of marijuana use, especially heavy use, but this study suggests there could be at least one serious consequence, and therefore, his message is:

"In the absence of more certain information, a decision to smoke marijuana recreationally means that one is taking a chance on one's future health."

http://www.medicalnewstoday.com/articles/138372.php

New EU Legislation Will Improve Pediatric Drug Treatment

European Parliament legislation will improve the regulation of pediatric drug treatment, according to an Editorial in the British Medical Journal (BMJ), this week's issue.

Author, Professor Imti Choonara, University of Nottingham, UK, explains that over the past decade studies have indicated that the use of unlicensed and off-label drugs to treat children is widespread. Eight years ago the European Union had expressed concern about the popularity of off-label drugs usage for children, rather than treatments which had been scientifically evaluated and licensed. In December last year the European parliament introduced legislation to make sure that drugs used for pediatric treatment are subject to high quality research.

It will also provide improved data on the advantages and disadvantages of medications used for babies and children, without subjecting children to needless clinical trials and without undermining the introduction of new drugs for adults.

The legislation encourages companies to study drugs for children, with some financial incentives. However, the author notes that in America drug companies tend to study drugs that have done well with adults - the ones that have made the most money - possibly at the expense of the clinical needs of infants and children.

A register of European clinical trials of pediatric drugs will be established, and the results which are sent to the regulatory agency will be available to the public. The writer stresses that transparency is crucial if it is to benefit European children. It will be necessary that the pharmaceutical industry work closely with pediatric health professionals to make sure that all clinical trials in children are designed and performed safely.

The new legislation will hopefully stimulate scientific interest in the study of pediatric drugs and raise the total number of pediatric clinical pharmacologists in the European Union, the writer concludes.

http://www.medicalnewstoday.com/articles/91876.php