Tag Archives: Sherry Boschert

Counties Pursue Safer Drug Disposal

New programs to make it easier and safer for San Francisco Bay Area residents to get rid of unused medications are some of the first to try this on a large scale, and may serve as models for other cities and counties.

Since May 2012, a pilot program in San Francisco has allowed residents to drop off old medications at 13 pharmacies and 10 police stations (where controlled substances must be brought). San Francisco supervisors initially considered forcing drug companies to fund the program, and instead agreed to accept $110,000 from Genentech and the Pharmaceutical Research and Manufacturers of America to fund the program.

(Photo by J. Troha, courtesy of National Cancer Institute)

On July 24, supervisors in Alameda County (which includes East Bay cities such as Oakland and Berkeley) are likely to approve a Safe Drug Disposal Ordinance that would require drug companies to pay for disposal of their products or face fines of up to $1,000 per day, The Bay Citizen reports. Public agencies currently fund 25 drug disposal sites there, and the cash-strapped county wants the comparatively wealthy pharmaceutical industry to take more financial responsibility for the lifecycle of its products in order to reduce overdoses, accidental poisonings, and water pollution.

As we reported earlier this year, making prescription-drug “recycling” a cultural norm is one of five emerging public policies that could help the medical system keep opioids available while reducing the risk of addiction, abuse and accidental overdose, according to Keith N. Humphreys, Ph.D. Smaller versions have met with success, such as a drug take-back day organized by sheriffs in a small town in Arkansas (population 20,000) that brought in 25,000 pills, said Dr. Humphreys, acting director of the Center for Health Care Evaluation, Veterans Health Administration, Menlo Park, Calif., and a professor of psychiatry at Stanford University. He reports having no financial conflicts of interest on this issue.

Not everyone is happy with the idea. Trade associations for the pharmaceutical industry and biomedical companies argue that there’s no evidence that these programs will reduce poisonings, and they haven’t ruled out the possibility of suing to block the Alameda County ordinance, The Bay Citizen reports. The compromise that San Francisco reached for voluntary instead of mandatory funding from the pharmaceutical industry may be a middle ground.

In an era when government agencies have less and less money for public programs, it’s probably inevitable that they’ll pursue alternative financing for programs like this.

If your community has a drug disposal program, let us know how it’s working. Will these programs succeed, and will they reduce abuse, addiction, and accidental overdoses? We’ll keep an eye on this topic, and keep you posted.

–Sherry Boschert (@sherryboschert on Twitter)

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VA Adopts Innovative Project Nationwide

An innovative medical project that we reported in April has made the big time — a nationwide pilot program in the immense Department of Veterans Affairs system, the nation’s largest integrated health care system.

Project ECHO (Extension for Community Healthcare Outcomes) has been working wonders in New Mexico, Washington State, and a few other locations to bring specialty care to thousands of people who previously had little access to this care. Created by Dr. Sanjeev Arora of the University of New Mexico, Project ECHO connects primary care physicians with specialists in weekly case-management and educational teleconferences to give primary care physicians the support they need to manage complex patients with hepatitis C, asthma, chronic pain, rheumatic or cardiac disease, HIV, substance abuse, mental illness, high-risk pregnancy, childhood obesity, and more.

Dr. Arora (center, back turned) leads a Project ECHO videoconference. (Courtesy Project ECHO)

The U.S. Department of Health and Human Services awarded Project ECHO an $8.5 million Health Care Innovation grant in May 2012 to expand its operations in two states.

Impressed, the Department of Veterans Affairs cloned Project ECHO and tomorrow will launch a nationwide pilot program in the VA system that could help veterans get care in the local communities instead of traveling to specialists for treatment of heart failure, chronic pain, hepatitis C, etc. In our April 2012 video interview with Dr. Rollin M. Gallagher, deputy national program director for pain management in the Veterans Health Administration, he explains why Project ECHO is so appealing to the VA

The VA’s version, called Specialty Care Access Network-ECHO (or SCAN-ECHO), will kick off officially with a briefing by a panel of experts in Washington, D.C., that also can be viewed by Webcast (how appropriate) on Wednesday, July 11, 2012 from 10 a.m. to 11:30 a.m. Eastern time. Register here to view the Webcast.

The panel will feature Dr. Arora with Dr. Robert A. Pretzel, under-secretary for health in the V.A. system, Dr. John R. Lumpkin, director of the Health Care Group for the Robert Wood Johnson Foundation, which has funded much of Project ECHO’s work, and both specialty and primary care providers from the Cleveland VA Medical Center.

With any luck, the success of Project ECHO will echo across the country as this model of care expands.

–Sherry Boschert (@sherryboschert on Twitter)

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IUD Contraception Cost May Inhibit Use

A copper intrauterine device (IUD) retails for the equivalent of $20 in France. In the United States, it costs $860, Dr. Eve Espey says.

“This is highway robbery. It has to change,” she said during a talk on long-acting reversible contraception at the annual meeting of the American College of Obstetricians and Gynecologists (ACOG). “Honestly,” she sighed, “If you went to Home Depot and picked up the supplies to make yourself an IUD, what would it cost? Like, under $1.” (Not that she’s advocating that.)

Dr. Eve Espey (Sherry Boschert/IMNG Medical Media)

Strong words, and they’re not coming from just any frustrated physician. Dr. Espey is chair of ACOG’s Working Group on Long-Acting Reversible Contraception and a professor of ob.gyn. at the University of New Mexico, Albuquerque.

The high U.S. price may be one reason that only 6% of U.S. women using contraceptives choose an IUD, even though studies show it’s one of the most effective kinds of contraception, along with levonorgestrel intrauterine systems and contraceptive implants, the other two kinds of long-active reversible contraceptives.

Sure, the cost of a copper IUD may be somewhat less than $860 if the physician or patient has access to government prices or other discounts, but it still creates a financial burden for physicians to stock their shelves with IUDs, not to mention inadequate reimbursement from insurers, she said.

“I think that the emerging, biggest barrier to IUD and implant use in this country is price,” Dr. Espey said. “ACOG is really trying to work to make a dent in that, but I think that until we see a cheaper IUD, it’s going to be a barrier to increased usage.”

Dr. Espey reported having no financial disclosures.

There’s only one copper IUD approved for use in the United States, so I contacted the makers of the ParaGard IUD, Teva Women’s Health. The “typical cost” for one ParaGard is $754, according to the company’s vice president for corporate communications, Denise Bradley. She said that the ParaGard’s price is “below most other forms of female birth control,” that most insurance plans cover ParaGard, and that the company offers women whose insurers don’t cover the IUD the option of paying by monthly installments.

She didn’t respond directly to the question of whether ParaGard’s cost is a barrier to use, but said, “Teva Women’s Health believes that increased access to all forms of contraception is of critical importance to all women of reproductive age.” She declined to comment on price differences between copper IUDs in the United States and other countries.

Recent data show that when financial barriers are removed and women receive standardized information about contraceptive choices, many more choose long-acting reversible contraception. The Reproductive CHOICE Project recruited nearly 10,000 women in the St. Louis area who desired contraception, gave them standardized counseling, and provided contraceptives for free.

A copper IUD. (Photo courtesy flickr/+mara/Creative Commons)

Results from the first 4,167 women to complete a year of follow-up found that 71% chose a long-acting reversible contraceptive (45% the levonorgestrel intrauterine system, 13% the copper IUD, and 13% an implant), Dr. Espey said. Others chose contraceptive pills, vaginal rings, transdermal patches, or another method.

After 12 months of use, 80% of IUD users reported being somewhat or very satisfied, compared with 54% of pill, patch, or ring users, she said. Only 55% of pill, patch, or ring users were on the same choice of contraception after 1 year compared with 84% of IUD users, 83% of implant users, and 88% of women who got a levonorgestrel intrauterine system.

The investigators recently reported that there have been 334 unintended pregnancies in 7,486 participants. Those using the pill, patch or ring were 22 times more likely to experience contraceptive failure compared with participants on long-acting reversible contraceptives (N. Engl. J. Med. 2012:366:1998-2007).

Long-acting reversible contraception was equally effective in all age groups, but use of the pill, patch, or ring was strikingly less effective in participants younger than 21 years, who were nearly twice as likely to have an unintended pregnancy compared with older women using those same methods of birth control.

–Sherry Boschert (on Twitter @sherryboschert)

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Focus Shifts from Children’s Self-Esteem To Self-Control

The child-rearing meme of self-esteem is being replaced by self-control. Well-intentioned efforts to promote children’s self-esteem in recent decades too often produced empty praise and, some argue, an epidemic of over-indulgence.

(Courtesy Wikimedia Commons/Dave Hogg/Creative Commons License)

Among physicians and therapists who counsel parents on effective child-rearing, “These days, self-esteem is out, self-control is in. In terms of concepts, we don’t talk about self-esteem any more,” says Laura Kastner, Ph.D.

Self-control is “a very powerful concept right now and, of course, is an important part of executive functioning,” she said at the annual meeting of the North Pacific Pediatric Society. “It’s not that self-esteem is not important, it’s just very imprecise as a measure.”

Measuring children’s self-control (ability to delay gratification, control impulses, and modulate expression of emotion) not only is easier and more precise, but it is producing important findings in longitudinal studies, added Dr. Kastner of the University of Washington, Seattle. She’s also co-author of the book “Getting To Calm: Cool-Headed Strategies for Parenting Tweens and Teens” (Parent Map 2009).

Children with “undercontrolled temperament” at age 3 were more than twice as likely to show evidence of a gambling disorder as adults at ages 21 and 32 compared with those who were well-adjusted at age 3, according to an analysis of data from a large, 30-year prospective cohort study in New Zealand (Psychological Science 2012;23:510-516).

The degree of childhood self-control predicted the likelihood of physical health, substance dependence, sound personal finances, and criminal records, another analysis of the cohort found (Proc. Natl. Acad. Sci. U.S.A. 2011;108:2693-2698).

Dr. Laura Kastner (Sherry Boschert/IMNG Medical Media)

Dr. Kastner said studies of this longitudinal data have shown that among the 20% of people with the lowest self-control as children, more than 40% had criminal records as adults, compared with criminal records for less than 15% of the 20% of people with the highest childhood self-control. Approximately 10% of the lowest self-control group was dependent on several drugs as adults, compared with less than 5% of the highest self-control group. Multiple health problems were reported by nearly 30% in the lowest self-control group compared with just over 10% of the highest self-control group. An annual income under $20,000 NZ (the equivalent of roughly $15,400 in U.S. dollars) was reported by more than 30% in the lowest self-control group and 10% of the highest self-control group.

The self-control meme is spreading rapidly, with books and articles exploring what it means and cultural differences in child-rearing. For one good example, see The New York Times article “Building Self-Control, the American Way.”

It remains to be seen whether interventions to help parents help their children to develop self-control will improve their lives later on.

–Sherry Boschert (on Twitter @sherryboschert)

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Making News at NEJM

Turns out there’s more to the process of deciding which studies to publish in top medical journals than simply peer review and the selections of sage editors. At the New England Journal of Medicine, editors conducted around a half-dozen informal polls in the past year to help them assess the worthiness of a particular research question, according to Editor-in-Chief Dr. Jeffrey M. Drazen.

Dr. Jeffrey M. Drazen (Sherry Boschert/IMNG Medical Media)

A case in point: When considering the study “Early vs. Late Parenteral Nutrition in Critically Ill Adults,” the editors knew that most ICUs in the United States don’t start parenteral nutrition for a week, and the study results supported this “late” start (New Engl. J. Med. 2011;365:506-517). So, was this a question that really needed to be answered?

Rather than rely on intuition or American self-absorption, the editors used an editorial intern who worked for the journal to do an informal survey by calling ICU doctors around the world. To their surprise, they found that ICUs in Australia, New Zealand, and most of Europe start parenteral nutrition earlier than in the United States, he said in a discussion at the annual meeting of the American Thoracic Society.

“Since we have more readers outside the U.S. than in the U.S., we figured this was something that was important to publish,” said Dr. Drazen, professor of medicine at Harvard University, Boston.

“I think it has a message for ICU interventions in general. Most of the things that we reasoned based on physiology – the physiology tells you that you need to provide these calories in order for the body to heal – may be wrong,” he added. “It’s hard to take the kind of physiology that we’ve learned in animals and translate it clinically to humans. We really didn’t test these questions one at a time.”

The journal sifts through 5,000 submissions to publish around 200 original research articles each year. “We take the job seriously,” and sometimes an informal poll helps the process, he said. The parenteral nutrition study didn’t seem to be so important at first, but “It turns out that we were wrong.

“We like to make decisions based on information rather than guessing,” Dr. Drazen said. “It should be the same when treating patients.”

–Sherry Boschert (on Twitter @sherryboschert)

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Teens with Eating Disorders Try Yoga

If the thought of yoga doesn’t bring to mind long-haired, half-naked gurus in India, it probably makes you think of thin young people in pretzel poses. True that, but it’s also become popular among populations that you might not expect. Yoga increasingly is being incorporated into treatment programs for young people who may be too thin or too fat – adolescents with eating disorders.

Yoginis relax and stretch. (Courtesy Wikimedia Commons/zivpu/Creative Commons License)

Dr. Cora C. Breuner helped conduct a study of 50 girls and 4 boys with diagnosed eating disorders. Participants were randomized to treatment with standard care (every-other-week appointments with physicians or dieticians) or standard care plus individualized yoga for 12 weeks. The yoga group showed significantly reduced food preoccupation immediately after each yoga session and significantly decreased Eating Disorder Examination scores at 12 weeks (J. Adolesc. Health;2010;46:346-51).

Speaking at the annual meeting of the North Pacific Pediatric Society, she gave a brief update: the teens in the yoga group showed greater improvements in weight a year after the study ended compared with the control group.

Dr. Cora C. Breuner (Sherry Boschert/IMNG Medical Media)

“Pretty much every eating disorders unit in the country now has yoga,” said Dr. Breuner, professor of pediatrics at the University of Washington, Seattle.

I don’t know about every eating disorders program, but a quick look on the Web found plenty that include yoga and lots of independent yoga classes geared toward people with eating disorders. On this list of eating disorder treatment programs from EDreferral.com, for example, yoga is mentioned by nine facilities in California and one each in Arizona, Hawaii, Mississippi, New Jersey, Pennsylvania, Tennessee, and Virginia. I found others online in Michigan and Washington, too, with just a few clicks.

Dr. Breuner’s 2010 study isn’t the only one endorsing yoga for eating disorders. Here’s another (Psychology of Women Quarterly 2005;29:207-19). Columbia University reported on this trend in 2007. And the Wall Street Journal reported in 2011 on increasing use of yoga not only for kids with disorders but for healthy students, under the clever headline, “Namaste. Now Nap Time.”

Some of the key goals of yoga are to strengthen the mind and body and the connection between the two. It’s not a solo treatment for eating disorders, but it supplements the standard strategies of weight stabilization, nutrition therapy, cognitive behavioral therapy, and family-based therapy.

That last one is another big change in the field that has happened since Stanford University researchers began showing in 2007 that it’s very helpful in treating children and adolescents to use parents as agents for positive change in a non-judgmental manner.

“Now we bring parents in right away to help with refeeding the child,” Dr. Breuner said.

It’s only a matter of time, I suspect, until we see special yoga classes for parents of children with eating disorders.

–Sherry Boschert (on Twitter @sherryboschert)

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Doctors Face Fallout from Adverse Events

When things go wrong medically or surgically – whether or not a mistake was made – two parties get hurt: the patient and the physician. It’s nice to see increasing attention on the effects of bad outcomes on physicians, as I reported in a previous post.

A new video helps ob.gyns. cope when things go wrong. (Sherry Boschert/IMNG Medical Media)

Here are the latest examples. The American College of Obstetricians and Gynecologists (ACOG) just released a new DVD that it is sending to all ob.gyn. residency program directors to view with their residents. Called “Healing Our Own: Adverse Events in Obstetrics and Gynecology,” the video features ob.gyns. describing the painful effects that adverse events have had on them, and how they recovered.

The video can be viewed in a members-only section of the ACOG website and it was shown in the Exhibit Hall during ACOG’s recent annual meeting.

Both members and non-members are welcome to join (for a fee) an ACOG-sponsored webinar on Adverse Events, Stress, and Litigation on July 10 at 1 p.m. Eastern Time. The webinar will address feelings of isolation, guilt, and shame that physicians commonly experience when bad things happen to their patients, feelings that only get exacerbated if the event leads to a lawsuit.

Ob.gyns. are the sixth most likely medical specialists to get sued regardless of whether a mistake was made, according to a 2011 report in the New England Journal of Medicine.

The stress created by adverse events is just a part of the higher than usual stress levels that physicians try to cope with every day. Tools like the American Medical Association’s A Physician’s Guide To Personal Health offer strategies for staying sane and healthy under stress. Non-profit groups like Medically Induced Trauma Support Services (MITSS) offer tools and templates for health care workers after adverse events, though they mainly focus on helping patients through the trauma. MITSS did post an extensive bibliography online for articles and resources related to the impact of adverse events on caregivers.

If you know of other medical specialty organizations like ACOG that are helping physicians cope with the fallout from adverse events, let us know and we’ll share the resources with our readers.

–Sherry Boschert (on Twitter @sherryboschert)

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