Category Archives: Preventive care
Alexander Tsai, MD, PhD, is an assistant professor of psychiatry at Harvard Medical School, a staff psychiatrist in the Massachusetts General Chester M. Pierce, MD Division of Global Psychiatry, and an honorary lecturer at the Mbarara University of Science and Technology in Uganda. He is an alumnus of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program (2010-2012), and a member of the core faculty in the Health & Society Scholars program at Harvard University.
When Robin Williams ended his life last month, his suicide sparked a raft of online and print commentary about the dangers of depression and the need to inject more resources into our mental health care system. I strongly agree with these sentiments. After all, as a psychiatrist at the Massachusetts General Hospital, I regularly speak with patients who have been diagnosed with depression or who are actively thinking about ending their lives.
But what if suicide prevention isn’t just about better screening, diagnosis and treatment of depression? What if there were a better way to go about preventing suicides?
It is undeniable that people with mental illnesses such as depression and bipolar disorder are at greater risk for suicidal thinking or suicide attempts. But not everyone with depression commits suicide, and not everyone who has committed suicide suffered from depression. In fact, even though depression is a strong predictor of suicidal thinking, it does not necessarily predict suicide attempts among those who have been thinking about suicide. Instead, among people who are actively thinking about suicide, the mental illnesses that most strongly predict suicide attempts are those characterized by anxiety, agitation and poor impulse control.
One of the challenges of health care reform is to realign financial incentives so that providers and hospitals have economic inducements to keep patients healthy, rather than just treating them when they’re ill.
In the latest Robert Wood Johnson Foundation (RWJF) Clinical Scholars Health Policy Podcast, Maryland Secretary of Health & Mental Hygiene Joshua Sharfstein, MD, discusses a hospital in Hagerstown, Md., that took charge of the local public school health program, hiring school nurses and more “because it’d be an economic winner for them.” The hospital’s economic incentives were such that, “If they did it well, and helped kids with asthma control their asthma so they didn’t need to go to the emergency room, [the hospital] would save money on ER visits,” Sharfstein explains.
Sharfstein is interviewed by Clinical Scholar Loren Robinson, MD. The video podcast is part of a series of RWJF Clinical Scholars Health Policy Podcasts, co-produced with Penn’s Leonard Davis Institute of Health Economics.
The video is republished with permission from the Leonard Davis Institute.
How Can Health Systems Effectively Serve Minority Communities? Promote Health In Community Settings.
To mark National Minority Health Month, the Human Capital Blog asked several Robert Wood Johnson Foundation (RWJF) scholars to respond to questions about improving health care for all. In this post, Monica E. Peek, MD, MPH, assistant professor of medicine and associate director of the Chicago Center for Diabetes Translation Research at the University of Chicago, responds to the question, “What are the challenges, needs, or opportunities for health systems to effectively serve minority communities?” Peek is an alumnus of the Harold Amos Medical Faculty Development Program.
With the health policy introduced by the Affordable Care Act, health systems have a unique opportunity (and admittedly, a challenge as well) to transform themselves in ways that promote health and not just treat illness. Such efforts are particularly relevant for racial/ethnic minorities, which disproportionately suffer from the morbidity and mortality of chronic diseases that are largely preventable in nature. Lifestyle changes (e.g. dietary patterns, physical activity, tobacco cessation, and limited alcohol intake) can prevent or help manage the majority of chronic diseases in the United States, which are disproportionately present within minority communities.
Adam L. Sharp, MD, MS is an emergency physician and recent University of Michigan Robert Wood Johnson Foundation Clinical Scholar (2011-2013). He works for Kaiser Permanente Southern California in the Research and Evaluation Department performing acute care health services and implementation research.
Violence is a leading cause of death and injury in adolescents. Recent studies show effective interventions can prevent violent behavior in youth seen in the Emergency Department (ED). Adoption of this type of preventive care has not been broadly implemented in EDs, however, and cost concerns frequently create barriers to utilization of these types of best practices. Understanding the costs associated with preventive services will allow for wise stewardship over limited health care resources. In a recent publication in Pediatrics, "Cost Analysis of Youth Violence Prevention," colleagues and I predict that it costs just $17.06 to prevent an incident of youth violence.
The violence prevention intervention is a computer-assisted program using motivational interviewing techniques delivered by a trained social worker. The intervention takes about 30 minutes to perform and was evaluated within an urban ED for youth who screened positive for past year violence and alcohol abuse. The outcomes assessed were violence consequences (i.e., trouble at school because of fighting, family/friends suggested you stop fighting, arguments with family/friends because of fighting, felt cannot control fighting, trouble getting along with family/friends because of your fighting), peer victimization (i.e., hit or punched by someone, had a knife/gun used against them), and severe peer aggression (i.e., hit or punched someone, used a knife/gun against someone).
Italo M. Brown, MPH, is a rising third-year medical student at Meharry Medical College. He holds a BS from Morehouse College, and an MPH in epidemiology and social & behavioral sciences from Boston University, School of Public Health. He is a Health Policy Scholar at the Robert Wood Johnson Foundation Center for Health Policy at Meharry Medical College. Read all the blog posts in this series.
In 1986, Congress took a step in the direction of patient advocacy by passing the Consolidated Omnibus Budget Reconciliation Act (COBRA). One part of this act, the Emergency Medical Treatment and Labor Act (EMTALA), has served as the precedent for federally mandated care and has largely shaped our understanding of urgent care delivery in America. While some have touted EMTALA as a public health victory, many have scrutinized the federal mandate, citing its imperfection and labeling it as a strong contributor to the current ailments of our emergency medical system.
However, 27 years after EMTALA became law, a greater emphasis is placed on preventive measures and comprehensive care, rather than urgent care, as a means to reduce negative health outcomes. Naturally, champions of cost-efficient comprehensive care have suggested that a federal mandate should be explored.
Adrian L. Ware, MSc, is a third-year graduate student in public health at Meharry Medical College. He holds a BSc in biology from Alabama Agricultural and Mechanical University, and an MSc in biology and alternative medicine from Alabama Agricultural and Mechanical University. He is a Health Policy Scholar at the Robert Wood Johnson Foundation Center for Health Policy at Meharry Medical College. He aspires to become a Christian psychiatrist serving the poor and underserved. Read all the blog posts in this series.
With innovation, brilliance, passion, and robust planning, public health students and practitioners ask: How can we protect the health of the nation? According to the Centers for Disease Control and Prevention, seven out of ten deaths in the United States are caused by chronic disease. The need for more cost-effective, comprehensive care has never been greater. Within the world of public health, there are three levels of prevention: primary, secondary, and tertiary.
Primary prevention reduces both the incidence and prevalence of a disease, because the focus is on preventing the disease before it develops. This can change the health of the nation for the better. Secondary and tertiary prevention are also significant.
It is well known that emergency care is vastly important, given the sheer complexity of episodic clinical cases that present to the emergency room in “life or death” situations. These “provisions” are necessary for the United States to uphold its high ideals of liberty and justice for all. Adequate, culturally competent, comprehensive health care for all citizens is a social justice issue, and a fundamental right. To this point, our health system’s extreme emphasis on tertiary care is amongst the most fiscally irresponsible ways to improve the health of the nation.
By Craig Pollack, MD, MS, MHS, a Robert Wood Johnson Foundation/U.S. Department of Veterans Affairs Clinical Scholar alumnus (2006-2009), assistant professor of medicine and associate director of the General Internal Medicine Fellowship program at Johns Hopkins University
The United States Preventive Services Task Force, a group never to shy away from controversy, recently released its final recommendations on prostate cancer screening. The Task Force gave prostate-specific antigen (PSA) testing a grade D, indicating that it should be discouraged as part of routine testing. They noted that there were substantial harms associated with testing and subsequent diagnosis and treatment: worry and anxiety; infections from biopsies; incontinence and erectile dysfunction. And the benefits were likely to be small—on the order of 1 life saved for every 1,000 men screened.
However, the recommendations have caused tremendous controversy. Critics question whether the Task Force has appropriately weighed the risks and benefits and balanced the existing evidence. Our research suggests that even those who agree with the recommendations will find it hard to stop screening. We are now working on a set of decision-making tools for primary care providers (PCPs) and patients to minimize unnecessary screening.
By David Krol, MD, MPH, FAAP, Robert Wood Johnson Foundation Human Capital Portfolio Team Director and Senior Program Officer
For many Americans, a visit to the dentist is a rarity—not by choice, but because their health plans don’t cover dental care, they can’t afford it, or because there is no dentist anywhere near where they live or work. If you’re on Medicare, you know that dental isn’t covered. If you’re part of the VA system, you know that dental benefits are treated differently. If you’re an adult on Medicaid or serve adult patients who are on Medicaid, you know the chances are slim that there’s great coverage for dental care, unless you are lucky to be in a state that still covers it. Why does this happen and what can result?
A study recently released by the Pew Center on the States offers startling data on the scope of the problem and its consequences. In 2009, some 830,000 Americans visited an emergency department for a preventable dental condition. It should be obvious that the emergency department isn’t the best place to seek dental care. The same year, 56 percent of Medicaid-enrolled children got no dental care whatsoever, not even a routine exam. That’s no care even with insurance for it!
Those numbers are alarming for many reasons, but mostly because they reveal a significant public health challenge confronting the nation: Many Americans simply aren’t getting the oral care they need, at any age, including the basic preventive services and education that can detect oral disease in early stages. They are putting their health at risk, and increasing the strain on an already-overwhelmed health care system.
As we head into 2012, the Human Capital Blog asked Robert Wood Johnson Foundation (RWJF) staff, program directors, scholars and grantees to share their New Year’s resolutions for our health care system, and what they think should be the priorities for action in the New Year. This post is by Laura Brennaman, MSN, RN, CEN, a fellow at the RWJF Nursing and Health Policy Collaborative at the University of New Mexico.
As we enter 2012, my resolution and wish for the U.S. health care system is a fundamental and transformative shift from a focus on disease management to one of health promotion. As Americans and health professionals, we must recognize that even the most advanced and best interventions to remedy diseases do not improve the overall health status of our country. Only preventing epidemics of chronic problems like metabolic syndromes, heart disease, and lung disease that plague our population can have significant wellness and economic benefits.
The Affordable Care Act offers a mechanism to foster such a change in emphasis with the establishment of the National Council for Prevention, Health Promotion, and Public Health that intertwines the governance of 17 executive agencies. Leadership from diverse arenas such as transportation, trade, agriculture and labor concentrating on health promotion strategies from within and across domains provides opportunities to affect many of the determinants of poor health and transform them into positive scenarios to improve health status of all Americans.
Actualizing new health promotion strategies through shifting spending from direct care provision to prevention mechanisms of social programs like job training, housing supports, public transportation systems, and childcare services has greater potential to improve health outcomes for Americans than new technology or pharmaceuticals for disease management.
In this coming election year, the candidates for office will propose a bevy of ideas concerning health care. However, we must pay heed to all programs they propose to enhance or curtail through a lens of health outcomes. Proposals dealing with environment, energy and economic issues will affect our health as surely as any health care reform plan.
Hence, my resolution for our health care system is holistic and comprehensive consideration of the health impact of every policy. Through such integrated deliberation, we will achieve improvement in health outcomes and reductions in health disparities for all Americans.
A newly released study from RWJF Clinical Scholar (2009-2011) Lenard Lesser, M.D., finds that Medicare covers only a fraction of the preventive care services recommended by a government task force, and that health care reform should be able to mend the current disconnect between Medicare reimbursement policies and the recommendations of the U.S. Preventive Services Task Force (USPSTF), charged by the government with reviewing clinical preventive health services. In particular, Lesser’s study points to the need to improve coordination between assessing the risk for certain illnesses and ensuring that patients receive the appropriate tests and follow-up clinical services. In addition, Lesser finds a persistent and disturbing lack of coverage for obesity and nutritional services, both of which are recommended by the task force and important for maintaining good health.
The study was published in the January/February issue of the Annals of Family Medicine.