Study questions the value of family medical history

It's the first thing you do at a doctor's visit after producing your proof of insurance -- fill out a family medical history. Many doctors ask detailed questions or require patients to complete long forms, and patients sometimes worry about not knowing or forgetting something important.

But does a medical history collection actually do any good? A new study casts some doubt about its value. Researchers funded by the Agency for Healthcare Research and Quality reviewed 137 studies on various aspects of family history-taking. The studies were performed between 1995 and March of this year. Researchers set out to examine three aspects of the issue: the pros and cons of collecting a family medical history; how well the history predicts an individual's risk of disease and how accurate patients report it.

They found that there were few studies that actually examined these questions thoroughly. Overall, there was not enough evidence to say how history collection affects patients' outcomes. The analysis found that patients tend to report the absence of disease in relatives better than the presence of disease.

"We understand the absolute importance of family history in assessing the risk of genetic conditions," said the lead author of the study, Dr. Brenda J. Wilson, an associate professor of epidemiology at the University of Ottawa. "But when you are looking at complex diseases, such as heart attacks, strokes, diabetes and so forth, we wouldn't expect the family history to tell us everything we need to know. Family history plays into it, but it's one of many factors."

Family history has been thought to serve two purposes. One is to assist doctors in assessing a patient's risk. The other is to motivate the patient to make changes that might lower risk. But the authors concluded that more research should be done to pinpoint what is helpful about a family history and how much it matters along with other risk factors. For example, Wilson says, a doctor looking at the risk of heart disease will take a patient's blood pressure, weight and will perform cholesterol and perhaps other tests.

"What we don't know is how useful family history is along with this other risk information," Wilson said. "For complex disorders, we need to develop the evidence for how to use it -- so physicians know how it factors in."

Methods for collecting family medical history should be simpler, she added. Electronic medical records and other information-gathering tools should be helpful.

"I think we are going to have to take family history more seriously," Wilson said. "We may want to put this in the hands of family members and have them gather it and be the custodians of it."

The study was published Monday in the Annals of Internal Medicine.

-- Shari Roan

Photo credit: Christopher Nielsen  /  For The Times

Lack of health insurance played a role in thousands of child deaths, researchers say

An analysis of 23 million hospital records from 37 states shows that a lack of health insurance likely played a role in the deaths of nearly 17,000 U.S. children over a 17-year period.

Researchers at Johns Hopkins Children's Center examined records from 1988 to 2005. They compared the risk of death in hospitalized children who were covered by health insurance with those who did not, and found that uninsured kids were 60% more likely to die, regardless of their medical condition. This does not mean that the children received less aggressive care at the hospital but that they were probably in poorer health before the arrived, researchers said. Insurance status did not affect how long a child spent in the hospital, according to the study.

The study did not count children who died outside the hospital or after leaving the hospital, which means that deaths among uninsured children are probably even higher. The report will be published Friday in the Journal of Public Health.

"Can we say with absolute certainty that 17,000 children would have been saved if they had health insurance? Of course not," a co-author of the study report, David Chang, said in a news release. "The point here is that a substantial number of children may be saved by health coverage. From a scientific perspective, we are confident in our findings that thousands of children likely did die because they lacked insurance or because of factors directly related to lack of insurance."

As the healthcare reform debate reaches a critical stage in Washington, the study is a reminder of the human cost of healthcare inequality. About 7 million American children are uninsured.

"In a country as wealthy as ours, the need to provide health insurance to the millions of children who lack it is a moral, not an economic issue," Dr. Peter Pronovost, a co-author of the study, said in a news release.

-- Shari Roan

Photo: Healthcare reform advocates protest outside the offices of Cigna Insurance in Los Angeles. Credit: Mark Ralston / AFP/Getty Images

Recommendations for new school meal nutrition standards

The nutrition standards behind the National School Lunch Program and the School Breakfast Program have not been updated since 1995. Today, the federal Institute of Medicine is issuing a report recommending new standards, calling for more produce, more whole grains. And for the first time, a limit to calories.

Thirty million children eat school lunch, and 10 million eat school breakfast -- and the IOM panel says it hopes new standards will help those children develop good habits that they carry into adulthood. That, the panel says, should help curb obesity and other health problems associated with diet.

The panel's recommendations go to the U.S. Department of Agriculture for possible implementation. It was the USDA which requested the report.

The panel says new standards would cost money -- for food as well as for training and capital improvements. But it says food costs would go up by less than 10% for breakfast and 25% or less for lunches. The government now spends $8.7 billion a year in reimbursements for school meals to school districts.

The recommendations are meant to bring school food in line with the dietary guidelines the government issues for Americans. It seeks to have the amount of sodium in school meals reduced by more than half over the next decade.

Among its recommendations: that calories be limited, based on age level, for breakfast and lunch, and that the sodium level for a typical lunch be eventually reduced to 740 milligrams. It also sets out targets for weekly servings of fruits and vegetables, and it calls for more whole grains.

"It's about time," says Matthew Sharp of the California Food Policy Advocates and one of the people who testified before the panel. Meals, he says, should be nutritious and affordable and they also should "teach kids healthy habits" and expose them to a variety of foods.

-- Mary MacVean

But surely people providing healthcare have health insurance

As the nation's leaders discuss who should get health insurance and in what fashion and how much it should cost, many people who provide healthcare are watching from the sidelines.

First, the Kaiser Family Foundation offered up an analysis this week of the nation's much-discussed 46 million uninsured people.

That report notes: "More than eight in ten of the uninsured are in working families -- about two thirds are from families with one or more full-time workers and 14% are from families with part-time workers. Only 19% of the uninsured are from families that have no connection to the workforce. Even at lower
income levels, the majority of the uninsured are in working families. Among the uninsured with
incomes below the poverty level ($22,025 for a family of four in 2008), 55% have at least one worker in
the family.

Then came a closer look at healthcare workers specifically, many of whom would fall into this category. (And by healthcare workers, think beyond doctors and nurses to include the people doing the most basic tasks.)

Using National Health Interview Survey data, researchers at the University of Minnesota found that 11% of healthcare workers are uninsured. Residential care workers are especially likely to lack coverage. 

Here's the abstract of that study, published online Thursday in the American Journal of Public Health.

-- Tami Dennis

And now a word from a connoiseur of world healthcare systems...

T.R. Reid's a busy guy. First the journalist and author schleps from one country to another in his quest to assess the world's healthcare systems -- and their treatment options for his aching shoulder. Then he schleps from one interview and appearance to the next in his quest to discuss his findings -- and the book that resulted.

That book, "The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care," explains in highly readable fashion how other countries manage to offer healthcare to their citizens -- and what those citizens can expect.

Reid wrote last month in a Newsweek article that synopsized his book quite efficiently:

"The design of any country's health-care system involves political, medical, and economic decisions. But the primary issue for any health-care system is, as President Obama made clear last week, a moral question: should a rich society provide health care to everyone who needs it? If a nation answers yes to that moral question, it will build a health-care system like the ones in Britain, Germany, Canada, France, and Japan, where everybody is covered. If a nation doesn't decide to provide universal coverage, then you're likely to end up with a system where some people get the finest medical care on earth in the finest hospitals, and tens of thousands of others are left to die for lack of care. Without the moral commitment, in other words, you end up with a system like America's."

The book lays out the precise differences among other nations' systems, not just the ones mentioned above. (His recount of the Ayurvedic approach in India is especially riveting.) And those differences are considerable even among countries that try very hard to get it right, with "universal healthcare" being markedly different than a universal approach. 

Whether you're primed to agree with Reid's bleak assessment of the U.S. healthcare system or not, his perspective -- both global and intimate -- makes for worthwhile reading as the nation tries to come to terms with its current and future approach to healthcare.

(Today's news story: Healthcare triumph gives way to heightened battle)

If you're looking for Reid giving a quick primer on the topic, here he is recently on NPR's "Fresh Air", in a question-and-answer article on Oprah.com, and in a podcast from Stanford School of Medicine. As noted, he's been busy.

Then there's the "Frontline" documentary that spawned it all: "Sick Around the World." And of course, the book itself.

-- Tami Dennis  

Photo: T.R. Reid.Credit: "Frontline" / PBS

MRIs plus low-back pain equals more dubious surgeries

Areas of the country with the highest number of MRIs have the highest incidence of surgery for lower-back pain, despite the lack of evidence showing that the surgeries are beneficial, Stanford researchers reported today in the journal Health Affairs. Previous studies have shown that increased surgery rates for back pain don't improve patient outcomes, "so heading in this direction is concerning," said senior author Laurence C. Baker, a professor of health research and policy at the Stanford University School of Medicine.

Between 2000 and 2005, the availability of MRI scanners in the United States more than tripled, from 7.6 machines per 1 million persons to 26.6 per million. State-of-the-art scanners cost more than $2 million apiece, so scans are expensive--about $1,500 for one low-back scan. The increased use of the scanners and the growing number of surgeries that result from such scans are one component in the increase in healthcare costs, Baker said.

Baker and Jacqueline D. Baras, a medical student, obtained Medicare claim data from 1998 to 2005 for about 20% of patients with non-specific low-back pain and compared it with data on the availability of MRI scanners, as determined by IMV Ltd., a healthcare consulting firm that provides such data to the medical industry. They found that the number of scans for low-back pain and the number of resulting surgeries in each of the 318 Metropolitan Statistical Areas were directly proportional to the availability of scanners. About two-thirds of the scans, moreover, occurred in the first month after the onset of pain, despite clinical guidelines that recommend at least a one-month delay because of the large number of patients who spontaneously recover.

"The net result is increased risks of unnecessary surgery for patients and increased costs for everybody else," said Dr. John Birkmeyer, a professor of surgery at the University of Michigan who was not involved in the study.

-- Thomas H. Maugh II

A state-of-the-art MRI can cost $2 million.

Credit: Jim Cole / AP

How does your state's healthcare rank?

The cost of healthcare, quality of healthcare, access to healthcare and overall outcomes related to healthcare ... they vary from state to state. Surprised? No. Interested in the details? The Commonwealth Fund is here for you.

Its second state scorecard ranks all the states on a variety of health-related measures and estimates the lives and money that could be saved with improvement.

Vermont, Hawaii, Iowa, Minnesota, Maine and New Hampshire are singled out as doing a pretty darned good job overall. California, on the other hand, ranks 31st overall -- moving up from 40th in 2007. The state didn't fare well in the prevention and treatment category, but in factors summed up under "healthy lives," it ranked fifth.

The summary stresses, on the downside, the state of insurance coverage for adults and rising healthcare costs and, on the upside, improvements in children's coverage.

-- Tami Dennis

Poll reflects the shifting tides of American support for health reform

Amid the mercurial American public, support for healthcare reform may have slid over the summer (blame it on the doldrums perhaps, if not individual performances), but now it's fall -- and the support seems to be ticking back up. 

In August, 53% of Americans said they wanted healthcare change; in September, 57% were behind it. In August, 42% thought the nation couldn't afford to tackle the issue at the moment; in September, that number had ebbed to 39%.

These numbers are found in a new poll from the Kaiser Family Foundation.

The percentage of Americans who think their family would be better off with reform moved upward as well, from 36% in August to 42%. Those who think they and their loved ones would fare more poorly declined, from 31% in August to 23%.

For a closer look at American public opinion, including support for various proposals (individual mandates, employer mandates, state program expansions and the like), go here.

(The site also offers an easy way to compare major healthcare reform efforts, for those truly riveted by the debate.)

Of course, more than a fourth of the nation still thinks health reform wouldn't affect them much one way or the other.

-- Tami Dennis

Photo credit: Gary Friedman / Los Angeles Times

Electronic records, medical errors -- and the inescapable human factor

We all know that medical errors happen -- and most of us have read that electronic medical records will help deal with that problem.

But electronic record-keeping doesn't remove the human factor. A study published in the Archives of Internal Medicine, has found that electronically alerting doctors of suspicious test results doesn't mean doctors will a) open the electronically delivered alert or b) act on it if they do.

And though you'd think that alerting more than one physician would reduce the chances that a patient would slip through the cracks, the study found just the opposite: Suspicious test results were less likely to be acted on, not more, presumably because each physician assumed the other doctor had taken the necessary steps.

The study, by Dr. Hardeep Singh of the Veterans Affairs Medical Center in Houston and co-workers, was conducted in a Veterans Affairs outpatient facility from November 2007 to June 2008. The VA has a fairly sophisticated electronic medical records system. The study focused on reports of imaging exams -- CT scans, MRIs, mammograms, sonograms and radiograms.

Under the system, when a result is abnormal and needs follow-up, an "alert" window comes up on the doctor's computer screen. It stays there for two weeks. Then it goes away.

During the time period studied, there were 123,638 imaging studies. Of those, there were 1,196 alerts indicating something was potentially abnormal.

Of the alerts, 217 (18.1%) were unopened after two weeks. 

And of the 1,196 alerts, 92 (7.7%) didn't receive timely follow-up, such as a call to a patient or ordering of more tests. (The definition of timely follow-up was within four weeks.)

Perhaps surprisingly, the rates of poor follow-up were about the same for reports that were unopened and reports that were opened.

But in cases when a radiologist actually got on the phone and talked to a physician about a test, follow-up was more likely. (This may have partly been due to those results being more serious than other abnormal tests, the authors said.)

The study doesn't say how this electronic system compares to ones where it's all paperwork and word of mouth: surprisingly, there aren't good comparative data to be had, the authors note. But it does have a few suggestions about what it found:

1) Something needs to be done about the information overload doctors experience. If you're peppered with alerts from left, right and center, you're more likely to ignore or miss some.

2) There has to be clear understanding about who, if more than one doctor is notified, is the responsible party for taking the next step.

3) Alerts that haven't been opened should stay up on doctors' screens for longer, "perhaps even indefinitely, and should require the healthcare provider's signature and statement of action before they are allowed to drop off from the screen."

4) The technology should do more than track whether doctors have opened alerts. They should track whether follow-up action was taken.

-- Rosie Mestel

Jaundice in newborns is common; chronic condition isn't. So what to do?

To reduce the number of newborns who develop severe jaundice, screen them all for high amounts of a blood pigment known as bilirubin. That's the word from researchers at UC San Francisco Children's Hospital and Kaiser Permanente.

If the conclusion seems fairly straightforward, consider the fuller picture....

In that new study, published today (here's the abbreviated version and the news release) in the journal Pediatrics, the researchers compared bilirubin levels in two groups of infants -- those born at hospitals that routinely screen for high bilirubin, or hyperbilirubinemia, and those born at non-screening hospitals.

Infants born at the screening hospitals were considerably less likely to have severe hyperbilirubinemia. They were also considerably more likely to have undergone treatment -- phototherapy -- for the condition, regardless of whether it may have been by-the-book necessary.

Before we proceed, a primer on bilirubin.... This pigment, created in the breakdown of red blood cells, is normally excreted via bile, which is made by the liver. But newborns' livers sometimes don't work at full power right off the bat, and the bilirubin can build up in the blood, leading to hyperbilirubinemia and the yellowish skin and yellowed eyes of jaundice. That condition is fairly normal, affecting about 60% of all newborns. It's also  fairly benign -- often resolving on its own. Here's more on jaundice in healthy newborns from KidsHealth.

Levels that are extremely high, however, can lead to a rare neurological condition known as chronic bilirubin encephalopathy, or kernicterus. The resulting brain damage can cause cerebral palsy, hearing and vision problems and death. Here's information from the Centers for Disease Control and Prevention on warning signs and risk factors:

Back to the fuller picture...

The U.S. Preventive Services Task Force has concluded that though screening may have its benefits, there just isn't enough proof that universal screening would prevent the more dire condition.

Those recommendations, or lack thereof, are published in the same issue of Pediatrics. As the task force's website notes:

"There is evidence that screening using risk factor assessment or bilirubin level measurement can identify infants at risk of developing hyperbilirubinemia, but there is no known screening test that will reliably identify all infants at risk of developing chronic bilirubin encephalopathy. Not all infants with chronic bilirubin encephalopathy have a history of hyperbilirubinemia, and not all infants who have extremely high levels of bilirubin develop chronic bilirubin encephalopathy."

The articles, just two in a larger collection, are part of the journal's wider look at the issue -- an issue with pros and cons yet to be resolved.

-- Tami Dennis

Photo: In a newborn, the blood test for bilirubin is usually taken from the heel, prompting a howl from the newborn and corresponding anguish from the new parent.

Credit: Los Angeles Times