nyc's sugar-betes

Hope everyone's having a happy holiday weekend!

Two diabetes-related pieces of news have surfaced recently. One: unfortunately, diabetes is on the rise in NYC. According to a November 2009 report from the NYC Department of Health and Mental Hygiene, diabetes is up 13% from 2002. It is more prevalent in men than women, and in those without a high school degree than those with a diploma. Interestingly, the death rate from diabetes has not moved since 2002 (it was then and is now 18 deaths per 100,000 New Yorkers) but it is likely to be underreported. As most reports on diabetes have noted, the illness disproportionately affects African Americans, Hispanics, and those from low income neighborhoods.

The other interesting item is that NYC's Health and Hospitals Corporation (the largest public health care provider in the country) has recently launched an online program to help the 58,000 diabetics under its care. The site features advice on how to control diabetes by eating healthfully and exercising. The site also features some patient success stories to motivate readers.

grad school blues

It's that time of year. Well, yes; it's the time of year when Santa posters appear in bodega windows and the radio plays Trans-Siberian Orchestra's version of "Carol of the Bells", which sounds like it belongs on the soundtrack of The Bourne Identity. But it's also the time of year when grad school really starts sneaking up on you.

I have not gotten my hair cut since September, and it is a streak that will remain unbroken into 2010. My room, usually neat, was an unholy mess when I left it last night to meet up with my boyfriend. My wallet is a quagmire of tickets, receipts, and business cards that will only with diligent searching give up a dollar bill. I am unsure when, how, and indeed if my Christmas shopping will get done. The scenario is this: I have class Mondays, clinical Tuesdays and Wednesdays, and work Thursdays and Fridays. I also occasionally have clinical on Saturday and am at work for a few hours every Sunday. Don't get me wrong; my life is great. I am finishing up a program that leads to a great career, I am working part time as I do it, and I still have the opportunity to maintain great relationships with friends/boyfriend/family/roommates. But all this comes at a cost: the little shit is not getting done.

I doubt I'm the only one who feels this way, as I doubt I am the only one who cannot justify her disproportionate crankiness about things like this. After all, what does it matter that I just dragged 20 lbs of laundry across the street because I couldn't get my act together before it weighed as much as a small child? That I haven't blogged in forever? (Although this blog obviously a collection of seminal insights into public health, I know everyone who reads it and they've all got better things to do than wait around for a post.) Why do I care that the bottom of my backpack is littered with...litter? Or that before dragging them off today, the last time I washed my sheets was...was...hmmm...

Anyway, it does matter. It does. Not because any one of these things is in and of itself important, but because these are the things that make me feel like I'm in charge, instead of my schedule. Like I am on top of things, instead of buried under a pile of incomplete tasks. Simply put: taking care of the little shit is how I maintain my illusion of control. And that illusion is fading.

I console myself with this thought: less than three more weeks. Time will handly what I evidently cannot. On December 14, I will have my final final. On December 19, I will complete my last clinical hour. And then, in all likelihood, I will go home and take a nap. Before getting up and washing my sheets.

new database helps patients anticipate costs

I'm a little late on this, but it's interesting: two weeks ago, NY Attorney General Andrew Cuomo announced the creation of a database of doctor's fees and insurance reimbursement rates, designed to help patients who want to see an out-of-network health care provider anticipate what it will cost.

The New York Times reports that insurers often reimburse only a percentage of the cost of an out-of-network provider. However, sometimes that cost is not what the provider has billed, but rather what the insurance company has determined is "reasonable and customary" based on the fees other providers in the same area charge for similar services. In the past, insurance companies have been accused of systematically lowballing the "reasonable and customary" number, leaving patients to make up the difference. The purpose of the database is both to help the insured estimate what they will be reimbursed before seeing the out of network specialist, and also to assess the fairness of their insurance company's "reasonable and customary" estimate.

The database is being funded by several insurance companies, in particular UnitedHealth Group, as part of a settlement with Mr. Cuomo reached last January when he brought suit against them for deflating their "reasonable and customary" estimates.

insurance and women's health

Few people realize pregnancy is one of those pesky "preexisting conditions" we've heard so much about. But the push/pull between insurance companies and reproductive health does not stop there. My roommate Ella, a labor and delivery nurse in the Bronx, sent me this blog post which features a woman who was denied coverage due to a previous (completely unremarkable) Cesarean section, and told she could only eligible for coverage if she was willing to have her tubes tied.

just in case...

I have been told I have seemed anti-vaccine as I have blogged about the mandatory H1N1 and flu vaccines for health care workers (HCWs). I did pause over the notion that something like this could be mandatory for half a million people, many of whom explicitly stated they did not want it, for me the central issue was not rights, but efficacy. To me, if the two vaccines had been proven to be very effective in preventing transmission of the flu, it would be justified to require health care workers to get them. Similar logic has been applied to the MMR vaccine, which is mandatory for NYS HCWs, despite challenges in court. However, if the efficacy was low or even not well established, I thought requiring it would be wrong

The logic of the mandate was that HCWs who got the vaccine would be less likely to transmit flu to their patients than non-vaccinated HCWs because their immune systems would be better equipped to fight off the infection. I was unable to find any studies addressing this point explicitly. However, I did find an article in the September issue of the New England Journal of Medicine addressing the overall effectiveness of the flu vaccine. The article was especially interesting because the objection I have head most to the flu is, "how well does it work in young, healthy people?", and participants in this study were all between 18 and 49 years of age. In fact, the mean age of participants was 23.3 with a standard deviation of 7.4 years. That said, no one was excluded from the study on the basis of health unless they had a condition for which the flu vaccine was contraindicated.

The study's intention was to compare the efficacy of the inactivated virus vaccine to the live virus vaccine. The 1952 subjects, all eligible to receive either vaccine, were randomized into two groups. Within these groups, 5 out of every six people received a vaccine, the sixth received a placebo. INTERESTINGLY, each of the vaccines contained three strains of flu, two type As and one type B. One of the type As was H1N1. Subjects were told to follow up if they had a respiratory symptom (stuffy nose, cough) combined with a "constitutional symptom" (fever, malaise). If and when they did, the organism infecting them was cultured.

In the end, 119 participants came down with the flu. One had H1N1, and the others were infected with either the other A strain contained in the vaccine, H3N2, or a B strain that was not in the vaccine. The efficacy of the vaccine with inactive virus when compared to the efficacy of placebo was 73%, the efficacy of the active virus compared to placebo was 51%. Obviously, the inactive vaccine was the more effective of the two.

So there you have it. If you get the inactive flu vaccine, even if you're young and probably healthy, there's a significantly smaller chance you'll get the flu than if you don't. To what extent this translates to a diminished likelihood of transmitting it to someone else is still unclear, although the inference that it would lead to a significantly diminished transmissions is more plausible in light of this rate of efficacy. Frankly, the results were more dramatic than I anticipated, and while I'm still not sure I agree with mandating the flu shot, I am more sympathetic to the idea than I was before seeing these results.

can they make us? no, no they can't

On Friday, October 16, a judge temporarily blocked the mandate that all health care workers (HCWs) in NYS get both a seasonal flu and a swine flu vaccine before November 30 or face disciplinary action. The judge granted a "temporary restraining order", which I gather means the requirement was temporarily suspended. A further hearing was scheduled for October 30, when the health department would have had the chance to continue making its case.

However, it's doubtful that that hearing will ever take place, since on Thursday, October 22, Governor Paterson rescinded the mandate that all HCWs get the vaccine due to a more limited supply of the vaccine than anticipated. The CDC has thus far only been able to produce about 23% of the anticipated amount of H1N1 vaccine, and the state government has decided it's more important to vaccinate those at risk of becoming seriously ill from the disease (pregnant women, for example) than those at risk of transmitting the disease.

The requirement sparked controversy from the beginning, with health care workers protesting in front of the capitol building and lawsuits filed by three separate groups. Interestingly, each group represented a different demographic: one was nurses, one was public employees, and one was teachers.

more grocery stores in NYC

In late September, the New York City Planning Commission approved an incentive program to encourage more grocery stores to open their doors in underserved parts of NYC. The incentives include: allowing residential buildings to be 20,000 square feet larger than permitted now if they include a grocery store, forgoing the requirement that smaller grocery stores provide parking for their customers, and providing grocery stores in the targeted areas with "tax abatements". In order to be eligible, stores must devote a least one half of their square footage to food, and a certain percentage on top of that to perishables such as fresh produce, meat, and dairy. These areas targeted by this program include: northern Manhattan, central Brooklyn, south Bronx, and downtown Jamaica in Queens. (I kind of see why Staten Island people get so bitter sometimes...)

exam one done

Today was my first exam of this semester. It was in Diagnosis and Management II, from the lectures on GI, urinary, hepatitis of all ilks, and emergency preparedness. It went fine, with the usual mix of questions that range from obvious to esoteric. Of course, I want them to post the grades ASAP...

After this, I have few actual assignments ahead of me. This class has two more exams, and my other class requires one case presentation and one paper. However, the paper is our "capstone", intended to serve as a master's thesis, and has been in the works since early 2009. That's it. The vast majority of the work will be in clinical, where I have to see patients and present them to my preceptor. This semester's preceptor is a character, who prides herself on being "forceful" and having "a big mouth" but also seems like a very good clinician who cares a lot about her patients.

Because of the extra day of clinical (two per week instead of just one) this semester has been more challenging for most of us than previous semesters. This is especially true for those of us who are working. I've been keeping a mental tally of the weeks completed; my friend has made a paper chain with one link per remaining week, which she can tear off on Saturday nights. Her husband ruefully noted it was longer than he had been hoping. Another friend happily told me last night there were only 73 more days until December 23. Nice.

flu and H1N1 vaccine: can they make us?

A recent NYS mandate that all health care works get both a seasonal flu shot and an H1N1 vaccine has stirred some controversy. Hospital workers have objected to making the two shots a requirement for continued employment, saying that it's "anti-American" for medical treatment (or in this case, prophylaxis) be mandated. The state has countered that in the past when the vaccine was voluntary, only 40% of workers got it. I have nurse friends who are passionate about public health who have up until now declined to get the shot. They question its efficacy in young, non-immunocommpromised workers, and point out that the shot only contains the fews strains epidemiologists guess will be most prevalent this season, and thus is far from a sure thing.

I believe (and I may be wrong) that as a student working in health care, I am subject to the same mandate. I am certainly required to get both shots. A few weeks ago, my school notified all health care graduate students (nursing, medical, dental, and possibly the physical therapists) that we were required to get the seasonal flu shot ASAP and could not do our clinical rotations, mandatory as a part of the curriculum, without them. Those students who had student health insurance could get the shots at student health services; those who did not had to go elsewhere. I ended up going to an NYS Department of Health site to get mine. I am not sure what I will do when H1N1 comes out. Frankly, I felt that if they were going to require I get the shot, they should have at least offered me the convenience of paying for it at student health services, as they offer us the convenience of buying books at the campus bookstore.

Anyway, to the few people who read this blog, I would be interested to hear what you all think. Should it be mandatory for nurses, doctors, and everyone else, to get the flu shot by order of NYS?

long island hospital moves towards EMRs

North Shore Long Island Jewish Health System, a network of 13 hospitals, has announced its intention to digitize its record system. The hospital hopes the new system will provide both a competitive advantage for itself and improved care for patients, mostly by better integrating records kept across the system. The estimated cost: $400 million. NYC's government has historically been a leader in encouraging the adoption of EMRs, but most of that has been in small private practices, nothing on the scale of a network like this.

NP stats

The Kaiser Family Foundation recently released a fact sheet on the number of nurse practitioners in the US, with a breakdown by state. In total, the US has 147,295 NPs. The states with the most NPs are: California, with 15,230 NPs, and New York, with 14,272. The states with the least: North Dakota, with 343 NPs, and South Dakota, with 372.

good cop bad cop

NYC has been sending public health mixed signals!

A recent Post article notes an unexpected trend: a reduction in the number of uninsured people in NYC over the last several years. According to the article, of the 2.7 million New Yorkers enrolled in a public health insurance program (Medicaid, Child Health Plus, Medicare...) approximately one million of them first received benefits since 2002. Moreover, 90% of the city's children are insured, even if one includes the children of undocumented immigrants. So, according to the article, NYC is about halfway there: 1 million down, 1.3 million to go.

On the other hand, a Brooklyn judge recently ruled that the state has discriminated against thousands of mentally ill residents by placing them in "adult homes" instead of "supported housing". The New York Times reports the suit was brought by Disability Advocates, a nonprofit legal services group, under the auspices of the Americans with Disabilites Act. The judge ruled that these adult homes were "segregated settings"that did not provide residents with appropriate opportunities to cultivate daily living skills and personal independence. Interestingly, the cost per resident associated with an adult home is about $7,000 greater per year than the cost per resident in a supportive housing facility. ($47,936 vs. $40,253).

I work in such a supportive housing facility, and I think it strikes an excellent balance for its residents. Medical care is provided by a GP and a psychiatrist, both of whom come in weekly, and medication administration and monitoring is performed by myself, an RN, who is in twice a week. Moreover, each resident has a social worker to help them with a huge number of issues: government benefits and the associated paperwork, bills and financial management, part time work, and coordinating medical care when it goes beyond the on-site staff. Meanwhile, the residents maintain a high level of independence and self-sufficiency. Overall, it's great.

gross!

NYC is mounting a new ad campaign to prompt New Yorkers to think about the unhealthy drinks they consume daily. The ads, which feature a dark-colored drink being poured into a glass filled with fat, urge readers not to "drink yourself fat". These ads are in the same aggressive vein as the anti-smoking PSAs featuring "Maria from the Bronx", which showed a woman holding up her hands, both of which are missing several fingers due to multiple amputations. The Daily News reports that the NYC Department of Health spent $277,000 and used focus groups to develop the tough strategy.

Interestingly, Gothamist pointed out that one of the bottles featured in the posters looks an awful lot like Snapple, the official beverage of NYC. Snapple has exclusive rights to distribute in NYC public schools and to stock the vending machines of NYC-owned buildings. Hmmm...mixed message, much?

back for more

OK, vacation's over, and I'm back to blogging. This post is kind of a grad student/public health combo. The grad student aspect of the blog is this: one more semester to go. I have one more semester until I am supposedly qualified to diagnose and treat a wide variety of ailments. Yike. The summer semester of my program, which ended just before my last post, was frighteningly bereft of clinical information. I had a class on violence and ways it may come up in clinical practice, which did make some excellent points. I had another class on the logistics of being an NP. It was devoted to admin things like licensing, practice agreements, insurance, etc. Important stuff, but it didn't really feel like it should take priority over, say, more diagnosis and management. Finally, we had a seminar where we presented cases, and that was useful. But we only met for two hours every other week, so...Anyway, suffice it to say I've gone online and bought some review books to supplement my already expensive education.

Now to public health. The President and CEO of the Kaiser Family Foundation, Drew Altman, recently wrote one of his "Pulling It Together" columns about the state of HIV prevention funding in the US. He notes that NYS is the top funder of HIV prevention, spending $88 of the $600 million spent nationally. This is slightly less impressive than it sounds, since NY is home to 17.6% of the people in the US living with HIV, and $88 million is only 14.6% of the overall funding. Still, a good start. However, the column notes these figures are for FY07, and things are likely to have changed since then thanks to the economy's shenanigans. The column also links to one of previous columns about attitudes towards HIV nationally.

whew

So it's been awhile since I last posted, and the main reason for that has been that I have been swept up in the process of looking for and moving in to a new apartment. My roommates and I, after nearly eight months of a never-quite-gone bed bug problem, left our old place after the lease was up. We moved from Washington Heights to Hamilton Heights, a neighborhood in northwest Harlem. So far, no bugs. :)

Bed bugs have been a huge problem in NYC of late: there have been articles in the New York Times, The Economist, and by the BBC covering the epidemic. NYC's governing bodies have formed committees to address the situation. However, the problem seems to be worsened because despite such committees, the bed bug problem has no real home in city government. The obvious candidate, the Department of Health, makes the point that the bugs are not disease carriers, and hence are not a public health threat. One might argue that bugs that bite you while you sleep, producing large, itchy, reddened wheals on the face, neck, arms, legs, and torso, don't need to carry disease to be a public health threat. But really, who's to say?

Anyway, now that the bed bug/moving situation has been sorted out, my next stop is a camp in upstate New York. The camp is designed for kids that have medical needs greater than those most camps are willing to accomodate. I'll be working as a nuse/nurse practitioner student.

Back to something that is an agreed-upon public health issue in New York: it seems the ban on trans fats is working. A recent study published in the Annals of Internal Medicine has found that the ban has reduced the number of restaurants in NYC using artificial trans fats from 50% rto 2%, resulting in foods with a significantly improved fatty acid profile. The total amount of saturdated and trans fat in French fries, for example, has decreased by 50%. Also, it seems others are following NYC's lead: thriteen other jurisdictions in the USA, including California, have adopted similar bans.

atul gawande on health care costs

Great article from the New Yorker (usually not my favorite publication) about controlling health care costs. Its author, MacAurthur Fellow Atul Gawande, investigated the out of control health care costs of McAllen, Texas, in an effort to understand why health care in America costs so much. I think it's an especially important read for clinicians.

iraqi nursing program

Great article from Fox News about a nurse training program in Anbar province, Iraq. The women, mostly in their mid-thirties, are being trained as nurses' aids. They are paid $200 a month by the U.S. State Department's Reconstruction team. For many of them, it is their first career.

Historically, nurses in Iraq have been met with suspicion, due to their willingness to work long hours in a coed setting. The founder of the program, Dr. Ayad al-Hadith, is a physician who specializes in child and maternal health and has devoted his professional life to loweing maternal health in Anbar province. He hopes some of the women trained will go on to become RNs.

new research about racial health disparities in nyc

In May, the Community Service Society (CSS) published the first report (seond link from bottom in sidebar) of a two part series looking at health care in New York. CSS is an advocacy group for the poor of New York, but this first report focused on the health care quality and its variance across racial groups. While the data is no longer new, I came across it relatively recently and think it’s worth blogging.

The report was based on data gathered from the Quality Assurance Reporting Requirement (QARR). This program enables the city to offer pay for performance incentives to various health care plans using the data generated. The study’s authors requested the data logged about all Medicaid enrollees over the course of three years. However, the information they received from the Department of Health and Human Services was primarily from 2007. The study’s authors felt that using data from only publicly insured patients would help control for differences in health outcomes based on wealth.

One of the report’s more depressing findings was that, “On a number of key health indicators, African Americans in New York experience disproportionately worse outcomes than other groups.” The report went to say that African Americans had statistically worse outcomes than the aggregate of other groups on 10 of the 12 measured outcomes

The outcomes measured by the study were divided into two categories: preventative care and management, and management of diabetes. The outcomes categorized as preventative care and management included: mammography, childhood immunizations, childhood dental visits, child asthma, and adult asthma. The management of diabetes outcomes were: HbAIc testing, poor HbA1c control, lipid profile, lipids controlled, blood pressure controlled, dilated eye exam (diabetics must have one dilated eye exam per year to screen for diabetic retinopathy), and nephropathy screening. Of these, the only two outcomes for which African Americans had similar outcomes to the population as a whole were childhood immunizations and nephropathy screening.

Other analyzed groups included: Caucasians, Asian/Pacific Islander, and Latino. Whites performed statistically better than the aggregate at childhood dental visits, child and adult asthma, poor HbA1c control, and blood pressure. They had worse outcomes in childhood immunizations, mammography, and nephropathy screening. Asian/Pacific Islanders had the better outcomes than the aggregate in every outcome except for nephropathy screening and childhood immunization. Latinos did better than the aggregate at childhood immunizations, childhood dental visits, mammography, and lipid profile and lipid control. They performed similarly to the aggregate for all other outcomes.

The report concluded with a few policy recommendations. The first was that the state monitor and report on disparities in health care among publicly insured individuals, breaking the data down by plan. The second was that the state use its purchasing power to promote health equity by using additional pay-for-performance initiatives targeted to reduce racial disparities in health care as well as and more aggressive monitoring. Elisabeth R. Benjamin, one of the authors of the study, told the New York Times, “Our position is that the health system is failing African-American folks, and we know that pay-for-performance works.” She went on to say, “We’re saying let’s use it [pay for performance] with a race lens, which has never been done in the country…We think this is one of the areas where New York State can take a lead in the country.”

The second report in the two part series, which I hope to read and write about later, analyzes involuntary disenrollments from public insurance plans.

EMR transition could be source of jobs

Last week, CBS News published an article about the job opportunities created in the health field by the transition from paper-based records to electronic charting.

Millions of charts will have to be transitioned from paper. Claire Dixon-Lee, of the American Health Information Management Association, points out that these charts will not only come from hospitals, but from doctor's offices, long-term care facilities, and even dentists. Her group has estimated that over 75,000 new jobs will be created in the health care industry to manage this transition. There is even a new field, "health information management", growing to accommodate the need. Typically, people going in to the field get and associate's degree and then can command salaries of $25,000-45,000.

New York City has an unusually strong health IT support. The Primary Care Information Project (PCIP) was designed and implemented by the city to encourage providers to transition to electronic charting. PCIP has targeted practices in underserved areas, and claims that 53% of the "smallest practices" work with the project, compared to a national average of 2%.

the lancet discusses global health

The British medical journal The Lancet's most recent issue features several articles of analysis of global health initiatives. This editorial (you have to register for the site to read it) serves as an interesting quick read of the broad trends discussed in this issue.

The editorial discusses the rising importance of nongovernmental, non-UN actors in global public health, such as the Gates Foundation or the World Bank. It points out this has its advantages, like more money going in to global public health, as well as its disadvantages, like a decreasing sense of financial/administrative ownership of the the health care system in the national governments of some of the countries receiving the most aid.

staten island steps up

On Thursday the Staten Island Ryan White HIV CARE Network launched its "Staten Island HIV Status Check Campaign". The campaign is designed to promote HIV testing among residents of Staten Island, and features a snazzy postcard that has information about free local testing centers. The postcard is available in English and Spanish, and will be distributed by local businesses and organizations along with HIV-related education literature and condoms.

A coordinator for the campaign, Karina Ryan, noted that 56% of Staten Island residents have never been tested for HIV. She also notes that while Staten Island has the lowest rate of infection of the five boroughs, it also has the highest HIV-related mortality rates. As with everywhere, Hispanics and blacks are disproportionately affected by the disease, comprising 19% and 50% new diagnoses in 2007 respectively, despite representing only 12% and 10% of the Island population.

For the campaign, the CARE Network is working with the Black Leadership Commission on AIDS and the City Council's Communities of Color Faith Initiative.

nyc singled out as having great health IT

Healthcare Information and Management Systems Society (HIMSS), a healthcare technology lobbying group, has singled out NYC's Primary Care Information Project (PCIP) as a potential model for future health IT projects across the nation.

The recent stimulus package offered a financial incentive to those providers who incorporate a "meaningful use" of health IT into their practices by 2011. To facilitate this, the government proposed establishing regional IT centers to support providers making the transition to electronic medical records (EMRs). PCIP, HIMSS argues, is a perfect model for just such a regional IT center.

PCIP was established in 2007 by the NYC Department of Health and Mental Hygiene. It currently targets providers looking to use EMRs who serve large groups of patients who rely on public insurance. PCIP helps them transition to EMRs by bulk purchasing eClinicalWorks, an EMR software, and contracting with its makers to provide two years of support to the providers who opt to use it. PCIP itself also works with these providers, developing trainings for the software, and evaluation rubrics that providers can access to assess how well they are using the software.

PCIP boasts a high level of buy in from targeted providers. The director of PCIP, Farzad Mostashari, told HIMSS, “We have been able to reach Medicaid providers in the city’s poorest neighborhoods in Harlem, the South Bronx, central Brooklyn...With the smallest practices that nationally have a 2 percent implementation rate of electronic health records, 53 percent of them are in our project.”

The practice I'm at for clinical uses eClinicalWorks, and it seems great to me. While I have never used any other EMR, and so can only compare it to paper charting, the difference between those two is huge. The program makes it incredibly easy to access notes from previous appointments, healthcare maitenance information like immunization status, and personal and familial medical histories, and to apply them immediately. Paper charts leave you fumbling for such information, and often present it in fragments so it's difficult to use in the moment.

two important points about domestic violence

This post is mostly for people who are health care or social workers. Two Mondays ago I listened to a great lecture about screening for domestic violence, and I've been meaning to blog about it since. The highlights of the lecture were two very important points, one of which I had considered before and one of which I hadn't. The first point was that nobody minds being asked by a health care professional if they feel safe when they're with their partner. I ask this question at least twice a day at clinical, and not once has anyone had a problem with it. Moreover, the presenter on Monday had run with a study in partnership with Mailman, Columbia's school of public health, which had corroborated my experience. People just don't mind. That said, I am sure one day I will offend one patient by asking. And on that day, I will be able to tell him/her, "I ask everyone." I am equally sure that one day when I ask this question, one of my patients will say, "No, I don't feel safe."

Honestly, I don't feel prepared for that moment. I don't feel like I'll know the right way to respond, and I'm concerned that if that is the first time my patient has told anyone about his/her situation, me screwing it up will have consequences. And this was where the second important point came up. When you ask someone if they feel safe, you're screening. Your goal is not to fix the situation by asking this question any more than it is to cure HPV by doing a pap smear. You're detecting the problem so the person can get help from someone who has more experience and more training. Once you've listened what the person has to say (obviously key), the presenter urged us to say something like, "What you are telling me is very important, and, if you are willing, I want you to share it with someone with a lot of experience with this kind of thing." And then give them a damn good referral, preferably in person. Like, walk them down the hall to the appropriate office. If that is not an option (private practice, social worker out that day) leave a message for the worker involved and ask the patient to schedule a follow up with you ASAP.

This ideas were really helpful for me, since I am obviously not a trained counselor, but am someone who wants my screenings to go somewhere. If anyone has any experience with this, please let me and other readers know via comments.

that's too bad

Another article, this one in the Wall Street Journal, about how the current recession has put the kibosh on the nursing shortage. Subawesome news for new grads like myself, great news for patients. I saw another article to this effect earlier in the Washington Post. Both articles said many nurses were returning to the workforce to alleviate the financial pressure created when a spouse lost a job, and both said this effect of the recession is a band aid on the nursing shortage, which will re-emerge. The WSJ article quoted a study which said the nation will be short a quarter of a million nurses by 2020; a pretty significant deficit in an industry that is meant to employ about two million per year.

ny daily news op/ed

There was an interesting opinion piece in Sunday's Daily News. Errol Louis focused his discussion on the fact that HIV infected New Yorkers who receive housing assistance through the city's HIV/AIDS Service Administration often have to put large chunks of their income to rent; he quotes figures as high as 56, 59, and 70%. Since the percentage is so high, Louis claims, evictions are common. Louis suggests that Albany simply cap that figure at 30% of income.

Louis rightly points out that keeping people with HIV/AIDS in stable housing situations is beneficial to public health. He states that people who are homeless are less likely to take their HIV medications as prescribed than those in stable housing, and points out such people are can wind up in emergency rooms at taxpayer's expense. He also claims that "studies show they [presumably HIV positive people, possibly not] are more likely to turn to prostitution", which would pose an obvious public health risk. That said, I have never heard of such a study. That sentence also does not make clear to whom HIV positive people are being compared by these studies, or even who exactly "they" are. Does he mean HIV positive people generally, or just HIV positive people with nowhere to live? Hmmm...

Finally, there is one paragraph in the column I find a little worrying. With regards to the eviction of HIV positive people, Louis writes:

That's an expensive and risky proposition for our city. People with AIDS or advanced HIV who get evicted often wind up living on the streets or sharing bathrooms with noninfected neighbors in homeless shelters, single-room occupancy buildings and welfare hotels.

I am, perhaps, reading this ungenerously, but is he implying that it is "risky" for an uninfected person to live on the streets/share a bathroom/occupy the same room with an infected person? It seems that he is, which is disturbing. HIV can only be spread via infected needles or sex. Period.

nurse practitionering

Lately I've been concentrating a lot on the "public health" aspect of this blog, and less on the grad school aspect. Since the blog really should be about both, this'd be a good time for me to talk more about studying to be a nurse practitioner.

Not everyone is totally clear what a nurse practitioner is. The basic idea is that a nurse practitioner is a registered nurse who has completed master's level coursework, and has been licensed by the state to diagnose and treat illness. An NP's privileges vary by the state: most states require that the NP work with a "supervising physician" and limit an NP's prescribing privileges. New York policy is very liberal: NPs here have full prescriptive power, and work with a "collaborating physician". Many NPs see the future of the profession in the provision of primary care; as US physicians become more and more specialized, and as we move (fingers crossed) towards more comprehensive health coverage, a "primary care gap" like the one that has emerged in Massachusetts since the insurance reforms of 2007 is expected to become more and more prevalent. This is, to the minds of many, where NPs come in.

In order to be an NP candidate, one must already be an RN, usually with a BSN, although there are some associate-to-master's programs. (Columbia used to have one, but it was discontinued.) My program is four semesters worth of coursework. The first semester was: Pharmacology, Physical Assessment, Health Policy, and Introduction to Primary Care. That semester had no clinical component. This past semester (Spring 2009) was Diagnosis and Management I, Seminar in Primary Care (basically case presentations), and Genetics. We also had a clinical requirement, which I have blogged about in the past.

I also work part time at a NYC facility for formerly homeless adults, but that's for another post. :)

exciting development

A new vaginal ring, which provides a combination of ART and contraception, has been shown in laboratory tests to prevent pregnancy and HIV transmission. The study, headed by Drs. Brij Saxena and Jeffrey Laurence, both of New York-Presbyterian Hospital, will be published in AIDS later this year.

The ring uses three ART drugs, released by the ring over a 28 day period, to prevent the transmission of HIV. The drugs are: AZT, the lesser known PMPA, and a new compound called Boc-lysinated betulonic acid, or dapivirine. "The combination of these antiviral drugs has proven to be potent agents that may block infection by the HIV virus," Dr. Saxena told the the Times of India. The contraception the ring provides, which is non-hormonal, prevents conception by raising the acidity of the vagina, thickening vaginal mucus, and diminishing sperm motility.

This is a huge step forward: a method to both prevent conception and the transmission of AIDS that depends only on female compliance has been a goal of researchers for a long time.

new health initiatives

This Saturday two public health groups, The Perinatal Network of Monroe County and the Finger Lakes Health Systems Agency, announced 13 initiatives to improve public health in northern New York.

The initiatives, which are aimed at reducing racial disparities in health, were developed by an interdisciplinary team of over 100 clergy, doctors, nurses, social workers, and insurers who which met from October to January. The initiatives include: studying the effect of maternity leave on fetal health, arranging community wide viewings of a documentary on racial health disparities, and trainings for clergy and social workers so they can teach clients how to manage chronic illnesses.

The Perinatal Network of Monroe County works to reduce racial and ethnic disparities in maternal fetal health. The Finger Lakes Health Systems Agency promotes public health by "providing a 'community table' where all stakeholders meet, conducting outreach to community groups, [and] retaining extensive data on the region's health and health care."

all i have to say about swine flu

This blog, which is about public health in New York City, has thus far said nothing about the most covered public health crisis in NYC this year: swine (H1N1) flu. This teriffic video in part explains why. The video is a quick exploration of the "death to news" ratio of swine flu and TB over the course of thirteen days. In sum: they're very different. The video's less than three minutes; click! If nothing else, the narrator makes it interesting.

in support of testing

A recent editorial appeared in Long Island's Newsday, supporting the bill before the state legislature to make HIV testing in New York more accessible. The editorial appears in its entirety here:

Bill would reduce stigma surrounding HIV testing

There's no harm in offering to test every adult for HIV when they're treated at a hospital or clinic. The harm is in not making the attempt. A quarter of the people who are HIV positive don't know they have the virus, and they're the source of the majority of new infections.

To slow the spread of this deadly virus, the State Legislature should make it mandatory for health care workers to offer testing. And it should lower barriers that discourage patients from giving their consent. Under current law, the offer isn't required. When it is made, rigid, pretest counseling is mandated and patients must sign a written consent form before they're tested. The goal should be to reduce the stigma of HIV testing by making it routine.

A bill by Assemb. Annette Robinson (D-Brooklyn) would do that by requiring doctors to offer the test, explain its purpose, how it's done and answer any questions, but then simply note in a patient's chart whether the offer was accepted or rejected. That would advance the critical public health objective here, which is to get people tested.

NYC Health Commissioner to head CDC

President Obama announced his intention to appoint NYC's Health Commissioner the head of the CDC. Dr. Thomas R. Frieden, an infectious disease specialist, is expected to begin work in a month. This is the second time the Obama administration has pulled an official from NYC; former city health commissioner Dr. Margaret A. Hamburg is expected to be confirmed as commissioner of the Food and Drug Administration.

Dr. Frieden's efforts as commissioner are well known to most New Yorkers: no smoking in bars and restaurants, free condoms, and more accessible HIV testing. The appointment was met with enthusiasm by public health advocates in New York City: Dennis deLeon, president of the Latino Commission on AIDS in New York City, told the NY Times of Dr. Frieden: “I found he’s willing to challenge the status quo in an effort to make a difference."

whoops!

I missed International Nurses' Day! It's celebrated every year on May 12 and honors nurses throughout the world. (This also means I missed my free CinnaBun, but oh, well.)

In honor of the day, Gary Cohen, a member of US Fund for UNICEF's board and an executive vice president at a medical technology firm, wrote this interesting column about health clinics for health care providers in the developing world, established and operated by the International Council of Nurses.

what the what?!?

A recent New York Post article begins with the provocative assertion that "It now costs more to buy health insurance than it does to rent a two-bedroom apartment in the Financial District."

The article then goes on to discuss the rise in health care costs for New York City dwellers in the past year. According to the newspaper's analysis, the average monthly premium has risen 13% since April 2008; then, the average family paid $3,866 per month, now, they pay $4,354. That, according to the Post, "exceeds the $3,947 monthly rent for a place in a no-doorman building downtown."

The Post breaks down the rise by insurance company; the company that raised its rates the most was GHI HMO select, whose out of network fees went up 35%, followed by Aetna, who raised rates 27%. Rates should go up even more, the article says, since companies are expected to pass along an $853 million dollar insurance-related tax in this year's state budget. The Post also noted that there are fewer insurers in New York now than in the past; in 2004, thirteen companies offered insurance in NYC, now eight do.

Finally, the cheery article noted that things will almost certainly get worse before they get better, since more and more New Yorkers are opting out of health insurance, leaving the pool of contributors smaller and sicker.

Blerg.

new bill to try to change HIV testing practices in NYS

On April 16, 2009, a new bill was introduced into the NYS Assembly arguing for a new HIV testing MO in the state of New York. The bill would require that HIV testing "to be part of a signed general consent to medical care" signed by the patient. The bill would also require that all EDs, hospitals, and doctor's offices offer HIV tests to patients on a regular basis, with some very limited exceptions (ie, they are being treated for a life-threatening illness at the time of their visit.)

But what does it mean for the HIV test to be "part" of a "signed general consent"? In an article published April 12, The Albany Democrat and Chronicle interpreted it to mean that patients "would check a box on a general medical-consent form, which would remain in force."

Advocates say that this is still too much of a barrier. C. Virginia Fields, chief executive officer and president of the National Black Leadership Commission on AIDS, is quoted in the Democrat: "What we're saying is routine testing is when you go to a doctor and get a blood work-up, and HIV should be among those (illnesses) tested."

I'm all for lowering barriers to testing for HIV, and myself have recommended several HIV (and chlamydia and herpes and gonorrhea) tests to several patients during my NP clinicals. However, I have trouble picturing HIV being added to "routine testing" because there is no such thing. That is, when a patient turns up at a clinician's office, either perfectly healthy and there for their annual exam, or with a looong list of episodic complaints, the clinician decides what tests to order based on the patient's characteristics. Admittedly, there are some tests (complete/basal metabolic panel, complete blood count, urinalysis) that are ordered for basically everyone, but these are not for diseases as such; they test organ function and indicate disease if abnormal. All of this is to say: in the absence of true "routine tests" for disease, a bill like this one is the only way to improve testing rates via legislation. Unless of course, the legislature wants to mandate that clinicians verbally offer the test for HIV to everyone on every visit. (Come to think of it, that's not a bad idea.) In the meantime, get tested.

Finally, an editorial from the NYT advocating greater awareness of HIV in the US, and more frequent testing for the disease.

exciting step in the right direction

Woot.

The article mentions PEPFAR, which the Washington Post also did an editorial on recently.

wide county by county variation in medicaid denials

Last Thursday the Rockefeller Institute of Government published a report on the county by county variation in denials of applications for Medicaid funding of long term care. Individuals in New York are eligible for Medicaid funding for nursing home care if they make less than $8,700 per year, and if their total assets are less than $13,500, not including their home. Federal law prohibits the transfer of assets by the elderly for five years prior to applying for Medicaid nursing home benefits; obviously the intention of the law is to prevent people would could afford a nursing home on their own from filing for benefits after giving their money family member, friend, etc. so they could access it later. The report, which analyzed the state's 57 counties outside New York City, studied the rate at which Medicaid benefits are denied because of a reported asset transfer.

In the last decade, 7% of the applications for Medicaid benefits for long term care have been denied on the basis of a recent asset transfer. However, the rate at which applications are denied varies wildly from county to county. Some of the counties that deny with the most frequency are: Rockland (24.2%), Ulster (22.6%), Saratoga (14.6%), and Suffolk (14.5%). Some that deny the least are: Westchester (0.5%), Duchess (1.0%), Schenectady (1.2%), Rensselaer (1.3%), Orange (1.4%), and Erie (2.1%). The report offered no opinion as to why the variation exists, but the authors did note their suspicion that the illegal asset transfers are underdetected.

New York has one of the most generous Medicaid programs in the country; in 2006, 42% of the $18.9 billion the State spent on Medicaid went to funding long term care.

report on health care workforce

The Center for Health Workforce Studies, at the University at Albany's School of Public Health, recently published a 136 page study of the health care workforce in New York. The report, which includes a section devoted to NYC, has some fascinating stuff: between 1990 and 2007, the health care workforce of NYC grew by 29%, whereas the workforce of NYC as a whole grew by 16% during the same period. Almost all of the jobs were in the private sector; private hospital jobs increased 3% while public hospital jobs went down 4%. (Hospitals provide about 50% of NYC's healthcare jobs.) Interestingly, the study reports that the number of RN positions in NYC went up 18.9% between 2002 and 2007, while the number of RNs increased only 3.1% between 2003 and 2007. The number of NPs went up 27% between 2003 and 2007. (Good luck with that job search, Laura.)

Overall, the study projects that there will be openings for nearly every type of healthcare job in NYC from 2006-2016. However, recent events have indicated that for RNs, and I would imagine other healthcare workers as well, the the picture has changed dramatically thanks to the recession.

Another unsurprising finding of the study is that minorities are underrepresented in New York State's physician workforce, even as the nonwhite portion of NYS' population continues to grow. Physicians who come from racial minorities are more likely to work in underserved communities and have on average a higher percentage of Medicaid patients.

no kidding

Interesting article Sunday in The Washington Post about how the recession has temporarily made the nursing shortage a thing of the past. Unsurprisingly, nurses are delaying retirement or returning to the workforce in an effort to stay afloat financially, which means even experienced nurses are having trouble finding work. Nursing advocates say this is obviously just a band-aid on the nursing shortage, and continue to urge legislators to consider measure that will alleviate the shortage when it reappears once the recession is over.

Anecdotal evidence from myself and my classmates (we graduated with our BSNs in May 2008) suggests this started to hit NYC last year. I applied to about a dozen hospitals late last summer and early fall, and although I was hired three times, in two cases a hiring freeze twice prevented me from taking the spot. (The third time there was an administrative mix-up.) I was not alone among my classmates in struggling to find work; many people were saying they couldn't even get interviews. Given the number of health sector lay-offs in the city in the past year, none of this is too surprising.

mrsa!

In clinical last Thursday I had the pleasure of seeing my very first suspected MRSA! MRSA is strain of staphylococcus aureus that is resistant to a standard antibiotic, methicillin, as well as other commonly used antibiotics such as penicillin, oxacillin, and amoxicillin. MRSA has been around NYC for some time now , and recently has been seen more and more in children; daycare facilities have been cited as places the infection can spread rapidly.

Prior to the past five years, MRSA was rarely seen outside the hospital, and infections were predominately found in immunocompromised people. However, since then, community acquired infections (CA-MRSA)have increased dramatically, and crowded cities like NYC have seen the biggest rate of infection. MRSA can linger in the nose, blood, urine, and on the skin. Generally the infection is transmitted among people who share personal items (razors, towels, athletic equipment). CA-MRSA typically manifests as boils or pimples.

Which brings me back to my patient. He presented with an abscess that had been pimple-like less than 48 hours ago, but in that short period had expanded into a one inch in diameter abscess surrounded by a large, reddened, indurated area about 3" by 5". My preceptor told me MRSA's nicer cousin, methicillin-suseptible staphylococcus aureus (MSSA), usually presents as a nice clean abscess you can drain without difficulty. MRSA, she said, presents like this: a hardened area where much of the pus has seeeped into the surrounding tissue. Think of it as the difference between using a needle to pop a water balloon vs using one to drain a sponge, she told me. Great. We gave him some Lidocaine and drained what we could before sending him off with Bactrim and the specimen to the lab. Fun update: the culture came back MSSA. Ah, well.

nyc anti-smoking campaign began yesterday

The NYC Department of Health and Mental Hygiene is hitting smokers where it hurts : by reminding them what smoking can do to their kids. The Department has developed two ads, based on Australia's Quit Victoria campaign, that depict how a parent's smoking habit can affect children. One of the ads features information on the side effects assoicated with secondhand smoke: asthma, pneumonia, ear infections. The campaign is called "Cigarettes are Eating You and Your Kids Alive". The second ad features a lost (and adorable) kid panicking as he looks for his parents. A voiceover features the comment: “If this is how your child feels after losing you for a minute, just imagine if they lost you for life.” Ouch.

The ads will run for about two weeks in both English and Spanish. The City Health Commissioner points out that about 400,000 smoking New Yorkers live wiht a child, and that about 8,000 New Yorkers die each year from smoking.

not a moment too soon

Yesterday, two my of roommates, both members of the New York State Nurses Association (NYSNA) received a mailer from that union. It's basically a four page pamphlet, listing hospital closings and layoffs in the NYC area. Consolidated like that, it is kind of jarring: in NYC and Long Island alone, there have been three hospital closings and six hospitals which have laid off more than 50 people in the past year alone. The mailer also says that according to an American Hospital Association survey, 50% of hospitals were considering staff cutbacks to deal with "financial stress" as of October 2008. The mailer includes two index card size postcards you can punch out, sign, and send to your state senator or assemblymember to urge them to oppose the $1.3 billion in healthcare budget cuts proposed by Governor Paterson. The NYSNA is not the only one organizing around the budget cuts; SEIU 1199 and the Greater New York Hospital Association launched a million dollar campaign against them earlier this year.

Presumably, the mailer went out prior to the HHC cuts. Interestingly, some of the responses I've read posted to articles about the HHC cuts discussed how difficult it already was for nurses to get a job in NYC even before those cuts were announced.

nyc hospital corporation announces cuts

Last Thursday the NYC Hospitals corporation announced that it was cutting 400 jobs and closing several facilities in an effort to close its budget gap or over $300 million. The "400 jobs" figure came from freezing 200 unfilled positions and laying off an additional 200 workers. The layoffs were expected to affect clerical, physician, nursing, and support staff. Unions affected included New York State Nursing Association, Union 1199, and DC 37, which has thus far been the most vocal in fighting off the layoffs. The facilities HHC anticipates closing include: three school based, one adolescent, and one adult mental health programs, four community clinics, three satellite pharmacies, two HIV case management centers, and a directly observed therapy program for TB. The announced cuts were expected to save about $100 million, but the anticipated shortfall is over $300 million and expected to grow. The City of New York provides about $500 million to fund the HHC, the State about $50million. The President of the HHC has called on the state to use some of it $10 billion in federal stimulus money close the gap.

Interestingly, these cuts come in the context of a capital expansion program for HHC. Among the projects is remodeling and expanding a long-term nursing care facility on the LES. The list, however, is long , and in the context of the current economic climate, it's hard not to second guess the desicion to lay off staff when so many projects are proceeding. However, until we kno what the next round of cuts will look like, it's too soon to judge.

terrific blog

For those of you who read this because you are considering becoming a nurse practitioner, make sure you read the great blog newFNP by a recently-graduated family nurse practitioner who works at an urban clinic. It's great.

RWJF announces another round of nurse-led innovation

Last week the Robert Wood Johnson Foundation announced this year's participants in its fascinating TCAB program. TCAB (Transforming Care at the Bedside) emphasizes developing nurse-lead patient safety innovations, such as falls prevention programs, or the use of white boards for patient goals. The rationale is that "nurses and other frontline staff are uniquely capable of identifying and implementing process improvements that could result in safer, more reliable care." I like it. :) Sixteen hospitals have been selected to participate, meaning that for the next year med/surg nurses at those hospitals on certain units will be developing, implementing, and testing new patient safety measures with RWJ's support.

Although no local hospitals are participating this year, North Shore Long Island Jewish, the hospital network behemoth, has participated in the past. One of their innovations was "rapid response" teams, an idea gaining popularity in hospitals across the country. The idea behind rapid response teams is to take serious, but pre-critical (ie, they're not coding yet), patient conditions and address them as quickly as possible. At Long Island, the rapid response team yielded a lower number of actual codes, and the hospital reported an improvement in "early assessment" skills. Another innocation was a standardized assessment tool that facilitated clearer physician/nurse communication when a patient's condition is worsening.

The RWJF is incredibly active in supporting nursing in the United States. Last month it created a coalition with the AARP's affiliated charity, the AARP Foundation, to address the nursing shortage, which is projected to worsen over the next several years as more and more nurses retire. The coalition, which includes health care providers, consumer organizations, and businesses, will also seek funding to improve nurse education, job satisfaction, and retention. The RWJF has worked with the AARP and the Department of Labor to address the nursing shortage in the past, and even offers $10,000 scholarships for student nurses, especially those from groups that are underrepresented in nursing or from disadvantaged backgrounds.

hospital error reporting

Sorry to have been off the grid for so long; but I'm back now. :)

Interesting article in Monday's NYT about the rate at which NYC hospitals are reporting errors. There are apparently huge disparities between comparable institutions, and some of the city's most prestigious hospitals are implicated in poor reporting. New York-Presbyterian, a combination of Columbia-Presbyterian and the former New York Hospital, which now goes by Weill Cornell Medical Center, reported only 20 adverse incidents per 10,000 discharges. Another "comparable institution", which the article did not name, reported 166 adverse incidents per 10,000 discharges. Of the hospitals owned and operated by the city, Bellevue, generally regarded as the most prestigious, is on a list of the 12 lowest reporters released by the city comptroller. Others included on that list are Lenox Hill and Mt. Sinai. The assumption is that these low reporting rates are the result of poor reporting rather than excellent care.

I wish this article was more explicit about to whom these errors should have been reported. The analysis that discovered these disparities was the city comptroller's office, but it seems unlikely, albeit possible, that hospitals are expected to routinely report adverse events to that office. The comptroller's website says nothing about hospitals, although it does include in its list of activities "audits of New York City agencies."

The point of raising this issue is that I wonder if there is a disparity between what hospitals report out and what they monitor internally. I bet there is, due to mostly to two factors: the hospitals' self-interest, and differing definitions of "adverse event". For example, a nurse friend of mine who works in one of the hospitals named in the study accidentally gave a medication intranasally instead of by injection. The patient was fine; the reason the route had been changed was because the intranasal med seemed to have no effect. But she still had to fill out an incident report, etc. because the hospital considered it an adverse event. I doubt errors of this nature were reported to whatever body this is by any hospital, but it was monitored internally by her institution. That is, just because an incident was not reported to an external body does not mean it went unnoticed. I would be curious to know how the external body to which hospitals are supposed to report adverse events defines "adverse event", but I can't find out because I don't know what that external body is If its definition is grave (ie, it's only an adverse event if it results in death or disability) that would mean these hospitals are concealing major errors and underreporting is really a cause for concern. If its definition is more trivial, the underreporting of adverse events is less of a worry, although it obviously shouldn't be tolerated.

shocker

A NYT article from Tuesday examines why some many people enrolled in Medicaid in New York State fail to re-enroll at the appropriate time. The major reason: the re-enrollment process is inefficient, untimely, and, according to one participant in focus groups, "takes a lawyer to figure out". The necessary documents fail to reach their intended recipients, or do so after they are due back to the state.

This is totally unsurprising. I work part time at a facility for formerly homeless people, packaging meds and giving shots. There are about 45 residents here who need aggressive case management by their social workers, and one of the social workers' most significant time commitments is working on these programs' red tape. One social worker told me it can take up to one third of her time (although she said lately it had been much better) and another told me it was about a sixth. They both work 35 hours per week; if we average those two, we get eight hours and forty five minutes spent per week on Medicare/Medicaid. On the one hand, yes, they are managing about a dozen people. But the head of a household whose healthcare comes via Medicare/Medicaid could easily have to act as a caseworker for three or four people, without the benefit of a Master's degree, colleagues to help them sort things out, or a paycheck for their time. No wonder people are failing to re-enroll.

two things

One, three more patient on Thursday who were losing their health insurance, and one who was developing an ulcer because he is stressed at work, since half his group got fired. Awesome.

Two, make sure you check out the Idealist in NYC blog. It's got a potpourri of stuff that might be of interest. Today's post is on PlaNYC, an NYC development project.

discouraging, but with a silver lining

As I have mentioned in a previous post, part of my MS in Nursing involves working with a nurse practitioner one day per week. The NP I work with is in private practice in downtown Manhattan, and has a healthy HIV caseload. On a typical day, I see about 12 of her 20ish patients, and my participation in the visit can range from being the primary provider (as in cases where someone is there for their annual exam) to just observing (as when someone needs a pap smear, something I haven’t been trained in yet.) Last week, I saw eleven patients. They were a diverse group, representing a wide range of ages, backgrounds, and health conditions. Three had one thing in common: they were about to lose their health insurance.

To be honest, the current economic crisis has not affected me much personally. As a student, I have debt, not savings. My parents, like so many other people who followed the commonsense strategy of long term, diversified investing, have taken a bath, but my finances have been largely unaffected. Only one person I know has even been in danger of losing his job, and ultimately he didn’t. So the crisis has been more or less abstract to me up to this point. That said, for three of my patients, it was very real. Below is a little bit about them, although I should note I have changed some important info in the interest of patient privacy.

One patient lost her job a few months ago and will only have health insurance until the middle of 2009. She was in the office for her annual physical, but she has a significant heart defect, for which she has already had serious surgery, that makes it incredibly risky for her to go without health insurance for any length of time. She is also overweight (although she is using the opportunity unemployment provides to go the gym and cook more). Another patient was in for a quick follow up; he had come in as soon as he lost his job for a bunch of tests, so he would have the chance of dealing with anything that might come up before his insurance ran out. Fortunately, he was in good shape. Finally, there was a young man pursuing a graduate degree who for reason would be dropped from his school’s insurance policy within a month or two; I believe he intended to take a semester off for financial reasons, but the calculus of his decision was obviously affected by the fact he would have to go without health insurance during that time. The third patient’s situation is perhaps not as much a consequence of the recession as the other two, but it does reinforce the point that’s been made over and over, that Americans need to have access to affordable insurance not tied to education/employment.

The silver lining last Thursday was the three patients who presented for a full STI panel. None of them had any signs or symptoms of an STI, or even any reason to think they had been exposed; they just had either recently switched partners or felt “it was time”. All had been tested less than two years ago. As a future provider, I’m sure I’ll wish all my patients were as conscientious and engaged as that group, and they definitely made a frustrating day better.

facebook for condoms

Like social networking and sexual health? Then the NYC Department of Public Health's new Facebook page for condoms is made for you. The site, which aims to promote sexual health and to raise awarenesss of the city's HIV statistics, gives users the opportunity to send "e-condoms". Over 6500 condoms have been sent as of Thursday afternoon, although a ranking of the senders has revealed a bunch have been sent by employees of the health department's communications office. Facts listed on the site include that NYC has more HIV cases than LA, San Francisco, DC, and Miami combined, and that one in four MSM in Chelsea has HIV. The site also features health updates from the health department and lively short videos encouraging condom use.

For Valentine's Day 2007, the City's health department introduced the official "city condom"; since it's introduction, over 70 million have been given away.

stimulus summary

This is the best summary I've found thus far on how health-related spending is faring in the stimulus package. To be brief: not well.

nursing and moral distress

Interesting article from the NYT about the changing ethics of nursing and medicine in general. The article focuses on "moral distress" the condition in which a doctor or nurse feels they know what's best for the client but in some way feels prevented from implementing it. This phenomenon is one I noticed even during my clinical rotations; sometimes a really good nurse would have a useful perspective about a client, but wouldn't talk about it with the team because she'd assume they'd brush her off. That said, I also saw a number of situations in which a nurse would see a problem, talk to the doc, and get someone in there to evaluate pretty quickly.

The study discussed in the article can be found in the February 2007 issue of Critical Care Medicine. As mentioned in the article, nurses at both the surveyed sites reported higher levels of moral distress than physicians. Both groups reported the highest incidence of moral distress when they were pressured to "unwarranted aggressive treatment". RNs who had higer moral distress scores also reported a lower perception of ethical environment, a lower satisfaction with the quality of care, and a lower perception of collaboration.

Thanks to Ella Gray, RN, for drawing my attention to this article.

primary care proposals

Great primary care oriented blog post written by Kevin Brumbach, MD, the chair of family medicine at UCSF. Part One gives the arguments for better primary care, and Part Two suggests interesting solutions to the shortage with an eye to cost.

budget cuts create controversy

Two powerful health care groups are mounting an aggressive public relations campaign against Governor Paterson's proposed reductions in health care spending, the New York Times reported Sunday. The two groups, Union 1199 and the Greater New York Hospital Association, are purchasing radio and TV spots, funding a phone bank, and mailing flyers throughout the state to protest the governor's $3.5 billion in health care spending cuts, part of a larger $15 billion package designed to balance the budget. The NYT estimates the radio and TV ads alone will cost more than $1 million per week.

Yesterday Paterson and Senate Democrats balanced this year's fiscal budget, which ends March 31, with many small cuts that collectively covered the $1.6 billion deficit. This cost health care in New York "$359 million...including cuts for nursing homes and health maintenance organizations, grants and higher assessments for health insurers" according to Reuters. Also among the cuts: $75 million for the Environmental Protection Fund, and $306 million from the Power Authority.

For FY2010, there is a projected $13-15 billion dollar deficit. In December 2008, the Governor proposed an additional $3.5 billion in health care spending reductions. The centerpiece of the cuts, profiled on the Governor's website , would cap Medicaid spending in New York at $16 billion, which would nevertheless be an increase over spending in 2008-2009. However, it is over $1 billion less than the projected need of $17.2 billion during FY2010, and would reduce the amount of federal aid spent in New York state. More later on other proposed cuts.

Union 1199, more formally 1199 S.E.I.U. United Healthcare Workers East, is the health care portion of Service Employees International Union, covers New York, NJ, Maryland, DC, and Massachusetts. Its members are typically technicians who work in the health care field: certified nursing assistants, xray technicians, home attendants, etc. There are also members who are registered nurses, but these are relatively few. The union boasts 300,000 members and claims to be the largest local union in the world. The GNYHA covers more than 300 hospitals in the greater NY area.

nursing school

So despite the fact that this blog is formally about grad school, I've had very little to say about my graduate experience thus far. That's largely because class for this semester only started last week. I'm in three courses: Genetics, Diagnosis and Management, and Seminar on Primary Care. It's the second semester worth of classes for my MS, and I'll have two more semesters to go after this.

In addition to my coursework, I am at a clinical site one day per week. The site is a private practice with two NPs near Union Square. The NP I work with seems knowledgeable and competent, and I am confident I'll learn a lot from her.

I'll have more to say as the semester progresses; if anyone reading this has any questions about becoming an NP, please don't hesitate to ask and I will do my best to respond.

new study on HIV trials in foster care

The Vera Institute of Justice released its report today on the participation of HIV positive NYC foster children in HIV drug trials from the last 1980s until 2005. The city's Administration for Children's services commissioned the report in 2005 when allegations arose concerning the participation of certain children in the study. These allegations included: that race was a factor in the selection of participants, that children were at times inappropriately removed from their homes and placed in foster care to facilitate their participation in the study, and that the trials themselves adversely affected the children's health.

First, the study found that no child died as a result of his or her participation in a study. Sadly, 80 of the 532 children enrolled in HIV trials over this period of time did die, but investigators could find no connection between these deaths and any clinical trial. The study also noted that while there were instances of side effects in the children, these side effects were consistent with the literature published about the drug at the time. The study also fond several instances in which physicians took note of these toxicities and made appropriate adjustments. Second, the study finds no evidence that children were removed from their homes to due parental refusal to allow children to participate in drug trials. The study notes that 3/4 of children enrolled in foster care were enrolled before they were one year old, and more than 1/2 were enrolled directly in the hospital from birth. Third, the study finds that the while the trials did predominantly involve black and Hispanic children, their representation in the trials was reflective of the demographics of the HIV epidemic at the time.

On the other hand, there were some findings of concern. A number of them centered around informed consent: in seven cases, consent was given by someone who had no legal right to do so, consent forms were often written in medical jargon, and consent was at times accepted in the form of handwritten notes or over the phone. Sixty four children were enrolled in trials that were never reviewed bu the city's own Medical Advisory Panel (MAP), which had been developed specifically for that purpose. Twenty one children were enrolled in trials that had been reviewed by MAP and were not recommended, although 13 of these had been enrolled prior to entering foster care.

The report concludes with a few concerns and recommendations, mostly centered around the need for clearer and more comprehensive policy around the participation of foster children in clinical trials.

Further coverage of the study can be found at the NYT website.

Finally, on a personal note, one of the study's seven authors is my roommate, Reena Gadhia, who used to work at Vera and is now an RN at the Allen Pavilion of Columbia Presbyterian. Reena worked on this project a lot while at Vera, and has since gone to DC to present her research at a conference. Congrats Reena!

Kaiser studies Medicaid/SCHIP eligibility

The Kaiser Foundation has released its eighth annual 50 state survey on Medicaid/SCHIP eligibility. Nationwide, the principal findings of the study were optimistic. It reports that “the commitment to children remains strong” and that many states have broadened Medicaid access in the past year despite economic challenges. The authors noted, however, that it is still more difficult for parents to get Medicaid than children.

The study broadly affirmed that New York has some of the most liberal Medicaid requirements in the country. New York’s Medicaid/SCHIP income eligibility requirements were consistently at or above the national median. Some things that set New York apart:
- New York both working and jobless parents could qualify for Medicaid even if their income was more than 100% of the federal poverty level (FPL). Nationally, the median cutoff is 68% of FPL for a working parent and 41% of FPL for a jobless parent. (In some states, even working parents must make less than 50% of FPL to qualify for Medicaid, which leads one to wonder how some state legislators interpret the word “poverty”.)
- New York provides Medicaid to pregnant women at 200% of FPL; the national median is 185%.
- New York provides children with SCHIP (In NY, Child Health Plus) up to 400% FPL. When New York passed legislation raising eligibility from 250% to 400%, the Center for Medicaid and Medicare Services (CMS) rejected the plan, and children who fall between 250% and 400% are now paid for with state funds.
- New York is one of 23 states in which a an adult working at the state minimum wage qualifies for Medicaid.

The study also discussed ways in which New York’s generous policies are expanding:
- New York has adopted the option to allow children leaving foster care upon reaching age 18 to keep their Medicaid coverage.
- In February 2008, New York introduced a “presumptive eligibility law” for SCHIP.

must read for primary care providers

Terrific blog post on Wonk Room from Friday. Covers the evolution of the health portion of the stimulus bill, including how it will incentivize the development of IT in primary care. There's a great point at the end about how IT is in some ways uniquely relevant to PCPs (primary care providers) who "own their infrastructure" in way most specialists don't.

new insurance proposal

Governor Paterson is working on a plan to extend the period of time employed adults ae permitted to claim their children as dependents for health insurance, the New York Times reports. Currently, New Yorkers can claim their children up to age 19, unless the child is a full time student, in which case they can claim up to age 22. The new plan would extend that age to 29. The plan is modeled on an NJ law that offered the same option to parents, provided the children are under 31, reside in the state or are enrolled in college, and have no dependents of their own.

Analysts note that the effects of the Jersey law have been "incremental", pointing out that 55% of the nations workers work for companies that self-insure, and are therefore subject only to federal regulations. However, since 800,000 people, or 31% of uninsured New Yorkers, fall into the demographic targeted by this plan, legislators are paying attention. Austin Shafran, a spokeman for new Senate majority leader Malcolm A. Smith, is quoted in the Times as saying: “The plan seems like a very legitimate step in the right direction toward improving access to health care. We’re really taking a look at it.”

safety net as stimulus?

The Kaiser Foundation put out this analysis over a week ago, but it’s still worth posting. It addresses an aspect of the health care safety net that I haven’t heard discussed much in the context of the recent recession: how the spending of these programs can actually bolster the economy. The analysis is a review of 29 studies of 23 states, as well as one national study conducted by Families USA.

The study’s main finding is “Medicaid spending generates economic activity, including jobs, income and state tax revenues, at the state level.” The study finds it does so in two ways: the trickle-down (or “multiplier”) effect, and the Federal Medical Assistant Percentage (FMAP). According to the study, the trickle-down effect varies according to the size of the health care sector in a given state, the extent to which the state relies on Medicaid, and the FMAP for that state, but it is always there. The FMAP is a federal match program in which the federal government provides at least one dollar of federal money for every one dollar of state money spent on Medicaid. It’s determined using a formula that compares the state’s average income to the national average income. The FMAP for Mississippi, the poorest state, is 76%; that is, 76% of the dollars spend on Medicaid in that state come from the federal government. New York’s FMAP is the minimum, 50%.

The authors make the point that the FMAP means Medicaid pulls at least as much money into the state as the state is spending, and, at times, significantly more. For example, if Mississippi were to cut $1 of Medicaid out of its budget, it would lose $4.17 of healthcare spending in that state. Since that $4.17 will no longer be circulating in the state, the state’s economy has lost more by limiting spending than it gained by saving. For every dollar New York cut, it would lose two in spending. This is an important point as legislators look for ways to trim budgets.

Although none of the state-specific studies analyzed are devoted to New York, the national study, conducted by healthcare watchdog group Families USA, does have New York-specific information. Published in April ‘08, the study uses the Regional Input-Output System (RIMS II) to quantify the trickle-down effect of Medicaid cuts proposed by President Bush last year. The study estimated that $1.5 billion in lost federal funding would result in $1.1 billion in lost wages, $3.1 billion in lost business activity, and 25,500 lost jobs for the state.

state of the city

Mayor Bloomberg gave his the Sate of the City address this afternoon at Brooklyn College. Understandably, the focus of his speech was on efforts to ameliorate the effects of the suffering economy on the city, and he announced a plan to create 400,000 jobs by 2015.

The Mayor also discussed public safety, certainly a component of public health, at some length. He outlined a three part plan to improve the safety of gun sales in the city (requiring a background check on employees of gun dealers, adding a mental health component to the background check of customers, and using "micro-stamp technology" on all guns sold in New York). He also proposed some measures designed to beef up the city's security: computer technology that could detect suspicious movements from camera footage, integrating the Police and Fire dispatch centers, and training more officers to respond to "simultaneous, multiple attacks."

The only explicit mention of health-related social services was the Mayor's expressed desire to crack down more on Medicaid fraud. However, he also did mentioned a plan to support growth in the medical sector in an effort to diversify the city's economy. Finally, the Mayor proposed opening a Family Justice Center in the Bronx, and develop a database that enables the NYPD to increase its home interventions.

Family Justice Centers are run by the Mayor's Office to Combat Domestic Violence; the offer integrative services (attorney consults, financial advice/aid) for the victims of domestic violence.

SCHIP passes Senate Finance Committee

The Senate Finance Committee passed a bill to reauthorize and expand the SCHIP (State Children's Health Insurance Program) yesterday. The new bill could add as many as four million children to the program's roster, and adds 31.5 billion dollars to the program over the next four and a half years, the AP/Boston Globe reports

In New York, SCHIP is called "Child Health Plus". To receive SCHIP benefits in the state of New York, a child's care provider can make up to 200% of the federal poverty level (FPL) ($34,340/year) if the child is less than one year old, 133% of the FPL ($22,836/year) if the child is between one and six, and 100% ($17,710/year)of the FPL if the child is between six and 18. In FY2007, New York spent $324 million of federal money on SCHIP. It also contributed about $174.5 million of state money.

SCHIP is a relatively young program (begun in 1997) funded by the federal government but administered by states to ensure health insurance for children; it was mostly designed for the children of families who have modest incomes but are not eligible for Medicaid. In the fall of 2007, President Bush vetoed two bills sent to him by Congress designed to reauthorize and expand SCHIP. In their place, in December 2007, the President authorized an extension of the plan that would maintain the program without expanding it through the end of March 2009.

mobile HIV testing

NYT today covered moible HIV testing units in Westchester county, which has the highest rate of HIV in the state outside of NYC. The testing uses a specimen obtained from a gum swab and takes about twenty minutes. The vans also offers counseling for anyone who needs it. This type of rapid response testing is the same offered in several EDs throughout NYC.

Great new graphic

This is a terrific tool to play with if you're interested in health disparities in NYC. It actually covers the entire state, but it's particularly useful for the city.

https://apps.nyhealth.gov/statistics/prevention/quality_indicators/start.map

You plug in a zip code, and they give the demographics of that area (size and population) as well the "hospital admission rate". This is the rate at which people in the area are admitted to hospitals for "preventable conditions": asthma, diabetes, hypertension, congestive heart failure, etc. The idea is that anywhere the hospital admission rate is more than 100%, the admission rates for that area are higher than those statewide. Obviously, there is an intuitive link between higher than average hospital admissions and poor primary/preventative care.

The numbers initially include all the conditions analyzed, but you can disambiguate the data using the drop down menu by the upper right hand corner of the map. I played around with it focusing on diabetes and asthma, and used my zip code in Washington Heights (10033) and a SoHo zip (10013) to get some pretty interesting statistics. Apparently there are health disparities in NYC; who knew?


Interestingly, the Kasier Foundation noted that the highest hospital admissions rates come from rural areas. Their summary, as well as link to an article in the Syracuse Post-Standard:

http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=56277

Hello

My first post will be just a quick introduction. I am a registered nurse pursuing a Master's degree in Nursing. My BS in Nursing was my second undergraduate degree; it was a one year accelerated program designed for students who wanted to be nurses but who already had four year degrees in other fields. My BA was in the social sciences, and one of the only two science classes I took in college was nicknamed "Sex" by the student body. (The course guide opted for the more discreet title "The Evolution of Human Nature", but it obviously fooled no one.) So transitioning into classes that actually had right and wrong answers was not easy. However, I was lucky enough to take care of my prereqs quickly, and to begin my nursing degree almost exactly a year after finishing undergad.

I was also lucky enough to get into my first choice nursing school: Columbia University. Its medical campus is centered around Columbia-Presbyterian Hospital, in the Washington Heights area of New York. A year after starting my degree at Columbia, I finished the bachelor's portion of the program and became a registered nurse. Like most people in my class, I moved on immediately to my Master's in Nursing, which, combined with passing the state's nursing boards, will qualify me to practice as a Nurse Practitioner in New York. I will complete my degree in December 2009.

In addition to nursing , I'm interested in public health, particularly in New York and particularly as it pertains to HIV. I intend for this blog to discuss all three subjects, although the ratio is to be determined. To that end, an interesting study recently came out from the New York Department of Health exploring a link between binge drinking and HIV among MSM. You can download the full study at the end of the press release.