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...)