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May 18, 2023

Concern grows around US health-care workforce shortage: ‘We don’t have enough doctors’ | CNN

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CNN
—

There is mounting concern among some US lawmakers about the nation’s ongoing shortage of health-care workers, and the leaders of historically Black medical schools are calling for more funding to train a more diverse workforce.

As of Monday, in areas where a health workforce shortage has been identified, the United States needs more than 17,000 additional primary care practitioners, 12,000 dental health practitioners and 8,200 mental health practitioners, according to data from the Health Resources & Services Administration. Those numbers are based on data that HRSA receives from state offices and health departments.

“We have nowhere near the kind of workforce, health-care workforce, that we need,” Vermont Sen. Bernie Sanders told CNN on Friday. “We don’t have enough doctors. We don’t have enough nurses. We don’t have enough psychologists or counselors for addiction. We don’t have enough pharmacists.”

The heads of historically Black medical schools met with Sanders in a roundtable at the Morehouse School of Medicine in Atlanta on Friday to discuss the nation’s health-care workforce shortage.

The health-care workforce shortage is “more acute” in Black and brown communities; the Black community constitutes 13% of the US population, but only 5.7% of US physicians are Black, said Sanders, chairman of the Senate Committee on Health, Education, Labor, and Pensions.

“What we’re trying to do in this committee – in our Health, Education, Labor Committee – is grow the health-care workforce and put a special emphasis on the needs to grow more Black doctors, nurses, psychologists, et cetera,” Sanders said.

At Friday’s roundtable, the leaders of the Morehouse School of Medicine, Meharry Medical College, Howard University and Charles R. Drew University called for more resources and opportunities to be allocated to their institutions to help grow the nation’s incoming health-care workforce.

“Allocating resources and opportunities matter for us to increase capacity and scholarships and programming to help support these students as they matriculate through,” Dr. Valerie Montgomery Rice, president of the Morehouse School of Medicine, told CNN.

“But also, the other 150-plus medical schools, beyond our four historically Black medical schools, owe it to the country to increase the diversity of the students that they train,” Rice said, adding that having a health-care workforce that reflects the communities served helps reduce the health inequities seen in the United States.

Historically Black medical schools are “the backbone for training Black doctors in this country,” Dr. Hugh Mighty, senior vice president for health affairs at Howard University, said at Friday’s event. “As the problem of Black physician shortages rise, within the general context of the physician workforce shortage, many communities of need will continue to be underserved.”

A new study commissioned by the National Institute on Minority Health and Health Disparities estimates that the economic burden of health inequities in the United States has cost the nation billions of dollars. Such inequities are illustrated in how Black and brown communities tend to have higher rates of serious health outcomes such as maternal deaths, certain chronic diseases and infectious diseases.

The researchers, from Johns Hopkins University and other institutions, analyzed excess medical care expenditures, death records and other US data from 2016 through 2019. They took a close look at health inequities in the cost of medical care, differences in premature deaths and the amount of labor market productivity that has been lost due to health reasons.

The researchers found that, in 2018, the economic burden of health inequities for racial and ethnic minority communities in the United States was up to $451 billion, and the economic burden of health inequities for adults without a four-year college degree was up to $978 billion.

“These findings provide a clear and important message to health care leaders, public health officials, and state and federal policy makers – the economic magnitude of health inequities in the US is startlingly high,” Drs. Rishi Wadhera and Issa Dahabreh, both of Harvard University, wrote in an editorial that accompanied the new study in the journal JAMA.

The Covid-19 pandemic “pulled the curtain back” on health inequities, such as premature death and others, Rice said, and “we saw a disproportionate burden” on some communities.

“We saw a higher death rate in Black and brown communities because of access and fear and a whole bunch of other factors, including what we recognize as racism and unconscious bias,” Rice said.

“We needed more physicians, more health-care providers. So, we already know when we project out to 2050, we have a significant physician shortage based on the fact that we cannot educate and train enough health care professionals fast enough,” she said. “We can’t just rely on physicians. We have to rely on a team approach.”

She added that the nation’s shortage of health-care workers leaves the country ill-prepared to respond to future pandemics.

The United States is projected to face a shortage of up to 124,000 physicians by 2034 as the demand outpaces supply, according to the Association of American Medical Colleges.

The workforce shortage means “we’re really not prepared” for another pandemic, Sanders said.

“We don’t have the public health infrastructure that we need state by state. We surely don’t have the doctors and the nurses that we need,” Sanders said. “So what we are trying to do now is to bring forth legislation, which will create more doctors and more nurses, more dentists, because dental care is a major crisis in America.”

In March, Bill McBride, executive director of the National Governors Association, wrote a letter to Sanders and Louisiana Sen. Bill Cassidy detailing the “root causes” of the health-care workforce shortage and potential ways some states are hoping to tackle the crisis.

“Governors have taken innovative steps to address the healthcare workforce shortage facing their states and territories by boosting recruitment efforts, loosening licensing requirements, expanding training programs and raising providers’ pay,” McBride wrote.

“Shortages in healthcare workers is not a new challenge but has only worsened in the past three years due to the COVID-19 pandemic. Burnout and stress have only exacerbated this issue,” he wrote. “The retirement and aging of an entire generation is front and center of the healthcare workforce shortage, particularly impacting rural communities.”

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May 8, 2023

Kids need to gain weight during adolescence. Here’s why | CNN

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Editor’s Note: Michelle Icard is the author of several books on raising adolescents, including “Fourteen Talks by Age Fourteen.”

CNN
—

I’ve worked with middle schoolers, their parents and their schools for 20 years to help kids navigate the always awkward, often painful, sometimes hilarious in hindsight, years of early adolescence.

Most of the social and development stretch marks we gain during adolescence fade to invisibility over time. We stop holding a grudge against the kid who teased us in class for tripping, or we forgive ourselves our bad haircuts, botched friendships and cringy attempts at popularity.

But one growing pain can be dangerously hard to recover from, and ironically, it’s the one that has most to do with our physical growth.

Children are supposed to keep growing in adolescence, and so a child’s changing body during that time should not be cause for concern. Yet it sends adults into a tailspin of fear around weight, health and self-esteem.

Kids have always worried about their changing bodies. With so many changes in such a short period of early puberty, they constantly evaluate themselves against each other to figure out if their body development is normal. “All these guys grew over the summer, but I’m still shorter than all the girls. Is something wrong with me?” “No one else needs a bra, but I do. Why am I so weird?”

But the worry has gotten worse over the past two decades. I’ve seen parents becoming increasingly worried about how their children’s bodies change during early puberty. When I give talks about parenting, I often hear adults express concern and fear about their children starting to gain “too much” weight during early adolescence.

Parents I work with worry that even kids who are physically active, engaged with others, bright and happy might need to lose weight because they are heavier than most of their peers.

Why are parents so focused on weight? In part, I think it’s because our national conversations about body image and disordered eating have reached a frenzy on the topic. Over the past year, two new angles have further complicated this matter for children.

Remember Jimmy Kimmel’s opening monologue at the Oscars making Ozempic and its weight-loss properties a household name? Whether it’s social media or the mainstream press, small bodies and weight loss are valued. It’s clear to young teens I know that celebrities have embraced a new way to shrink their bodies.

Constant messages about being thin and fit are in danger of overexposing kids to health and wellness ideals that are difficult to extract from actual health and wellness.

Compound this with the American Academy of Pediatrics recently changing its guidelines on treating overweight children, and many parents worry even more that saying or doing nothing about their child’s weight is harmful.

The opposite is true. Parents keep their children healthiest when they say nothing about their changing shape. Here’s why.

Other than the first year of life, we experience the most growth during adolescence. Between the ages of 13 and 18, most adolescents double their weight. Yet weight gain remains a sensitive, sometimes scary subject for parents who fear too much weight gain, too quickly.

It helps to understand what’s normal. On average, boys do most of their growing between 12 and 16. During those four years, they might grow an entire foot and gain as much as 50 to 60 pounds. Girls have their biggest growth spurt between 10 and 14. On average, they can gain 10 inches in height and 40 to 50 pounds during that time, according to growth charts from the US Centers for Disease Control and Prevention.

Boys do most of their growing between ages 12 and 16 on average. They may even grow an entire foot.

“It’s totally normal for kids to gain weight during puberty,” said Dr. Trish Hutchison, a board-certified pediatrician with 30 years of clinical experience and a spokesperson for the American Academy of Pediatrics, via email. “About 25 percent of growth in height occurs during this time so as youth grow taller, they’re also going to gain weight. Since the age of two or three, children grow an average of about two inches and gain about five pounds a year. But when puberty hits, that usually doubles.”

The American Academy of Pediatrics released a revised set of guidelines for pediatricians in January, which included recommendations of medications and surgery for some children who measure in the obese range.

In contrast, its 2016 guidelines talked about eating disorder prevention and “encouraged pediatricians and parents not to focus on dieting, not to focus on weight, but to focus on health-promoting behaviors,” said Elizabeth Davenport, a registered dietitian in Washington, DC.

“The new guidelines are making weight the focus of health,” she said. “And as we know there are many other measures of health.”

Davenport said she worries that kids could misunderstand their pediatricians’ discussions about weight, internalize incorrect information and turn to disordered eating.

“A kid could certainly interpret that message as not needing to eat as much or there’s something wrong with my body and that leads down a very dangerous path,” she said. “What someone could take away is ‘I need to be on a diet’ and what we know is that dieting increases the risk of developing an eating disorder.”

Many tweens have tried dieting, and many parents have put their kids on diets.

“Some current statistics show that 51% of 10-year-old girls have tried a diet and 37% of parents admit to having placed their child on a diet,” Hutchison said in an email, adding that dieting could be a concern with the new American Academy of Pediatrics guidelines.

“There is evidence that having conversations about obesity can facilitate effective treatment, but the family’s wishes should strongly direct when these conversations should occur,” Hutchison said. “The psychological impact may be more damaging than the physical health risks.”

It’s not that weight isn’t important. “For kids and teens, we need to know what their weight is,” Davenport said. “We are not, as dietitians, against kids being weighed because it is a measure to see how they’re growing. If there’s anything outstanding on an adolescent’s growth curve, that means we want to take a look at what’s going on. But we don’t need to discuss weight in front of them.”

In other words, weight is data. It may or may not indicate something needs addressing. The biggest concern, according to Davenport, is when a child isn’t gaining weight. That’s a red flag something unhealthy is going on.

“Obesity is no longer a disease caused by energy in/energy out,” Hutchison said. “It is much more complex and other factors like genetics, physiological, socioeconomic, and environmental contributors play a role.”

It’s important for parents and caregivers to know that “the presence of obesity or overweight is NOT an indication of poor parenting,” she said. “And it’s not the child or adolescent’s fault.”

It’s also key to note, Hutchison said, that the new American Academy of Pediatrics guidelines, which are only recommendations, are not for parents. They are part of a 100-page document that provides information to health care providers with clinical practice guidelines for the evaluation and treatment of children and adolescents who are overweight or obese. Medications and surgery are discussed in only four pages of the document.

Parents need to work on their own weight bias, but they also need to protect their children from providers who don’t know how to communicate with their patients about weight.

“Working in the field of eating disorder treatment for over 20 years, I sadly can’t tell you the number of clients who’ve come in and part of the trigger for their eating disorder was hearing from a medical provider that there was an issue or a concern of some sort with their weight,” Davenport said.

Hutchison said doctors and other health providers need to do better.

“We all have a lot of work to do when it comes to conversations about weight,” Hutchison said. “We need to approach each child with respect and without (judgment) because we don’t want kids to ever think there is something wrong with their body.”

The right approach, according to American Academy of Pediatrics training, is to ask parents questions that don’t use the word “weight.” One example Hutchison offered: “What concerns, if any, do you have about your child’s growth and health?”

Working sensitively, Hutchison said she feels doctors can have a positive impact on kids who need or want guidance toward health-promoting behaviors.

Kids can misunderstand doctors' discussions about their weight and internalize incorrect information.

Davenport and her business partner in Sunny Side Up Nutrition, with input from the Carolina Resource Center for Eating Disorders, have gotten more specific. They have created a resource called Navigating Pediatric Care to give parents steps they can take to ask health care providers to discuss weight only with them — not with children.

“Pediatricians are supposed to ask permission to be able to discuss weight in front of children,” Davenport said. “It’s a parent’s right to ask this and advocate for their child.”

Davenport advises parents to call ahead and schedule an appointment to discuss weight before bringing in a child for a visit. She also suggests calling or emailing ahead with your wishes, though she admits it may be less effective in a busy setting. She said to print out a small card to hand to the nurse and physician at the appointment. You can also say in front of the child, “We prefer not to discuss weight in front of my child.”

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April 29, 2023

US cigarette smoking rate falls to historic low, but e-cigarette use keeps climbing | CNN

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CNN
—

The percentage of adults who smoked cigarettes in the United States fell to a historic low last year, the US Centers for Disease Control and Prevention found. However, e-cigarettes are becoming even more popular.

About 11% of adults told the CDC last year that they were current cigarette smokers, according to the latest preliminary data from the National Health Interview Survey, a biannual survey that provides general information about health-related topics. The survey includes responses from 27,000 people age 18 and older. In 2020 and 2021, about 12.5% of adults said they smoked cigarettes.

This is a significant drop from when surveys like these started. Surveys of Americans in the 1940s found that about half of all adults said they smoked cigarettes. Rates began to decline in the 1960s, and more recently, in 2016, 15.5% of adults said they smoked cigarettes.

Recent studies have shown some groups are still at higher risk. While the latest CDC survey doesn’t capture this level of detail, cigarette smoking rates among some communities – including Native Americans, Alaska Natives and members of the LGBTQ community remain “alarmingly high” according to the 2023 State of Tobacco Control report from the American Lung Association.

The general drop in cigarette smoking among adults should have a positive impact on public health.

Cigarette smoking is still the leading cause of preventable death and disability in the US. So many people have died from smoking, the CDC finds, that more than 10 times as many US citizens have died prematurely from cigarette smoking than have died in all the wars fought by the US.

Smokers are 90% of the lung cancer cases in the United States, but smoking can also cause someone to have a stroke, coronary heart disease, and COPD, as well as other cancers including bladder, colon, kidney, liver, stomach and other cancers. People who live with smokers also are at a greater risk of death, because of secondhand smoke.

This latest survey does not capture why fewer people smoked cigarettes, but the number has been on the decline since the 1960s, after the US surgeon general released the first report on smoking and health that concluded that smoking causes serious health problems.

Experts credit a variety of efforts for the decline in cigarette smoking – anti-smoking campaigns, programs that educate children about the danger of smoking, laws that severely restrict where people could smoke and where cigarette companies could advertise, as well as better access to smoking cessation programs and higher taxes that make cigarettes expensive.

However, Congress hasn’t raised federal tobacco taxes in 14 years. The federal cigarette tax remains $1.01 per pack, and taxes vary for other tobacco products. No state increased its cigarette taxes in 2022.

The pandemic may also have had an influence. Smokers were much more vulnerable to the severe consequences of Covid-19 and that gave some people the extra motivation they needed to quit – and may have given doctors the extra motivation they needed to help them too, according to Dr. Panagis Galiatsatos, a volunteer medical spokesperson with the American Lung Association. At some level, the pandemic also made the medical establishment easier to access.

“The pandemic, I think, really allowed physicians time they never probably had in the past to conduct these telemedicine visits that were appropriate just for smoking cessation strategies, helping them help patients quit and stay quit,” said Galiatsatos, who is a pulmonary and critical care medicine physician and is director of the Tobacco Treatment Clinic with Johns Hopkins Medicine.

Galiatsatos points to the US Surgeon General report released during the Trump administration, just prior to the start of the pandemic. The report detailed that of the patients they have now that smoke, the few that are left are going to be the most resistant to quitting. Then-Surgeon General Jerome Adams’ report encouraged more doctors to help their patients quit. The report found that 40% of smokers are not routinely told by their doctors to stop.

Still, the culture has changed. Smoking is much less socially acceptable in some cultures in the US.

E-cigarette use, though, seems to be more socially acceptable, especially among younger people studies show, and that may explain why those numbers are up.

The current survey found that e-cigarette use rose to nearly 6% last year, that’s up from about 4.9% the year before.

Some argue that e-cigarettes are a good substitute for regular cigarettes, and in some countries they are even promoted as a smoking cessation devices, but the CDC says that “e-cigarettes are not safe for youth, young adults, and pregnant women, as well as adults who do not currently use tobacco products.”

A BMJ study published in February found that people who used e-cigarettes to quit smoking found them to be less helpful than more traditional smoking cessation aids.

The US Food and Drug Administration says there is not enough evidence to support claims that these products are effective tools to help people quit smoking. None are approved for this purpose. The FDA says there are no safe tobacco products, including e-cigarettes, vapes, and other electronic nicotine delivery systems.

“I always hold no stigma or judgment when anyone wants to smoke a traditional cigarette or use electronic cigarettes, but as a lung doctor, I will always promote only air to come into the lungs,” said Galiatsatos. “From my standpoint, I think we should still have a public health mindset around e-cigarette usage because for some individuals, they’re going to have health consequences from this product.”

He said people may choose to vape instead of smoke cigarettes, but clinicians should be prepared to help this population if they do want to quit.

E-cigarettes can, though, produce a number of chemicals that are not good for human health, including acrolein, acetaldehyde, and formaldehyde. Studies show these chemicals are known as aldehydes and can cause lung and heart disease, according to the American Lung Association.

Among teens, nicotine exposure can harm the developing brain, according to the US surgeon general.

E-cigarettes are much more popular than cigarettes among teens, so the adult e-cigarette user numbers will likely continue to grow.

About 14% of high school students said they used e-cigarettes, and 2% of high school students smoked cigarettes last year, according to separate CDC data.

The rate of kids that use e-cigarettesis high, the American Academy of Pediatrics says.

Specifically, in 2022, nearly 5% of middle school and about 17% of high school students reported some form of current tobacco use, according to CDC data from an earlier survey. In 2021, about 11% of middle schoolers and 34% of high schoolers said they had ever tried tobacco.

These “try rates” are important because most adult smokers started at young ages, according to the CDC.

The AAP continues to encourage pediatricians to screen for tobacco use as part of a child’s regular checkup. A talk about tobacco should start no later than age 11 or 12, the report says.

For adult smokers, the CDC encourages encourages people to call 1-800-QUIT-NOW where people can get free confidential coaching. The government also offers free online resources and even text programs that can help people quit.

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April 26, 2023

Amid contradictory laws, hospitals in one state were unable to explain policies on emergency abortion care, study finds | CNN

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CNN
—

Oklahoma’s laws restricting abortions have created a confusing, contradictory environment that may have a chilling effect on health care, new research says.

After the US Supreme Court overturned the right to an abortion last year with the Dobbs v. Jackson Women’s Health Organization decision, several states quickly passed laws that restricted such procedures. A report released Tuesday and described in the medical journal the Lancet finds that the laws in at least one state left workers at many hospitals confused about how to proceed.

When the court made its decision, the Oklahoma law that criminalized abortion in 1910 went back into effect, according to the state’s attorney general. Lawmakers then created multiple overlapping laws that further criminalized abortion and increased penalties for those who performed or assisted in an abortion procedure, according to the new report from Physicians for Human Rights, Oklahoma Call for Reproductive Justice and the Center for Reproductive Rights.

The Oklahoma laws allow abortion in the case of a medical emergency, but one doesn’t define a medical emergency. Another says it allows for the “preservation of life in a medical emergency,” defined as causing “substantial and irreversible body of bodily impairment” – which is not a medical term, experts say.

To understand exactly how well Oklahoma hospitals understood the laws, the researchers used a “secret shopper method,” study co-author Dr. Michele Heisler said.

Researchers posed as prospective patients and called 34 hospitals to ask about the emergency pregnancy care they offered.

Heisler said that when the researchers designed the study, she expected the hospitals to tell the patients that they could get help in an emergency but that a second provider might have to sign off on an abortion or that a doctor would have to get the decision past an “onerous” hospital oversight committee.

“What we weren’t expecting is that there would be so much confusion and contradictory information and really not clear information,” said Heisler, who is medical director at Physicians for Human Rights and a professor of internal medicine and public health at the University of Michigan.

The researchers said that none of the hospitals they contacted in Oklahoma was totally able to articulate clear, consistent policies for emergency obstetric care to potential patients.

Specifically, 65% – 22 of the 34 hospitals – were unable to provide information about policies, procedures or the support provided to doctors when it is clinically necessary to terminate a pregnancy to save the life of a pregnant patient.

In 14 of the 22 cases, hospital representatives provided unclear and/or incomplete answers about whether doctors require approval to perform a medically necessary abortion.

Three of the hospitals said they do not provide abortions at all, even though it remains legal in the case of a medical emergency or to “preserve the life” of the pregnant person. Four others provided information that was factually wrong, the report says.

Four hospitals said they had formal approval processes that clinicians must go through if they have a situation in which it is medically necessary to terminate a pregnancy; they cannot make that decision on their own.

Three hospitals indicated that they have policies for these situations but refused to share any information about them.

“Unfortunately, it is being just left up to individual health systems and clinicians to try to make sense of these laws and provide guidance and support,” Heisler said.

The Oklahoma Hospital Association said it has been in conversations with Oklahoma’s medical licensure boards to seek clarity about the state’s conflicting abortion laws.

The association sent guidance to its members in September to explain what it interpreted as “saving the life of a pregnant woman” and what the laws would mean for a person made pregnant through rape or incest, among other issues. The guidance explains that the state’s criminal laws do not make an exception for these circumstances unless it is to save the life of someone who is pregnant in a medical emergency.

The guidance also warns that a person convicted of “administering, prescribing, advising, or procuring a woman to take any medicine drug or substance, or a person convicted of using or employing any instruction or ‘other means whatever,’ with the intent to procure an abortion, shall be guilty of a felony punishable by two (2) to (5) years imprisonment. From August 27, 2022, forward, a person convicted of performing or attempting to perform an abortion shall be guilty of a felony punishable by a fine not to exceed One Hundred Thousand ($100,000.00) and/or imprisonment not to exceed ten (10) years.”

The guidance says the “persons potentially liable” are the provider, not the pregnant person.

Study co-author Rabia Muqaddam, a senior staff attorney at the Center for Reproductive Rights who is working on multiple cases challenging the abortion bans in Oklahoma, called the overlapping laws a “bizarre” situation.

“Aside from the fact that there are so many of them is that they all conflict,” she said. “All of the laws have inconsistent definitions, which is where a lot of the confusion comes from for health care providers. What’s most dangerous for patients is the fact that the definitions of medical emergency and life-preserving abortions is unclear and inconsistent.”

“If I was the hospital general counsel and I was looking at these laws, I have absolutely no idea what my physician could or could not do in any particular circumstance,” she said.

When there is a lack of clarity and when penalties are involved, “what you get is massive chill.”

“Physicians are terrified. They’re terrified that if they make the wrong decision, they’re going to go to jail. They’re going to lose their license. And at the other end of that is that patients are being seriously harmed,” Muqaddam said.

Sonia M. Suter, a professor of law at George Washington University who was not involved in the new research, said recent abortion laws have created “such a mess.”

“You are telling physicians that they have two conflicting obligations,” said Suter, whose scholarship focuses on issues at the intersection of law, medicine and bioethics, with a particular focus on reproductive rights.

There is an obligation to stabilize patients in emergencies that may not always qualify as “life-threatening,” but doctors and hospitals could also risk being sued because the doctors are not following the standard of care, “which you can’t do with how some of these exceptions are worded.”

She said hospitals also don’t know how the laws will be applied. Lawyers typically will instruct institutions to interpret the law as conservatively as possible, and physicians may be equally conservative because they don’t want to risk their licenses or face stiff penalties.

“It’s just devastating for everybody,” Suter said. “It’s just cruel.”

Molly Meegan, general counsel for the American College of Obstetricians and Gynecologists, said state laws to restrict abortion with emergency exceptions are not comprehensive.

“They can’t be applied in a medical situation. They just aren’t practical,” she said. “They have an ethical and personal duty to their patients to do what is best for their patients. It can at times be in direct conflict with whatever the laws are, especially if they’re vague, and most of the ob/gyns throughout the country, including in Oklahoma, are in an impossible situation.”

Meegan and Suter both believe the confusion will lead to the deaths of more women. Those who survive may be left with dire health problems, including losing the ability to have children in the future.

“They already have horrific maternal mortality and infant mortality rates,” Suter said. “It feels like the end of evidence-based medicine.”

According to the US Centers for Disease Control and Prevention, Oklahoma persistently ranks among the states with the worst rates of maternal deaths, even before the new abortion laws went into effect. The state had a maternal mortality rate of 25.2 deaths per 100,000 live births for 2018-20, well above the national average.

For communities of color, the rate is significantly worse, according to the Oklahoma Health Department.

White women had 23.2 maternal deaths per 100,000 live births for 2018-20, the lowest rate overall in Oklahoma. The rates for Black women and Native American women were about twice as high: 49.4 and 44.4, respectively.

Oklahoma is not alone. The 13 states where most abortions are banned generally have some of the highest infant and maternal mortality rates in the country, Heisler said. Even more states could be restricting abortion access soon, the experts believe, with potentially more problems to come.

“The hostile climate many states are creating for the health care field by enacting criminal and other penalties for abortion care is an outcome whose reverberations we are only just beginning to see,” said Kelly Baden, vice president for public policy at the reproductive health nonprofit Guttmacher Institute.

Heisler noted that the researchers don’t blame the hospitals or the doctors for this confusion. Overall, she said, the staffers who talked to the researchers “were wonderful,” despite the circumstances.

“They were empathetic. They said, ‘I completely understand.’ They tried to give answers. They acted in good faith. But really, none of the hospitals were really able to say what we were hoping for, which is to unequivocally state that they would stand behind their clinicians and that clinicians at their facilities would be able to use their best clinical judgment for the individual case and that it would be made as medical decisions should be in collaboration with the patient, taking into account to their needs, their preferences and their values,” she said.

“We are recognizing that hospitals and clinicians are in an untenable situation,” Heisler added.

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April 18, 2023

More people with Down syndrome are living longer, but medical systems aren’t keeping up | CNN

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Montrose, Missouri
KFF
—

It took Samantha Lesmeister’s family four months to find a medical professional who could see that she was struggling with something more than her Down syndrome.

The young woman, known as Sammee, had become unusually sad and lethargic after falling in the shower and hitting her head. She lost her limited ability to speak, stopped laughing, and no longer wanted to leave the house.

General-practice doctors and a neurologist said such mental deterioration was typical for a person with Down syndrome entering adulthood, recalled her mother, Marilyn Lesmeister. They said nothing could be done.

The family didn’t buy it.

Marilyn researched online and learned the University of Kansas Health System has a special medical clinic for adults with Down syndrome. Most other Down syndrome programs nationwide focus on children, even though many people with the condition now live into middle age and often develop health problems typically associated with seniors. And most of the clinics that focus on adults are in urban areas, making access difficult for many rural patients.

The clinic Marilyn found is in Kansas City, Kansas, 80 miles northwest of the family’s cattle farm in central Missouri. She made an appointment for her daughter and drove up.

The program’s leader, nurse practitioner Moya Peterson, carefully examined Sammee Lesmeister and ordered more tests.

“She reassured me that, ‘Mom, you’re right. Something’s wrong with your daughter,’” Marilyn Lesmeister said.

With the help of a second neurologist, Peterson determined Sammee Lesmeister had suffered a traumatic brain injury when she hit her head. Since that diagnosis about nine years ago, she has regained much of her strength and spirit with the help of therapy and steady support.

Sammee, now 27, can again speak a few words, including “hi,” “bye,” and “love you.” She smiles and laughs. She likes to go out into her rural community, where she helps choose meals at restaurants, attends horse-riding sessions at a stable, and folds linens at a nursing home.

Without Peterson’s insight and encouragement, the family likely would have given up on Sammee’s recovery. “She probably would have continued to wither within herself,” her mother said. “I think she would have been a stay-at-home person and a recluse.”

The Lesmeisters wish Peterson’s program wasn’t such a rarity. A directory published by the Global Down Syndrome Foundation lists just 15 medical programs nationwide that are housed outside of children’s hospitals and that accept Down syndrome patients who are 30 or older.

The United States had about three times as many adults with the condition by 2016 as it did in 1970. That’s mainly because children born with it are no longer denied lifesaving care, including surgeries to correct birth defects.

Adults with Down syndrome often develop chronic health problems, such as severe sleep apnea, digestive disorders, thyroid conditions, and obesity. Many develop Alzheimer’s disease in middle age. Researchers suspect this is related to extra copies of genes that cause overproduction of proteins, which build up in the brain.

“Taking care of kids is a whole different ballgame from taking care of adults,” said Peterson, the University of Kansas nurse practitioner.

Sammee Lesmeister is an example of the trend toward longer life spans. If she’d been born two generations ago, she probably would have died in childhood.

She had a hole in a wall of her heart, as do about half of babies with Down syndrome. Surgeons can repair those dangerous defects, but in the past, doctors advised most families to forgo the operations, or said the children didn’t qualify. Many people with Down syndrome also were denied care for serious breathing issues, digestive problems, or other chronic conditions. People with disabilities were often institutionalized. Many were sterilized without their consent.

Such mistreatment eased from the 1960s into the 1980s, as people with disabilities stood up for their rights, medical ethics progressed, and courts declared it illegal to withhold care. “Those landmark rulings sealed the deal: Children with Down syndrome have the right to the same lifesaving treatment that any other child would deserve,” said Brian Skotko, a Harvard University medical geneticist who leads Massachusetts General Hospital’s Down Syndrome Program.

The median life expectancy for a baby born in the U.S. with Down syndrome jumped from about four years in 1950 to 58 years in the 2010s, according to a recent report from Skotko and other researchers. In 1950, fewer than 50,000 Americans were living with Down syndrome. By 2017, that number topped 217,000, including tens of thousands of people in middle age or beyond.

The population is expected to continue growing, the report says. A few thousand pregnant women a year now choose abortions after learning they’re carrying fetuses with Down syndrome. But those reductions are offset by the increasing number of women becoming pregnant in their late 30s or 40s, when they are more likely to give birth to a baby with Down syndrome.

Skotko said the medical system has not kept up with the extraordinary increase in the number of adults with Down syndrome. Many medical students learn about the condition only while training to treat pediatric patients, he said.

Few patients can travel to specialized clinics like Skotko’s program in Boston. To help those who can’t, he founded an online service, Down Syndrome Clinic to You, which helps families and medical practitioners understand the complications and possible treatments.

Charlotte Woodward, who has Down syndrome, is a prominent advocate for improved care. She counts herself among the tens of thousands of adults with the condition who likely would have died years ago without proper treatment. Woodward, 33, of Fairfax, Virginia, had four heart surgeries as a child and then a heart transplant in her 20s.

Woodward, who is an education program associate for the National Down Syndrome Society, has campaigned to end discrimination against people with disabilities who need organ transplants.

She said her primary care doctor is excellent. But she has felt treated like a child by other health care providers, who have spoken to her parents instead of to her during appointments.

She said many general-practice doctors seem to have little knowledge about adults with Down syndrome. “That’s something that should change,” she said. “It shouldn’t just be pediatricians that are aware of these things.”

Woodward said adults with the condition should not be expected to seek care at programs housed in children’s hospitals. She said the country should set up more specialized clinics and finance more research into health problems that affect people with disabilities as they age. “This is really an issue of civil rights,” she said.

Advocates and clinicians say it’s crucial for health care providers to communicate as much as possible with patients who have disabilities. That can lead to long appointments, said Brian Chicoine, a family practice physician who leads the Adult Down Syndrome Center of Advocate Aurora Health in Park Ridge, Illinois, near Chicago.

“It’s very important to us that we include the individuals with Down syndrome in their care,” he said. “If you’re doing that, you have to take your time. You have to explain things. You have to let them process. You have to let them answer. All of that takes more time.”

Time costs money, which Peterson believes is why many hospital systems don’t set up specialized clinics like the ones she and Chicoine run.

Peterson’s methodical approach was evident as she saw new patients on a recent afternoon at her Kansas City clinic. She often spends an hour on each initial appointment, speaking directly to patients and giving them a chance to share their thoughts, even if their vocabularies are limited.

Her patients that day included Christopher Yeo, 44, who lives 100 miles away in the small town of Hartford, Kansas. Yeo had become unable to swallow solid food, and he’d lost 45 pounds over about 1½ years. He complained to his mother, Mandi Nance, that something “tickled” in his chest.

During his exam, he lifted his shirt for Peterson, revealing the scar where he’d had heart surgery as a baby. He grimaced, pointed to his chest, and repeatedly said the word “gas.”

Peterson looked Yeo in the eye as she asked him and his mother about his discomfort.

The nurse practitioner takes seriously any such complaints from her patients. “If they say it hurts, I listen,” she said. “They’re not going to tell you about it until it hurts bad.”

Nurse practitioner Moya Peterson speaks to Christopher Yeo of Hartford, Kansas. Peterson leads an rare clinic for adults with Down syndrome.

Yeo’s mother had taken him to a cardiologist and other specialists, but none had determined what was wrong.

Peterson asked numerous questions. When does Yeo’s discomfort seem to crop up? Could it be related to what he eats? How is his sleep? What are his stools like?

After his appointment, Peterson referred Yeo to a cardiologist who specializes in adults with congenital heart problems. She ordered a swallowing test, in which Yeo would drink a special liquid that appears on scans as it goes down. And she recommended a test for Celiac disease, an autoimmune disorder that interferes with digestion and is common in people with Down syndrome. No one had previously told Nance about the risk.

Nance, who is a registered nurse, said afterward that she has no idea what the future holds for their family. But she was struck by the patience and attention Peterson and other clinic staff members gave to her son. Such treatment is rare, she said. “I feel like it’s a godsend. I do,” she said. “I feel like it’s an answered prayer.”

Peterson serves as the primary care provider for some of her patients with Down syndrome. But for many others, especially those who live far away, she is someone to consult when complications arise. That’s how the Lesmeisters use her clinic.

Mom Marilyn is optimistic Sammee can live a fulfilling life in their community for years to come. “Some people have said I need to put her in a home. And I’m like, ‘What do you mean?’ And they say, ‘You know ― a home,’” she said. “I’m like, ‘She’s in a home. Our home.’”

Sammee’s sister, who lives in Texas, has agreed to take her in when their parents become too old to care for her.

Marilyn’s voice cracked with emotion as she expressed her gratitude for the help they have received and her hopes for Sammee’s future.

“I just want her to be taken care of and loved like I love her,” she said. “I want her to be taken care of like a person, and not a condition.”

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April 17, 2023

To protect kids from tobacco, pediatricians say, focus should be on quitting — or never starting | CNN

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CNN
—

Although smoking rates for adults in the US are at their lowest recorded levels, more must be done to stop children from using tobacco, according to a new set of policy statements from the American Academy of Pediatrics.

The statements, published Monday, are the association’s first tobacco policy update since 2015. They’re based on newer science and better reflect how many children now use e-cigarettes as more kid-friendly products have flooded the market.

AAP policy statements are created by expert pediatricians to help leaders craft more effective public health policy and to guide physicians on how to keep kids safe – in this case, from tobacco.

Researchers have been telling Americans for generations that tobacco products are bad for them, yet nearly 200 US children take up smoking every day, according to the US Centers for Disease Control and Prevention.

Tobacco use is the No. 1 cause of preventable death in the United States, the CDC says.

The rates of kids who use e-cigarettes are high, the AAP says, and the use of hookahs and cigars has not declined. However, the pediatricians note, traditional cigarette smoking has declined over the years.

Specifically, in 2022, nearly 5% of middle school and about 17% of high school students reported some form of current tobacco use, according to the CDC. In 2021, about 11% of middle schoolers and 34% of high schoolers said they had ever tried tobacco.

These “try rates” are important because most adult smokers started at young ages, according to the CDC.

And in smoking rates remain disproportionately high in certain communities, including those who are Black, Hispanic, Native American, Alaska Native or LGBTQ+.

In its updated policy statements, the AAP continues to encourage pediatricians to screen for tobacco use as part of a child’s regular checkup. A talk about tobacco should start no later than age 11 or 12, the report says.

For kids who want to quit tobacco, pediatricians should refer them to behavioral interventions like counseling or prescribe nicotine replacement therapy, which has been shown to be effective with children who have moderate or severe tobacco addiction.

That practice has shifted over the years, according to Dr. Susan Walley, co-author of the new policy statements. In medical school, she said, her professors didn’t talk much about smoking except to tell people to quit.

“Now, we know it’s an addiction and a chronic medical disease. Telling someone just to quit would be like telling somebody who’s diabetic, ‘you just need to think about making your blood sugar better.’ We’ve learned so much,” said Walley, a pediatrician at Children’s National in Washington, D.C.

The new report notes that children who smoke cigarettes should not be encouraged to use e-cigarettes as an alternative. Some experts have argued that e-cigarettes are a good smoking cessation tool, but the AAP says evidence is lacking.

At the checkup, pediatricians should also ask caregivers about their tobacco habits and make recommendations. Nearly 40% of kids are regularly exposed to secondhand smoke, the AAP says, and caregiver use is the biggest reason children are exposed to secondhand smoke.

In children, secondhand smoke can lead to respiratory and ear infections and asthma attacks. Since 1964, more than 2.5 million nonsmokers who didn’t smoke have died from health problems caused by exposure to secondhand smoke, according to the CDC.

The AAP is urging the US Food and Drug Administration to better regulate all tobacco and nicotine products and the federal government to fund child-specific tobacco prevention, screening and treatment programs.

Despite getting nearly $27 billion from a tobacco settlement and tobacco taxes this year, states shortchange programs designed to prevent kids from using tobacco products and help people quit, according to the Campaign for Tobacco-Free Kids.

The AAP recommends raising the prices on tobacco products, as higher prices can act as a deterrent for young users.

Taxes are also considered one of the most effective ways to reduce smoking, particularly among children, studies have found. However, Congress hasn’t raised federal tobacco taxes in 14 years. The federal cigarette tax remains $1.01 per pack, and taxes vary for other tobacco products. No state increased its cigarette taxes in 2022, either.

The AAP policy statements on tobacco recommend a total flavor ban, including menthol.

In April, the FDA proposed eliminating two tobacco products popular with children: flavored cigars and menthol cigarettes. But it could be years before that becomes a reality, as even if that rule is finalized this year, manufacturers will probably sue to keep it from going into effect.

Tobacco companies have long used menthol to mask the unpleasant flavors of their products. Studies show that it makes the products more attractive to new users and makes it harder for people to quit.

Tobacco companies are also frequently introducing flavored products in child-friendly disposable vapes in flavors like blue raspberry and sour apple.

“Sadly, they also have very, very high levels of nicotine. Just the tobacco products themselves, they have really exploded. Part of it is the lack of regulation, and then on top of that, there’s these new oral nicotine products that are unfortunately gaining a lot of popularity from our youth,” Walley said.

Walley is optimistic that more children can quit tobacco or not start in the first place, but she knows that pediatricians have their work cut out for them, based on what her sons tell her about school.

“I’m a parent of three boys, and when I hear from my boys [that] they don’t want to go to the bathroom because people will be vaping in there, it just breaks my heart that they’re not having a bathroom break all day because of that,” she said. “That kids are so addicted that they have to sneak away to the bathroom, or they are vaping in class using some covert pieces of clothing, shows this really is a public health crisis.

“We at the AAP want to make sure that people remember, this is one of the most modifiable things in terms of social determinants of health,” Walley said. “A lot of the social determinants of health, we really can’t control, but whether you use tobacco or whether you start using tobacco is something that we can do something about.”

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April 16, 2023

‘Big step forward’: New lab tests may accelerate Parkinson’s diagnosis and research | CNN

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CNN
—

A lab test that can tell doctors if someone has Parkinson’s disease is a long-sought goal of researchers.

Doctors currently diagnose the progressive condition by looking for telltale physical symptoms: tremors, a halting gait, stiffness or trouble balancing. About 90,000 Americans are diagnosed on the basis of these symptoms each year, according to a recent study.

These signs can be subtle at first, and it can be difficult to discriminate Parkinson’s from other disorders until the disease is more advanced and affects more of the brain.

The lack of a lab test that can pick up the disease in its early stages has also stymied the search for new treatments. Studying a group of people with the same movement symptoms could mean inadvertently including those whose condition could be caused by something else.

It also means people are usually studied when the disease process is well under way. Many therapies work best when they’re given at the first sign of symptoms, or even before.

All this may soon change, thanks to new tests that are able to detect traces of a key protein that misfolds and gums up specific areas of the brain, called alpha-synuclein.

One test, SYNTap, which looks for seeds of this misfolded protein in spinal fluid, was just vetted in the Parkinson’s Progression Marker’s Initiative, a large study undertaken by the Michael J. Fox Foundation. Several companies are developing versions of this type of test.

It joins another test called Syn-One, which detects traces of the protein in skin. Syn-One has been available since 2019 and is being studied with funding from the National Institutes of Health.

When they return positive results, the new tests don’t diagnose Parkinson’s disease but rather point to a group of disorders caused by abnormal clumping of the alpha-synuclein protein. Those include dementia with Lewy bodies and multiple system atrophy, a rare disorder that causes damage to several areas of the brain. Parkinson’s is the most common of these disorders.

Parkinson’s affects the nervous system and, in addition to movement-related symptoms, can cause problems such as depression, anxiety, cognitive impairment, trouble sleeping, hallucinations and loss of smell. It’s not fatal, but it can have serious complications. The exact cause is largely unknown.

The tests usher in “a bit of a new chapter for us in Parkinson’s disease, where we can really focus on biology,” said Dr. Kathleen Poston, a professor of neurology and neurological sciences at Stanford University, who participated in a study of the SYNTap test.

“I think that will very hasten our engagement and clinical trials and, I hope, allow us to have more successful therapeutic clinical trials in in the next five years,” Poston said.

The test is available to doctors, but it had not been shown to be reliable in a large clinical trial.

In a study published Wednesday in the journal Lancet Neurology, the SYNTap test proved to be accurate when given to 1,100 participants, including people with Parkinson’s, people with genetic or clinical risk factors who had not been diagnosed, and healthy controls. Overall, the test correctly identified people with Parkinson’s disease 88% of the time and correctly ruled it out 96% of the time.

“It shows that this method is fairly accurate for detecting Parkinson’s disease, even in patients who do not yet have symptoms,” said Dr. Andrew Ko, a neurosurgeon at the University of Washington School of Medicine who was not involved in the research. “This is a big step forward showing that this type of test is accurate.”

The test was most accurate in people without any known genetic risks for Parkinson’s disease, who also had loss of their sense of smell. In this group, the test correctly detected the disease 99% of the time. If they didn’t have a loss of smell, the accuracy dropped to 78%.

In people with the most common genetic risk, a mutation in their LRRK2 gene, the test correctly flagged Parkinson’s only about 67% of the time.

That means the test is very good at ruling out Parkinson’s, but it will miss some people who actually do have it.

“If you had this test and it was ‘normal’ or negative … it doesn’t mean you don’t have Parkinson’s disease,” said Dr. Kelly Mills, a neurologist and director of the Movement Disorders Division at Johns Hopkins University, who was not involved in the research.

For the time being, that means the test itself won’t be so helpful to individual patients.

“I think it’s a big deal for research, which is going to be a huge deal for patients,” Mills said.

The study’s authors agree.

“Right now, the test has sort of only a modest utility in routine clinical care,” said study author Dr. Andrew Siderowf, a neurologist at the University of Pennsylvania’s Perlman School of Medicine.

Parkinson’s treatment is based on relieving symptoms, and all the test can do is to help a doctor refine a diagnosis. It won’t change how a patient is treated, but it might bring some people peace of mind that their diagnosis is correct, Siderowf said.

It’s also a very invasive test that requires a painful procedure called a spinal tap, although researchers hope to soon translate their results to other kind of biological samples, such as blood or saliva, that would be easier to collect.

One of the most promising results of the study was in people who had early changes that are known to be strongly tied to the development of Parkinson’s disease. In 18 people who had lost their sense of smell, the test detected alpha-synuclein in 16. In another group of 33 people with REM sleep behavior disorder, which makes people kick, punch or hit in their sleep as they act out their dreams, the test detected alpha-synuclein in 28.

Because this group was so small, the researchers say, those tests will have to be repeated to learn whether it can detect the disease before movement is impaired.

But that is the goal, according to the study’s funders at the Michael J. Fox Foundation, who believe that this test will revolutionize research.

“We have a really robust current pipeline of therapeutics that are looking to interfere with the the biology and the disease,” said Deborah Brooks, CEO of the foundation. “We will continue at a rapid and aggressive pace,” she said.

Brooks said that when they learned the results of the SYNTap tests, she flew out to see actor and philanthropist Fox, who was vacationing with his family, to tell him personally. Fox has been living with Parkinson’s since 1991.

Together, they called one of the foundation’s scientists, Dr. Todd Sherer, a neuroscientist who is also the foundation’s chief mission officer.

“I said, ‘so, you know, Todd’s calling in, but he’s gonna tell you all the details. I’m just gonna give you the headline: We’ve had a breakthrough,’ ” Brooks said.

Fox and Sherer had been searching for a biomarker for the condition for over a decade.

When Sherer finished his presentation, Brooks said, Fox leaned over, picked up the laptop and kissed him on the head.

“This is awesome,” he said.

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April 14, 2023

Clinics and doctors brace for more restrictions on women’s health care after court ruling on abortion drug | CNN

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CNN
—

Less than a year after the US Supreme Court ended legal protection for abortions nationwide, clinics that provide reproductive health care across the United States are bracing for more restrictions on the care they provide to women.

If a judge’s ruling takes effect Friday, it may soon be illegal for doctors to prescribe mifepristone, the first in a two-drug regimen that can help women terminate a pregnancy at home – and that has other uses.

At Northeast Ohio Women’s Center, staffers are calling patients who expected to get medication abortions next week, telling them to change their plans.

“They’re scrambling to change their schedules to get in to see us earlier,” said Dr. David Burkons, the physician who runs the clinics.

About half of abortions in the US use mifepristone, which is sold under the brand name Mifeprex.

Mifeprex blocks the hormone progesterone, which effectively stops a pregnancy from continuing. For an abortion, women take mifepristone first, followed one or two days later by misoprostol, a drug that causes the uterus to contract, cramp and bleed, similar to a heavy period. It empties out the uterus, ending the pregnancy. It can be used up to 10 weeks of pregnancy.

But the uses of mifepristone go beyond abortion.

The drug helps soften and open the cervix, the neck of the uterus, and doctors depend on it to help when women are having a miscarriage and when a pregnancy needs to be terminated quickly if the life of the mother is at stake.

In certain situations, when a pregnancy has become too risky, time is of the essence, says Dr. Alison Edelman, who directs the division of Complex Family Planning at Oregon Health and Sciences University.

“The more expediently that we can have somebody not be pregnant, the better, and mifepristone helps us speed that process up and make it safer for patients,” she said.

Doctors also use mifepristone before procedures in which they need to go into the uterus, such as to remove bleeding polyps. Studies have shown that the drug helps reduce the amount of force needed to open the cervix and reduces the amount of blood loss associated with the procedure.

Studies also show that mifepristone has moderate to strong benefits for inducing labor and treating uterine fibroids and endometriosis, sometimes helping avoid surgery, according to the American Society of Health Systems Pharmacists.

It can be used to prevent bleeding between periods and to control hyperstimulation of the ovaries during in-vitro fertilization, the society said in a statement.

Doctors say they still have other ways to treat those problems, but when considering the needs of individual patients, they will be missing a valuable tool.

“We have our gold standard of what we provide – the safest, most effective regimen – and then if it’s not available, we use the next best one. And that’s what we would be left with,” Edelman said.

Mifepristone has been approved by the US Food and Drug Administration for 23 years, and it has been used by over 5 million women in the United States. FDA data shows that less than 1% of women who take it have significant adverse events. A CNN analysis of FDA data found that mifepristone was even less risky than some other common medications, including Viagra and penicillin.

Medication abortions have become an increasingly important option for women in states that restricted abortion access after the Supreme Court’s ruling last year that ended legal protections for abortions in every state. They are also sometimes the only kind of abortion many women can get in rural areas that have lost abortion providers.

This ease of access has also made the medication regimen a target for abortion opponents.

“They want to see a national ban, and this is in fact what they are going for in this case,” said Kristen Moore, director of the EMAA Project, a nonprofit that is seeking to make it easier to get abortion medications in the US.

What will happen next is far from settled. Appeals have been filed to stop the ruling in Texas from taking hold, and higher courts will have to weigh in.

Even if the court does take mifepristone off the market in the US, doctors say, they will still be able to provide medication abortions using misoprostol alone.

In fact, some abortion providers have been planning on using misoprostol by itself in case mifepristone is isn’t available.

Carafem, which provides telehealth abortion care, has been offering a misoprostol-only regimen since the Covid-19 pandemic began, Chief Operating Officer Melissa Grant says.

“In 2020, we started to use misoprostol alone as an option,” she said. Workers have since been tweaking the regimen and gathering data.

“We now feel confident that, even though we would much prefer to use both, that we can use misoprostol alone effectively and are ready to switch gears to have a higher percentage of our clients or even 100% of our colleagues use that option if necessary,” Grant said.

Still, some providers said it’s not ideal.

The misoprostol-only regimen is slightly less effective than the one that uses both drugs, and it causes more cramping and bleeding, which can mean more complications.

“We’re more likely to see failures and therefore more likely to need surgical intervention after misoprostol alone,” said Dr. Erika Werner, chair of the Department of Obstetrics and Gynecology at Tufts Medical Center.

Still, doctors want women to know that medication abortions and miscarriage care will still be available even if mifepristone isn’t. And they hope that higher courts will intervene to keep this medication on pharmacy shelves.

“The clinicians would have to use these other options instead of choosing based on their own expertise, knowledge and judgment when rendering such care,” Dr. Iffath Hoskins, president of the American Congress of Obstetricians and Gynecologists, said Monday. “Frankly, as a clinician, I do not want to be in that position.”

Correction: This story has been updated to include the correct name of Tufts Medical Center.

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April 8, 2023

Maternity units are closing across America, forcing expectant mothers to hit the road | CNN

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CNN
—

In picturesque Bonner County, Idaho, Leandra Wright, 40, is pregnant with her seventh child.

Wright is due in August, but three weeks ago, the hospital where she had planned to deliver, Bonner General Health, announced that it would be suspending its labor and delivery services in May.

Now, she’s facing a potentially precarious drive to another hospital 45 minutes from her home.

“It’s frustrating and worrisome,” Wright said.

Wright has a history of fast labors. Her 15-year-old son, Noah, was born on the way to the hospital.

“My fifth child was born on the side of the highway,” Wright said. “It was wintertime, and my hospital at the time in California was about 40 minutes away, and the roads were icy, so we didn’t make it in time.”

By the time she and Noah got to the hospital, about 15 minutes after he was born, his body temperature was lower than normal.

“It worries me not to have a doctor there and worries me to have to go through that,” Wright said.

Residents of Bonner County aren’t the only ones dealing with unexpected maternity unit closures.

Since 2011, 217 hospitals in the United States have closed their labor and delivery departments, according to a report by the health care consulting firm Chartis.

A CNN tally shows that at least 13 such closures have been announced in the past year alone.

Services provided at maternity units vary from hospital to hospital. Most offer obstetrics care in which an obstetrician will deliver a baby, either vaginally or via cesarean section. These units also provide perinatal care, which is medical and supportive care before and after delivery.

Other services provided may include lactation specialists and private delivery rooms.

After May 19, Bonner General Health will no longer offer obstetrical services, meaning there will be zero obstetricians practicing there. Consequently, the hospital will no longer deliver babies. Additionally, the unit will no longer provide 24-hour anesthesia support or post-resuscitation or pre-transportation stabilization care for critically ill newborns.

Some hospitals that have recently closed their maternity units still offer perinatal care, along with routine gynecological care.

Bonner General is planning to establish a clinic where perinatal care will be offered. Gynecological services – such as surgical services, preventative care, wellness exams and family planning – will still be provided at a nearby women’s health clinic.

The Chartis report says that the states with the highest loss of access to obstetrical care are Minnesota, Texas, Iowa, Kansas and Wisconsin, with each losing more than 10 facilities.

Data released last fall by the infant and maternal health nonprofit March of Dimes also shows that more than 2.2 million women of childbearing age across 1,119 US counties are living in “maternity care deserts,” meaning their counties have no hospitals offering obstetric care, no birth centers and no obstetric providers.

Maternity care deserts have been linked to a lack of adequate prenatal care or treatment for pregnancy complications and even an increased risk of maternal death for a year after giving birth.

Money is one reason why maternity units are being shuttered.

According to the American Hospital Association, 42% of births in the US are paid for by Medicaid, which has low reimbursement rates. Employer-sponsored insurance pays about $15,000 for a delivery, and Medicaid pays about $6,500, according to the Health Care Cost Institute, a nonprofit that analyzes health care cost and utilization data.

“Medicaid funds about half of all births nationally and more than half of births in rural areas,” said Dr. Katy Kozhimannil, a public health researcher at the University of Minnesota who has conducted research on the growing number of maternity care deserts.

Kozhimannil says communities that are most likely to be affected by maternity unit closures tend to be remote towns in rural counties in states with “less generous Medicaid programs.”

Hospitals in larger cities are often able to offset low reimbursement rates from Medicaid births with births covered by employer-sponsored insurance, according to Dr. Sina Haeri, a maternal-fetal medicine specialist and CEO of Ouma Health, a company that provides virtual prenatal and perinatal care to mothers living in maternity care deserts.

Many large hospitals also have neonatal intensive care units.

“If you have a NICU, that’s a substantial revenue generator for a hospital,” Haeri said.

Most rural hospitals do not have a NICU, only a nursery where they care for full-term, healthy babies, he said. Due to that financial burden, it does not make financial sense for many rural hospitals to keep labor and delivery units open.

A low volume of births is another reason for the closures.

In announcing the closure, Bonner General noted that in 2022, it delivered just 265 babies, which the hospital characterized as a significant decrease.

Rural hospital administrators providing obstetric care say it takes at least 200 births annually for a unit to remain safe and financially viable, according to a study led by Kozhimannil for the University of Minnesota’s Rural Health Research Center.

Many administrators surveyed said they are working to keep units open despite low birth rates.

“Of all the folks that we surveyed, about a third of them were still operating, even though they had fewer than 200 births a year,” Kozhimannil said. “We asked why, and they said, ‘because our community needs it.’ ”

Another issue for hospital administrators is staffing and recruitment.

The decision to close Bonner General’s labor and delivery unit was also directly affected by a lack of experienced, qualified doctors and nurses in the state, said Erin Binnall, a Bonner General Health spokesperson.

“After May 19th, Bonner General Health will no longer have reliable, consistent pediatric coverage to manage neonatal resuscitations and perinatal care. Bonner General’s number one priority is patient safety. Not having board-certified providers certified in neonatal resuscitation willing to provide call and be present during deliveries makes it unsafe and unethical for BGH to provide these services,” Binnall told CNN by email.

The American Hospital Association acknowledges the staffing challenges some hospitals face.

“Simply put, if a hospital cannot recruit and retain the providers, nurses, and other appropriately trained caregivers to sustainably support a service then it cannot provide that care,” the association said in a statement. “Such challenges are only magnified in rural America, where workforce strain is compounded by aging demographics that in some communities has dramatically decreased demand for services like Labor and Delivery.”

Wright is considering moving because of the lack of maternity and pediatric care available in Bonner County.

More stringent abortion laws may be playing a role in the closures, too.

Bonner General said in a news release last month that due to Idaho’s “legal and political climate, highly respected, talented physicians are leaving. In addition, the Idaho Legislature continues to introduce and pass bills that criminalize physicians for medical care nationally recognized as the standard of care.”

According to the Guttmacher Institute, Idaho has one of the strictest anti-abortion laws in the country: a complete ban that has only a few exceptions.

Idaho requires an “affirmative defense,” Guttmacher says, meaning a provider “has to prove in court that an abortion met the criteria for a legal exception.”

No matter the reason, Kozhimannil said, closures in rural communities aren’t just a nuisance. They also put families at risk.

“That long drive isn’t just an inconvenience. It actually is associated with health risks,” she said. “The consequence that we saw is an increase in preterm births. Preterm birth is the largest risk factor for infant mortality. It is a huge risk factor for developmental and cognitive delays for kids.”

Haeri says the decline in maternal care also has a clear effect on maternal mortality rates.

The maternal death rate for 2021 – the year for which the most recent data is available – was 32.9 deaths per 100,000 live births in the US, compared with rates of 20.1 in 2019 and 23.8 in 2020, according to a report from the National Center for Health Statistics. In raw numbers, 1,205 women died of maternal causes in the US in 2021.

Conditions such as high blood pressure, obesity, and diabetes may raise a person’s risk of complications, as can being pregnant with multiples, according to the National Institutes of Health. Pregnant women over the age of 35 are at a higher risk of pre-eclampsia.

As labor and delivery units continue to shut their doors, possible solutions to the growing problem are complex, Haeri says.

“I think anyone that comes to you and says the current system is working is lying to you,” he said. “We all know that the current maternity system is not good.”

Kozhimannil’s research has found that many women who live in maternity care deserts are members of minority communities.

“When we conducted that research, we found the communities that were raising the alarm about this … tended to be Black and indigenous, or tribal communities in rural places,” she said. “Black communities in the South and East and tribal communities throughout the country, but especially in the West, Mountain West and Midwest.”

Haeri says one possible solution is at a woman’s fingertips.

“I always say if a woman’s got a cell phone, she should have access,” he said.

A 2021 study found that women who live in remote areas of the US could benefit from telehealth visits, which would decrease the number of “in-person prenatal care visits and increase access to care.”

The American College of Obstetricians and Gynecologists recommends 12 to 14 prenatal care appointments for women with low-risk pregnancies, and the study suggests that expansion of prenatal telehealth appointments could help women living in remote areas better adhere to those guidelines.

Ouma works with mothers who are typically remote and high-risk, Haeri says.

He also believes that promoting midwifery and doula services would help bolster maternity care in the US.

Certified nurse midwives often assist remote mothers who are high-risk or who decide to give birth at home, he says.

Midwives not only deliver babies, they often work with medical equipment and can administer at-home physical exams, prescribe medications, order lab and diagnostic tests, and assess risk management, according to the American College of Nurse Midwives. Doulas – who guide mothers through the birthing process – are often present at home births and even hospital births.

“That midwifery model shines when it comes to maternal care. [And] doula advocacy involvement leads to better outcomes and maternity care, and I think as a system, we haven’t made it easier for those two components to be really an integral part of our maternity care in the US,” Haeri said.

After living in Idaho for 10 years, Wright says, she and her fiancé have considered leaving the state. The lack of maternity and pediatric care at Bonner General Health is a big reason why.

“I feel safe being with [my] doctors. Now, I have to get to know a doctor within a couple of months before my next baby is born,” Wright said.

As she awaits the arrival of her new son, she feels doubtful that there is a solution for mothers like her.

“Everywhere – no matter what – everybody has babies,” she said. “It’s posing a problem for people who have babies who don’t have the income to drive or have high risk pregnancies or first-time mothers who don’t even know what to expect.”

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March 21, 2023

Pediatric hospital beds are in high demand for ailing children. Here’s why | CNN

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CNN
—

Effie Schnacky was wheezy and lethargic instead of being her normal, rambunctious self one February afternoon. When her parents checked her blood oxygen level, it was hovering around 80% – dangerously low for the 7-year-old.

Her mother, Jaimie, rushed Effie, who has asthma, to a local emergency room in Hudson, Wisconsin. She was quickly diagnosed with pneumonia. After a couple of hours on oxygen, steroids and nebulizer treatments with little improvement, a physician told Schnacky that her daughter needed to be transferred to a children’s hospital to receive a higher level of care.

What they didn’t expect was that it would take hours to find a bed for her.

Even though the respiratory surge that overwhelmed doctor’s offices and hospitals last fall is over, some parents like Schnacky are still having trouble getting their children beds in a pediatric hospital or a pediatric unit.

The physical and mental burnout that occurred during the height of the Covid-19 pandemic has not gone away for overworked health care workers. Shortages of doctors and technicians are growing, experts say, but especially in skilled nursing. That, plus a shortage of people to train new nurses and the rising costs of hiring are leaving hospitals with unstaffed pediatric beds.

But a host of reasons building since well before the pandemic are also contributing. Children may be the future, but we aren’t investing in their health care in that way. With Medicaid reimbursing doctors at a lower rate for children, hospitals in tough situations sometimes put adults in those pediatric beds for financial reasons. And since 2019, children with mental health crises are increasingly staying in emergency departments for sometimes weeks to months, filling beds that children with other illnesses may need.

“There might or might not be a bed open right when you need one. I so naively just thought there was plenty,” Schnacky told CNN.

The number of pediatric beds decreasing has been an issue for at least a decade, said Dr. Daniel Rauch, chair of the Committee on Hospital Care for the American Academy of Pediatrics.

By 2018, almost a quarter of children in America had to travel farther for pediatric beds as compared to 2009, according to a 2021 paper in the journal Pediatrics by lead author Dr. Anna Cushing, co-authored by Rauch.

“This was predictable,” said Rauch, who has studied the issue for more than 10 years. “This isn’t shocking to people who’ve been looking at the data of the loss in bed capacity.”

The number of children needing care was shrinking before the Covid-19 pandemic – a credit to improvements in pediatric care. There were about 200,000 fewer pediatric discharges in 2019 than there were in 2017, according to data from the US Department of Health and Human Services.

“In pediatrics, we have been improving the ability we have to take care of kids with chronic conditions, like sickle cell and cystic fibrosis, and we’ve also been preventing previously very common problems like pneumonia and meningitis with vaccination programs,” said Dr. Matthew Davis, the pediatrics department chair at Ann & Robert H. Lurie Children’s Hospital of Chicago.

Pediatrics is also seasonal, with a typical drop in patients in the summer and a sharp uptick in the winter during respiratory virus season. When the pandemic hit, schools and day cares closed, which slowed the transmission of Covid and other infectious diseases in children, Davis said. Less demand meant there was less need for beds. Hospitals overwhelmed with Covid cases in adults switched pediatric beds to beds for grownups.

As Covid-19 tore through Southern California, small hospitals in rural towns like Apple Valley were overwhelmed, with coronavirus patients crammed into hallways, makeshift ICU beds and even the pediatric ward.

Only 37% of hospitals in the US now offer pediatric services, down from 42% about a decade ago, according to the American Hospital Association.

While pediatric hospital beds exist at facilities in Baltimore, the only pediatric emergency department in Baltimore County is Greater Baltimore Medical Center in Towson, Maryland, according to Dr. Theresa Nguyen, the center’s chair of pediatrics. All the others in the county, which has almost 850,000 residents, closed in recent years, she said.

The nearby MedStar Franklin Square Medical Center consolidated its pediatric ER with the main ER in 2018, citing a 40% drop in pediatric ER visits in five years, MedStar Health told CNN affiliate WBAL.

In the six months leading up to Franklin Square’s pediatric ER closing, GBMC admitted an average of 889 pediatric emergency department patients each month. By the next year, that monthly average jumped by 21 additional patients.

“Now we’re seeing the majority of any pediatric ED patients that would normally go to one of the surrounding community hospitals,” Nguyen said.

In July, Tufts Medical Center in Boston converted its 41 pediatric beds to treat adult ICU and medical/surgical patients, citing the need to care for critically ill adults, the health system said.

In other cases, it’s the hospitals that have only 10 or so pediatric beds that started asking the tough questions, Davis said.

“Those hospitals have said, ‘You know what? We have an average of one patient a day or two patients a day. This doesn’t make sense anymore. We can’t sustain that nursing staff with specialized pediatric training for that. We’re going to close it down,’” Davis said.

Registered nurses at Tufts Medical Center hold a

Saint Alphonsus Regional Medical Center in Boise closed its pediatric inpatient unit in July because of financial reasons, the center told CNN affiliate KBOI. That closure means patients are now overwhelming nearby St. Luke’s Children’s Hospital, which is the only children’s hospital in the state of Idaho, administrator for St. Luke’s Children’s Katie Schimmelpfennig told CNN. Idaho ranks last for the number of pediatricians per 100,000 children, according to the American Board of Pediatrics in 2023.

The Saint Alphonsus closure came just months before the fall, when RSV, influenza and a cadre of respiratory viruses caused a surge of pediatric patients needing hospital care, with the season starting earlier than normal.

The changing tide of demand engulfed the already dwindling supply of pediatric beds, leaving fewer beds available for children coming in for all the common reasons, like asthma, pneumonia and other ailments. Additional challenges have made it particularly tough to recover.

Another factor chipping away at bed capacity over time: Caring for children pays less than caring for adults. Lower insurance reimbursement rates mean some hospitals can’t afford to keep these beds – especially when care for adults is in demand.

Medicaid, which provides health care coverage to people with limited income, is a big part of the story, according to Joshua Gottlieb, an associate professor at the University of Chicago Harris School of Public Policy.

“Medicaid is an extremely important payer for pediatrics, and it is the least generous payer,” he said. “Medicaid is responsible for insuring a large share of pediatric patients. And then on top of its low payment rates, it is often very cumbersome to deal with.”

Pediatric gastroenterologist Dr. Howard Baron visits with a patient in 2020 in Las Vegas. A large portion of his patients are on Medicaid with reimbursement rates that are far below private insurers.

Medicaid reimburses children’s hospitals an average of 80% of the cost of the care, including supplemental payments, according to the Children’s Hospital Association, a national organization which represents 220 children’s hospitals. The rate is far below what private insurers reimburse.

More than 41 million children are enrolled in Medicaid and the Children’s Health Insurance Program, according to Kaiser Family Foundation data from October. That’s more than half the children in the US, according to Census data.

At Children’s National Hospital in Washington, DC, about 55% of patients use Medicaid, according to Dr. David Wessel, the hospital’s executive vice president.

“Children’s National is higher Medicaid than most other children’s hospitals, but that’s because there’s no safety net hospital other than Children’s National in this town,” said Wessel, who is also the chief medical officer and physician-in-chief.

And it just costs more to care for a child than an adult, Wessel said. Specialty equipment sized for smaller people is often necessary. And a routine test or exam for an adult is approached differently for a child. An adult can lie still for a CT scan or an MRI, but a child may need to be sedated for the same thing. A child life specialist is often there to explain what’s going on and calm the child.

“There’s a whole cadre of services that come into play, most of which are not reimbursed,” he said. “There’s no child life expert that ever sent a bill for seeing a patient.”

Low insurance reimbursement rates also factor into how hospital administrations make financial decisions.

“When insurance pays more, people build more health care facilities, hire more workers and treat more patients,” Gottlieb said.

“Everyone might be squeezed, but it’s not surprising that pediatric hospitals, which face [a] lower, more difficult payment environment in general, are going to find it especially hard.”

Dr. Benson Hsu is a pediatric critical care provider who has served rural South Dakota for more than 10 years. Rural communities face distinct challenges in health care, something he has seen firsthand.

A lot of rural communities don’t have pediatricians, according to the American Board of Pediatrics. It’s family practice doctors who treat children in their own communities, with the goal of keeping them out of the hospital, Hsu said. Getting hospital care often means traveling outside the community.

Hsu’s patients come from parts of Nebraska, Iowa and Minnesota, as well as across South Dakota, he said. It’s a predominantly rural patient base, which also covers those on Native American reservations.

“These kids are traveling 100, 200 miles within their own state to see a subspecialist,” Hsu said, referring to patients coming to hospitals in Sioux Falls. “If we are transferring them out, which we do, they’re looking at travels of 200 to 400 miles to hit Omaha, Minneapolis, Denver.”

Inpatient pediatric beds in rural areas decreased by 26% between 2008 and 2018, while the number of rural pediatric units decreased by 24% during the same time, according to the 2021 paper in Pediatrics.

Steve Inglish, left, and registered nurse Nikole Hoggarth, middle, help a father with his daughter, who fell and required stiches, inside the emergency department at Jamestown Regional Medical Center in rural North Dakota in 2020.

“It’s bad, and it’s getting worse. Those safety net hospitals are the ones that are most at risk for closure,” Rauch said.

In major cities, the idea is that a critically ill child would get the care they need within an hour, something clinicians call the golden hour, said Hsu, who is the critical care section chair at the American Academy of Pediatrics.

“That golden hour doesn’t exist in the rural population,” he said. “It’s the golden five hours because I have to dispatch a plane to land, to drive, to pick up, stabilize, to drive back, to fly back.”

When his patients come from far away, it uproots the whole family, he said. He described families who camp out at a child’s bedside for weeks at a time. Sometimes they are hundreds of miles from home, unlike when a patient is in their own community and parents can take turns at the hospital.

“I have farmers who miss harvest season and that as you can imagine is devastating,” Hsu said. “These aren’t office workers who are taking their computer with them. … These are individuals who have to live and work in their communities.”

Back at GBMC in Maryland, an adolescent patient with depression, suicidal ideation and an eating disorder was in the pediatric emergency department for 79 days, according to Nguyen. For months, no facility had a pediatric psychiatric bed or said it could take someone who needed that level of care, as the patient had a feeding tube.

“My team of physicians, social workers and nurses spend a significant amount of time every day trying to reach out across the state of Maryland, as well as across the country now to find placements for this adolescent,” Nguyen said before the patient was transferred in mid-March. “I need help.”

Nguyen’s patient is just one of the many examples of children and teens with mental health issues who are staying in emergency rooms and sometimes inpatient beds across the country because they need help, but there isn’t immediately a psychiatric bed or a facility that can care for them.

It’s a problem that began before 2020 and grew worse during the pandemic, when the rate of children coming to emergency rooms with mental health issues soared, studies show.

Now, a nationwide shortage of beds exists for children who need mental health help. A 2020 federal survey revealed that the number of residential treatment facilities for children fell 30% from 2012.

“There are children on average waiting for two weeks for placement, sometimes longer,” Nguyen said of the patients at GBMC. The pediatric emergency department there had an average of 42 behavioral health patients each month from July 2021 through December 2022, up 13.5% from the same period in 2017 to 2018, before the pandemic, according to hospital data.

When there are mental health patients staying in the emergency department, that can back up the beds in other parts of the hospital, creating a downstream effect, Hsu said.

“For example, if a child can’t be transferred from a general pediatric bed to a specialized mental health center, this prevents a pediatric ICU patient from transferring to the general bed, which prevents an [emergency department] from admitting a child to the ICU. Health care is often interconnected in this fashion,” Hsu said.

“If we don’t address the surging pediatric mental health crisis, it will directly impact how we can care for other pediatric illnesses in the community.”

Dr. Susan Wu, right, chats with a child who got her first dose of the Pfizer-BioNtech Covid-19 vaccine at Children's Hospital Arcadia Speciality Care Center in Arcadia, California, in 2022.

So, what can be done to improve access to pediatric care? Much like the reasons behind the difficulties parents and caregivers are experiencing, the solutions are complex:

A lot of it comes down to money

Funding for children’s hospitals is already tight, Rauch said, and more money is needed not only to make up for low insurance reimbursement rates but to competitively hire and train new staff and to keep hospitals running.

“People are going to have to decide it’s worth investing in kids,” Rauch said. “We’re going to have to pay so that hospitals don’t lose money on it and we’re going to have to pay to have staff.”

Virtual visits, used in the right situations, could ease some of the problems straining the pediatric system, Rauch said. Extending the reach of providers would prevent transferring a child outside of their community when there isn’t the provider with the right expertise locally.

Increased access to children’s mental health services

With the ongoing mental health crisis, there’s more work to be done upstream, said Amy Wimpey Knight, the president of CHA.

“How do we work with our school partners in the community to make sure that we’re not creating this crisis and that we’re heading it off up there?” she said.

There’s also a greater need for services within children’s hospitals, which are seeing an increase in children being admitted with behavioral health needs.

“If you take a look at the reasons why kids are hospitalized, meaning infections, diabetes, seizures and mental health concerns, over the last decade or so, only one of those categories has been increasing – and that is mental health,” Davis said. “At the same time, we haven’t seen an increase in the number of mental health hospital resources dedicated to children and adolescents in a way that meets the increasing need.”

Most experts CNN spoke to agreed: Seek care for your child early.

“Whoever is in your community is doing everything possible to get the care that your child needs,” Hsu said. “Reach out to us. We will figure out a way around the constraints around the system. Our number one concern is taking care of your kids, and we will do everything possible.”

Nguyen from GBMC and Schimmelpfennig from St. Luke’s agreed with contacting your primary care doctor and trying to keep your child out of the emergency room.

“Anything they can do to stay out of the hospital or the emergency room is both financially better for them and better for their family,” Schimmelpfennig said.

Knowing which emergency room or urgent care center is staffed by pediatricians is also imperative, Rauch said. Most children visit a non-pediatric ER due to availability.

“A parent with a child should know where they’re going to take their kid in an emergency. That’s not something you decide when your child has the emergency,” he said.

Jaimie and Effie Schnacky now have an asthma action plan after the 7-year-old's hospitalization in February.

After Effie’s first ambulance ride and hospitalization last month, the Schnacky family received an asthma action plan from the pulmonologist in the ER.

It breaks down the symptoms into green, yellow and red zones with ways Effie can describe how she’s feeling and the next steps for adults. The family added more supplies to their toolkit, like a daily steroid inhaler and a rescue inhaler.

“We have everything an ER can give her, besides for an oxygen tank, at home,” Schnacky said. “The hope is that we are preventing even needing medical care.”

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