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H E A L T H,   S A F E T Y,   &   S O C I A L   I S S U E S

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Clearing the Air

Asthma-related hospitalizations and deaths have increased 75 percent since 1980, with the disease now afflicting some 17.3 million Americans. It is the most common chronic disease among children in the United States. High death rates among African Americans with asthma and in poor urban areas with substantial minority populations are of particular concern.

Researchers trying to explain the increased incidence of asthma have been looking indoors for answers. People spend most of their day inside the home, school, or workplace, so scientists naturally began searching there for clues as to how indoor air quality may contribute to the disease.

Studies have determined that allergens produced by cats aggravate asthma symptoms in individuals who are particularly sensitive to them. But according to a new report by a committee of the Institute of Medicine, cats aren’t the only ones to blame. Exposure to material shed and excreted by cockroaches and microscopic dust mites also make certain asthmatics sicker. In fact, recent scientific studies indicate that exposure to material from dust mites can lead to asthma in children who are predisposed to developing the disease.

And secondhand smoke worsens asthma symptoms in preschoolers, with some evidence suggesting that it puts children this age at greater risk for developing asthma in the first place, the committee said.

Besides the effects caused by dust mites, cats, cockroaches, and tobacco smoke, the committee found an association between worsening symptoms in some asthmatics and exposure to dogs, fungi and mold, and viruses responsible for the common cold and other respiratory illnesses. In addition, older or malfunctioning gas appliances in poorly ventilated kitchens may result in brief, high levels of nitrogen dioxide, which can lead to problems for asthmatics who also are exposed to other forms of indoor air pollution.

Possible links between asthma complications and other potential indoor contaminants such as cleaning and building supplies, pesticides, houseplants, rodents, and fragrances in personal care and household products were evaluated by the committee, but they found evidence to be too limited or inadequate to draw conclusions. More research also is needed on how secondhand smoke affects the health of older children or adults with asthma.

Exterminating pests, prohibiting smoking, thoroughly cleaning the home — especially carpets, bedding, and upholstered furniture that trap allergenic material — as well as the unpopular task of removing a pet, are some of the steps people can take to relieve the symptoms of asthmatics. — Bill Kearney & Neil Tickner

Clearing the Air: Asthma and Indoor Air Exposures. Committee on the Assessment of Asthma and Indoor Air, Division of Health Promotion and Disease Prevention, Institute of Medicine (2000, 375 pp.; ISBN 0-309-06496-1; available from National Academy Press, tel. 1-800-624-6242; $44.95 plus $4.50 shipping for single copies).

The committee was chaired by Richard B. Johnston Jr., professor, department of pediatrics, National Jewish Medical and Research Center, University of Colorado School of Medicine, Denver. The study was funded by the U.S. Environmental Protection Agency.

Extending Medicare

Close to 39 million older Americans rely on Medicare to pay their medical bills. Since Medicare’s inception in 1965, Congress has periodically broadened the program’s coverage to include some additional services, such as breast-cancer screening and a few prescription drugs. Before it considered expanding Medicare coverage further, Congress asked the Institute of Medicine (IOM) to study the medical benefits and costs of covering five more specific services.

The IOM formed three committees to examine whether Medicare should pay for nutrition therapy, skin-cancer screening, medically necessary dental services, immunosuppressive drugs for transplant recipients, and routine care during clinical trials.

The committee looking at nutrition therapy found that the available — albeit limited — evidence supports nutrition counseling as an effective tool for the management of several conditions common among senior citizens, including diabetes, high cholesterol, and hypertension. With an estimated 86 percent of Americans over the age of 65 having at least one of these conditions, the committee said Medicare should cover nutrition therapy prescribed by a physician. Such therapy is most helpful when provided in an outpatient or home care setting, and Medicare should reimburse professionals who deliver this care, beginning with qualified registered dietitians.

Medicare already covers doctor visits prompted by a physician’s or patient’s concern about changes in a mole or other skin feature. But studies are lacking on the effectiveness of screenings for Medicare beneficiaries who have no such concerns, which led the committee to say there was insufficient evidence to either support or reject coverage for routine skin-cancer screenings. Although the evidence again is limited, there is some indication that dental care can help certain seriously ill patients avoid life-threatening infections and bone damage, which the committee said makes it reasonable for Medicare to cover dental care that is helpful during the treatment of certain serious medical conditions.

It is also reasonable for Congress to eliminate restrictions on how long transplant recipients are covered for drugs needed to suppress their immune systems so that the body does not reject the new organ, the committee said. There are more than 20,000 transplants performed each year in the United States, and advances in immunosuppressive drugs have allowed 60 percent of transplant recipients to live longer than five years. Medicare currently covers immunosuppressive drug therapy for only 44 months; however, the committee found suggestive but limited evidence that when this coverage ends, some patients who can find no other way to pay for these expensive drugs may experience transplant failures.

The committee examining care in clinical trials — studies designed to determine the safety and effectiveness of medical treatments — said that Medicare should cover routine care of beneficiaries enrolled in clinical trials, just as it would pay for this care outside of clinical trials. Doing so is not likely to result in any significant cost increase since it appears that, in practice, health care providers often submit reimbursement claims for Medicare patients in clinical trials, and usually the claims are paid. However, the Medicare statute has been widely interpreted to exclude reimbursement of routine care that occurs in clinical trials, so the federal government should issue unambiguous rules to end this uncertainty.
— B.K., N.T., & Cheryl Greenhouse

The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Committee on Nutrition Services for Medicare Beneficiaries, Food and Nutrition Board, Institute of Medicine (1999, 280 pp.; ISBN 0-309-06846-0; available from National Academy Press, tel. 1-800-624-6242; $33.00 plus $4.50 shipping for single copies).

The committee was chaired by Virginia A. Stallings, chief of nutrition section, division of gastroenterology and nutrition, Children’s Hospital of Philadelphia; and professor of pediatrics, University of Pennsylvania School of Medicine, Philadelphia.

Extending Medicare Coverage for Preventive and Other Services. Committee on Medicare Coverage Extensions, Division of Health Care Services, Institute of Medicine (1999, 325 pp.; ISBN 0-309-06889-4; available from National Academy Press, tel. 1-800-624-6242; $62.75 plus $4.50 shipping for single copies).

The committee was chaired by Robert S. Lawrence, associate dean for professional education and programs, and professor of health policy, Johns Hopkins University School of Hygiene and Public Health, Baltimore.

Extending Medicare Reimbursement in Clinical Trials. Committee on Routine Patient Care Costs in Clinical Trials for Medicare Beneficiaries, Division of Health Care Services, Institute of Medicine (1999, 84 pp.; ISBN 0-309-06888-6; available from National Academy Press, tel. 1-800-624-6242; $18.00 plus $4.50 shipping for single copies).

The committee was chaired by Henry J. Aaron, senior fellow in economic studies, The Brookings Institution, Washington, D.C.

All three studies were funded by the U.S. Department of Health and Human Services’ Health Care Financing Administration.

Stateside Smokeout

As part of the debate on what action states can take to reduce smoking, some officials have posed a fundamental question: Do state tobacco-control programs work? A new report offers a clear answer: Yes.

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In reviewing 10 years of regulatory experience, the National Cancer Policy Board — a joint program of the Institute of Medicine and the National Research Council — found that states which have mounted substantial tobacco-control programs have seen greater drops in smoking. For example, between 1989 and 1993, California had the most comprehensive and aggressive tobacco-control program in the country, including an extensive advertising campaign. During that period, cigarette use in California declined 50 percent faster than the national average.

The report assesses actions that states can take to reduce smoking. One way is through special advertising and public-education campaigns. An evaluation of California’s campaign concluded that its effectiveness waned as spending on it declined.

Another approach states can take is to establish smoke-free zones. Requiring that work sites, schools, and other public places be smoke-free has proven to be a powerful strategy that encourages people to quit and reduces smoking among those who continue to do so, the report says.

Raising the price of tobacco products through taxation is one of the fastest and most effective ways to discourage children and teens from starting to smoke, and to encourage smokers of all ages to quit. But the report notes that some governors and legislators are reluctant to raise these taxes — in part because of the tobacco settlement reached by states and manufacturers. Under this agreement, the amount paid to a state is tied to tobacco sales. Cutting consumption, therefore, also reduces the amount states are paid. But the report says this drop may be offset by savings in health care expenses borne by states. Plus, direct revenues from tax increases on tobacco can more than offset losses as consumption falls.

Nicotine addiction, like other addictions, is a treatable condition. States can help support treatment efforts in two ways — by running public health campaigns alerting smokers that help is available, and by ensuring that state-funded insurance programs such as Medicaid cover the costs.

The report notes that a balanced state program also will include school-based prevention efforts, as well as vigorous enforcement of laws outlawing sales to those under 18. Such laws are on the books in every state and territory.

Results from tobacco-control efforts don’t come quickly, the report cautions. Significant reductions in smoking take years, even in the states with the most effective programs. To ensure that control efforts improve and that money is well-spent, states should include a budget for evaluation and monitoring so that programs can be carefully assessed and state officials held accountable. — N.T.

State Programs Can Reduce Tobacco Use. National Cancer Policy Board, Institute of Medicine and National Research Council (2000, 17 pp.; available only on the Internet).

Peter Howley, chairman of the department of pathology, Harvard University, Cambridge, Mass., chairs the National Cancer Policy Board. The study was funded by the National Cancer Institute, the Centers for Disease Control and Prevention, the American Cancer Society, Amgen Inc., Abbott Laboratories, and Hoechst Marion Roussel Inc.

Radiation Study Fallout

Certain communities in the Pacific Northwest have long suspected that they were being exposed to contamination from a nuclear weapons production site known simply as Hanford. Their suspicions were confirmed in 1986, when the U.S. Department of Energy revealed that its Hanford Atomic Products Operation in Washington state had released radioactive iodine-131 into the environment on a number of occasions between 1944 and 1957.

The human thyroid easily absorbs iodine-131, and exposure can lead to cancer and other thyroid diseases. So people who grew up downwind of Hanford were anxious to know whether the radioactive isotope that had blown their way led to an increase in thyroid disease among the local population. Their representatives in Congress were likewise interested and in 1988 ordered a study to examine the issue.

The study was funded by the Centers for Disease Control and Prevention (CDC) and carried out by the Fred Hutchinson Cancer Research Center in Seattle. Since children’s smaller thyroids are especially vulnerable to iodine-131, the researchers set out to contact 5,199 people born near Hanford at the time of the radiation releases. As children, they were exposed to iodine-131 mainly by consuming milk which came from cows that had eaten contaminated grass.

Eventually more than 3,400 people enrolled in the study, and in January 1999 the Hutchinson researchers were ready to present a draft final report of their nine-year, $18 million study. But before they could release their research results publicly, a copy of the draft report was leaked to a newspaper. An article appeared revealing the research team’s conclusion that there was no evidence for a link between radiation exposure from Hanford and the frequency of thyroid disease found in the study population.

Soon after the draft report was issued, the CDC asked the National Research Council to review the scientific soundness of the study and the manner in which its findings were communicated to the public.

In a new Research Council report, the committee that examined the Hutchinson study found it to be well-designed, but said the conclusiveness of the findings were overstated. For example, when presenting their findings to reporters and the public, the Hutchinson researchers used emphatic language, indicating that their results were statistically powerful and leaving little doubt about how correct they were.

The Research Council committee discovered shortcomings in the analytical and statistical methods used in the study to detect radiation effects. It was particularly concerned that incorrect assumptions about the amount of iodine-131 released from Hanford and the amount transferred from pasture grass to cow’s milk were used to estimate exposure. Uncertainties about individual milk consumption from decades ago also made it difficult to determine exposure levels, but these uncertainties were not acknowledged in the draft report. The committee urged the Hutchinson researchers to re-interpret the study results using new statistical calculations that take into account all the uncertainties.

Nevertheless, the Research Council committee applauded the researchers for conducting thorough medical examinations on a large portion of the most relevant population. In addition, it said the Hutchinson study’s lack of evidence showing a relationship between iodine exposure and thyroid disease suggests, but does not prove, that there is no large risk for thyroid disease from Hanford fallout, though a small risk probably cannot be ruled out. — B.K.

Review of the Hanford Thyroid Disease Study Draft Final Report. Subcommittee to Review the Hanford Thyroid Disease Study Final Results and Draft Report, Committee on an Assessment of Centers for Disease Control and Prevention Radiation Studies from DOE Contractor Sites, Board on Radiation Effects Research, Commission on Life Sciences (1999, 228 pp.; ISBN 0-309-06883-5; available from National Academy Press, tel. 1-800-624-6242; $46.50 plus $4.50 shipping for single copies).

The subcommittee was chaired by Roy E. Shore, professor of environmental medicine and director of the epidemiology and biostatistics program at New York University School of Medicine. The study was funded by the Centers for Disease Control and Prevention.

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Detecting Breast Cancer

Medical researchers are looking for better ways to detect breast cancer in its early stages. Doctors rely mainly on mammograms, a kind of X-ray that can show many breast cancers but not all. The failure rate for the procedure can be as high as 25 percent. Sometimes it gives a "false negative," failing to detect a growing cancer. Other times it can give a "false positive" — an erroneous indication that something is wrong. As a result, some women may undergo unnecessary biopsies.

To help assess progress in the field, the Institute of Medicine has formed a study committee to analyze existing and developing technologies, including those intended to enhance the tools currently used to detect breast cancer. For example, digital mammography might help doctors manipulate X-ray images so they can get better views of areas where a tumor might be growing. Computer-assisted diagnosis is intended to provide a backup to the radiologist — a second pair of "eyes" — to prevent false negative readings.

The committee also will review research into detection methods that do not rely on X-rays. When mammography is not very effective — such as in detecting early tumors in younger women — magnetic resonance imaging might be a good alternative. Bio-engineers also are exploring the use of ultrasound and other techniques to pick up differences between normal and cancerous breast tissues, including devices that measure the electrical output of normal and abnormal cells, and various "probes" designed to detect molecular and genetic changes that signal the start of a cancer.

In addition, the committee will examine the process of bringing technology from the laboratory into general use, to identify potential obstacles. A report will be issued later this year, to be followed by four annual updates of progress in the field. — N.T. (See listing under New Projects.)

To Err Is Human

Serious mistakes by health professionals add up to make medical errors one of the leading causes of death in the United States. More people die each year from hospital errors alone than from traffic accidents, breast cancer, or AIDS. And the problem extends even further, afflicting every health care setting.

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As the first step in an Institute of Medicine (IOM) initiative to improve the quality of health care in this country, a new report from an IOM committee recommends a series of fundamental, system-wide changes. The problem is not just a few bad apples recklessly disregarding patient safety. Because everyone — including health care professionals — makes mistakes, the system must be re-engineered to make it easy to do things right, and hard to do them wrong. The idea is to construct safety nets to catch mistakes, and keep small errors from causing serious harm to patients. For example, if a particular drug must be diluted before it is administered, it should never be stored full-strength in treatment areas of a hospital.

Other high-risk industries have systematically built safety into their operations at all levels, cutting the error rate dramatically. The report recommends a similar approach in health care, laying out a four-part plan designed to create both financial and regulatory incentives that will lead to improved patient safety.

First, to provide a national focal point, a center for patient safety should be created within the Agency for Health Care Policy and Research of the U.S. Department of Health and Human Services. The report estimates the initial cost at about $35 million, eventually rising about to about $100 million a year — a fraction of the cost incurred by medical errors.

The second step calls for a mandatory, nationwide reporting system to make sure that serious mistakes get fully analyzed and the lessons widely communicated. Hospitals, and eventually other places where patients get care, would be responsible for reporting such events to state governments. Currently, about a third of the states have their own mandatory reporting requirements.

Not all medical errors cause serious harm to patients. But some of these “near misses” can teach important lessons and help health care organizations and practitioners correct problems before someone does get seriously hurt. To gain that kind of information, the report recommends the establishment of voluntary reporting systems, and calls on Congress to protect the confidentiality of this information. Without such legislation, health care organizations and providers may be unwilling to participate, fearing that reported information might ultimately be subpoenaed and used in lawsuits.

The third part of the plan calls on consumers — especially businesses that buy coverage for their workers — to urge health care organizations to put greater attention on safety and quality. Professional licensing and accreditation bodies also should give more emphasis to safety and training in their evaluations.

Finally, the providers themselves must create a "culture of safety," and make the necessary organizational changes so that safety becomes a top priority.

As a start, the report calls for a 50 percent reduction in serious medical errors over the next five years. It cautions, however, that there are no "magic bullets" — no one part of the plan will be sufficient to bring about the degree of change needed. But with adequate leadership, attention, and resources, the challenge to improve patient safety can be met. — N.T.

To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Board on Health Care Services, Institute of Medicine (1999, 223 pp.; ISBN 0-309-06837-1; available from National Academy Press, tel. 1-800-624-6242; $34.95 plus $4.50 shipping for single copies).

The committee was chaired by William C. Richardson, president and chief executive officer, W.K. Kellogg Foundation, Battle Creek, Mich. The study was funded by the National Research Council and the Commonwealth Fund.

Copyright National Academy of Sciences. All rights reserved.