Media Still Floundering on Responsible Reporting of Suicide

The news media still does not have a firm grasp on how to report on suicide to mitigate the “contagion” effect that may prompt others to take their own lives, new research indicates.

Various groups, including the World Health Organization, have developed recommendations to help guide journalists report on suicide in a way that does not censor or compromise the news, while at the same time does not glamorize it and make it attractive to someone who may be considering suicide.

However, new research, led by Mark Sinyor, MD, FRCPC, assistant professor of psychiatry, University of Toronto, Canada, found that five major Canadian newspapers, a news magazine, and three news websites failed to adhere to the guidelines.

In addition, the use of certain harmful elements in stories about suicide was associated with an increase in suicide in Toronto in the week after articles containing such elements were published.

The study was published online July 30 in the Canadian Medical Association Journal.

Graphic Reporting Leads to Harm

In the survey of articles published from 2011 to 2014, the investigators found that certain factors were associated with increased odds of death by suicide. These factors included statements that suicide is inevitable (1.97 odds ratio); identifying the method of suicide in the headline (1.41); and reporting on suicide by celebrities (1.27).

Other factors that increased risk included mention of asphyxia other than by car exhaust, but not hanging (1.72); jumping from a building (1.70); and a suicide pact (1.63).

Interestingly, suicide by use of firearm was described in 13% of articles, but that method was responsible for fewer than 5% of deaths in Toronto. Articles that described a suicide death by firearm was associated with 1.28 increased odds of later suicide.

Reports of suicide in older adults (1.25) also increased risk. Stories in newspapers may disproportionately affect older adults, who are more likely to get their news from the print or online versions of publications, Sinyor told Medscape Medical News.

But older adults are also overrepresented among suicide deaths, which could make the effect easier to detect, the investigators note.

The stories also had few of the factors that the investigators labeled as “protective” against suicide contagion — a finding that Ian Colman, PhD, called “disheartening” in an accompanying commentary.

Colman, associate professor and Canada Research Chair in Mental Health Epidemiology at the University of Ottawa, Ontario, noted that fewer than one in five articles discussed alternatives to suicide, and fewer than 2% mentioned community resources for those considering suicide.

It has not been definitively proven that including protective factors can lead to fewer suicides, but it is clear that the media can educate the public about suicide and provide information about how to get help, said Vasilis Pozios, MD, a psychiatrist who advises the media on mental health issues through the consulting practice, Broadcast Thought.

No Inclusion of Protective Factors

Pozios told Medscape Medical News that he found it surprising that so few of the Canadian articles studied included the putatively protective factors.

“I don’t expect journalists to be clinicians, but they could avoid hurting people at the least,” agreed Praveen Kambam, MD, who practices with Pozios and is on the communications committee of the American Psychiatric Association.

The Canadian study reported some positive changes — such as a reduction in stories about suicide on the front pages — “but, on the other hand, the putative protective factors were not happening as much as we’d like. Journalism and news reporting have changed in some ways, but there’s other ways we could be better,” Kambam told Medscape Medical News.

Colman noted that one of the most striking features of the Sinyor study is “how commonly media reports on suicide described the method used, despite clear guidelines to avoid this practice.”

Almost half of the 6367 articles that reported on suicides identified the method used, and 13% described the method in specific detail.

The group Reportingonsuicide.org recommends against mentioning many of the harmful factors described in the Sinyor study.

“Risk of additional suicides increases when the story explicitly describes the suicide method, uses dramatic/graphic headlines or images, and repeated/extensive coverage sensationalizes or glamorizes a death,” according to the group, which compiled reporting guidelines through a collaborative effort led by the American Foundation for Suicide Prevention (AFSP). A number of government agencies, journalism schools, patient advocates, and psychiatry experts participated.

The media outlet NPR told Medscape Medical News that NPR follows those AFSP-led guidelines when reporting on suicide. Other outlets did not return requests for comment. News organizations seem to be imperfect at best at covering suicide.

Kate Spade

A late August New York Times article about the death of a 9-year-old boy in Colorado said that he “committed suicide.” Number one on the AFSP’s list of recommendations: “Do not use the word ‘committed’; instead, use ‘died by suicide’ or ‘took his/her life.’ ”

Many media outlets did not responsibly report on the death of New York–based fashion designer Kate Spade, who took her own life in June 2018. The New York Times was among the first to report Spade’s death, on June 5. The story adhered somewhat to reporting guidelines, citing information regarding the method of suicide as coming from the police and also mentioning that a note was being reviewed by the police without saying what was in the note, as is recommended.

The New York Times’ article also mentioned that Spade was being treated for depression and did not speculate as to why she had taken her life. The article ended with an italicized note: If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK) or go to SpeakingOfSuicide.com/resources for a list of additional resources.

In contrast, People magazine described the manner of her death — “suicide by hanging” — in the headline of a June 7 story and quoted Spade’s husband as saying, “There was no indication or warning.”

Reportingonsuicide.org urges against such “no warning” statements. “Most, but not all, people who die by suicide exhibit warning signs,” said the group, which also recommends including lists of warning signs and what-to-do lists in stories. People did include a note of assistance at the end of the story: “If you or someone you know is considering suicide, please contact the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).”

The New York Daily News had the most lurid and harmful story, complete with the headline, “Kate Spade found dead in her NYC home, leaves heartbreaking suicide note telling daughter it’s not her fault.” In addition, the first sentence of the story stated that Spade “hanged herself with a scarf in the bedroom.” The story also described the contents of the note that was found and contained no reference to the National Suicide Prevention Lifeline.

Past studies have shown that news reports that include positive elements — such as talking about alternatives to suicide or how to approach someone who is depressed — can lead to positive behaviors in despondent readers.

The Canadian study reported that contagion was less likely if a person took their life by stepping in front of a train or by cutting or stabbing, or if the suicide involved someone who might be considered unsavory or had participated in a murder-suicide.

Education, Not Censorship

Mental health professionals do not want news outlets to censor coverage of suicide, said Sinyor.

“The goal is not to hide that a suicide has happened but to contextualize it and to use it as an opportunity to dispel myths as well as to educate the public,” he told Medscape. “The key is to present the story for what it is — a tragic, missed opportunity to have gotten help in someone who was unwell,” he said.

Sinyor would like to see more stories about effective treatments for those mental illnesses that are associated with suicide and about people who have overcome a suicidal crisis.

The journalist’s job becomes more difficult when suicide involves celebrities or others who might be viewed sympathetically. “Commonly, people who have died by suicide will be portrayed in ways that some readers will identify with, and it is in these situations that journalists need to take great care to prevent harm to vulnerable readers,” Sinyor told Medscape.

Pozios said that journalists should include statements to the effect that treatment works or that there is hope. “I don’t think that’s overly burdensome to ask,” he said.

An evolving challenge: that journalism is changing as social media eats into territory that used to be owned by traditional outlets such as newspapers. “The whole model is built on sensationalism and getting clicks,” said Pozios. The need to draw in audiences makes it harder for journalists to tell the story in a responsible way, said Kambam.

Both Sinyor and Kambam note that social media’s impact on suicide is understudied and is not well understood. On the one hand, a post on social media from someone who is in crisis could bring a rapid response. But such sites also have the potential to spread suicide contagion quickly. In addition, Pozios notes, a message — even a positive one — on social media is difficult to control.

Sinyor said he is currently working on a study of social media. He said that despite the limitations of his traditional media study, it does provide some data specific to Canada to help inform working journalists.

The research should be viewed as definitive in an important way, said Colman. “Sinyor and colleagues’ new paper must close the book on whether the media may do harm when reporting on suicide, and whether there is sufficient justification for guidelines on reporting on suicide,” he writes.

The study was supported by the American Foundation for Suicide Prevention (AFSP). Dr Sinyor receives grant support from the AFSP and the Physicians’ Services Incorporated Foundation, the Dr. Brenda Smith Bipolar Fund, the University of Toronto Department of Psychiatry Excellence Fund, and the Innovation Fund of the Alternative Funding Plan from the Academic Health Sciences Centres of Ontario. Co-author Jane Pirkis, PhD, receives grant support from the AFSP.

CMAJ. Published online July 30, 2018. Full text, Commentary

https://www.medscape.com/viewarticle/901408#vp_1

Mutations, drugs drive cancer by blurring growth signals

Genetic mutations in a form of non-small cell lung cancer (NSCLC) may drive tumor formation by blurring cells’ perception of key growth signals, according to a new laboratory study published August 31, 2018 in Science. The research, led by UC San Francisco researchers, could have important implications for understanding and ultimately targeting the defective mechanisms underlying many human cancers.

Healthy cells rely on the central Ras/Erk growth signaling pathway (also known as the Ras/MAPK pathway) to interpret external cues about how and when to grow, divide, and migrate, but defects in how these messages are communicated can cause cells to grow out of control and aggressively invade other parts of the body. Such mutations are found in the majority of human cancers, making treatments for Ras/Erk defects a “holy grail” of cancer research.

Decades of study have led scientists to believe that Ras/Erk-driven cancers occur when mutations cause one or more components of the pathway to get stuck in a pro-growth state. Researchers have labored to develop targeted treatments that flip these broken switches back off, but so far most have failed to make it through clinical trials. Now, using a high-throughput technique developed at UCSF that allows scientists to take control of Ras/Erk signaling using pulses of light, and then quickly read out resulting genomic activity, researchers have made a surprising discovery about this extensively studied pathway.

Optogenetics — in which light-sensitive proteins are genetically engineered into cells in order to make them respond to pulses of light — has been a transformative laboratory technique in neuroscience, allowing researchers to control and study electrical activity patterns within networks of neurons with exquisite precision. By using the same approach to explore patterns of chemical communication within individual cells, the new research has revealed that some Ras/Erk mutations may trigger cancer by altering the timing, rather than the intensity, of cellular growth signals. The new study also shows that this blurring of signal timing may explain why some targeted drugs designed to shut off defective Ras/Erk signaling can paradoxically activate the pathway instead potentially raising the risk of new tumor formation.

“This new technique is like a diagnostic instrument that we hook up to a diseased cell, which lets us stimulate and interrogate the cell with many light-based stimuli to see how it responds,” said UCSF synthetic biologist Wendell Lim, PhD, one of the study’s senior authors. “Using this approach, we were able to identify cancer cells that have certain defects in how they process signals, behaviors that lead to cell proliferation in response to signals that normally are filtered by the cell circuits.”

UCSF medical oncologist and cancer biologist Trever Bivona, MD, PhD, and Princeton molecular biologist Jared Toettcher, PhD, formerly a postdoctoral researcher in Lim’s lab, were co-senior authors of the new study. The study’s lead author was Lukasz Bugaj, PhD, of the University of Pennsylvania, also formerly a postdoctoral researcher in Lim’s lab.

Optogenetics Reveals Corruption of Cellular Growth Signaling by Mutations, Drugs

The Ras/Erk pathway is complex, but at its core is a cascade of four proteins — Ras, Raf, Mek, and Erk — that activate one another like a chain of falling dominoes in response to growth signals from outside the cell. Ras sits at the cell membrane and receives incoming signals, then passes them along to Raf and Mek, which process and amplify them, until finally Erk (also called MAP Kinase or MAPK) transports the signal into the cell nucleus, where it can activate the appropriate genetic programs.

Previously, researchers had little understanding of how the timing of growth signals impacted cells’ behavior. To address this question, the new research made use of a novel optogenetic tool which was developed by Toettcher as a post-doc in the Lim lab. This tool, OptoSOS, can be engineered into cells to trigger Ras activity in response to precisely timed pulses of light.

To track cells’ responses to different patterns of Ras activation, the researchers engineered the OptoSOS system into multiple lines of healthy and cancerous cells, and placed different groups of these cells into an array of small wells in a laboratory dish. By illuminating this dish with a specially designed device — dubbed the optoPlate — the team was able to rapidly stimulate hundreds of different experimental groups of cells with a variety of test patterns, and simultaneously read out their responses under a microscope.

These techniques revealed that healthy cells respond selectively to long-lasting growth signals, while ignoring signals that flicker on and off — presumably considering them to be irrelevant “noise.” In contrast, the researchers found that certain non-small cell lung cancer (NSCLC) cell lines appear to misinterpret these intermittent noisy signals as stronger, sustained signals, triggering excessive growth and tumor formation.

“Cancer biologists expect oncogenic mutations to turn a pathway on to a constant, high level,” Toettcher said.”Our work shows that there is a second option, where mutant cells can still sense external inputs but alter the dynamics of their response.”

This misreading of signals appears to occur because of a specific type of mutation in the protein B-Raf corrupts the timing of incoming growth signals, the researchers found, causing short pulses of Ras activation to reverberate for longer within an affected cell — similar to how the “sustain” pedal on a piano causes individual notes to be drawn out and blur together.

When the researchers activated Ras in healthy cells with a brief pulse of OptoSOS stimulation, Erk would turn on and off again with only about a two-minute lag. In contrast, in B-Raf mutant cells, it took Erk activity 20 minutes to dissipate following OptoSOS stimulation, and further experiments showed that this resulted in activation of downstream genetic programs associated with cell growth and proliferation.

The researchers also showed that some targeted cancer drugs that are intended to shut down overactive components of the Ras/Erk signaling pathway may blur the fidelity of signaling much as B-Raf mutations do. Specifically, they found that vemurafenib and SB590885 — part of a class of drugs called paradox activating B-Raf inhibitors — significantly slowed how long it took Ras/Erk activity to shut off following OptoSOS stimulation, which could help researchers understand these drugs’ known risk of triggering new tumor formation in patients.

“This research teaches us about a previously underappreciated dimension to oncogenic signaling and suggests that the timing of growth signaling could play an important role in a wider variety of human cancers,” Bivona said. “There may be future diagnostic and therapeutic opportunities that leverage the ability to detect aspects of signal corruption on a functional level that are not apparent by merely sequencing the cancer genome with the descriptive approaches that are currently standard in the field.”

Lim added, “We can now use interrogative tools like optogenetics to achieve a much more quantitative and systematic understanding of how cellular circuits work and how they break. This approach may be able to help us uncover what goes wrong in many diseases involving malfunctioning decision-making circuits in cells, ranging from cancer to autoimmunity.”

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Story Source:

Materials provided by University of California – San Francisco. Note: Content may be edited for style and length.

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Journal Reference:

1. L. J. Bugaj, A. J. Sabnis, A. Mitchell, J. E. Garbarino, J. E. Toettcher, T. G. Bivona, W. A. Lim. Cancer mutations and targeted drugs can disrupt dynamic signal encoding by the Ras-Erk pathway. Science, 2018; 361 (6405): eaao3048 DOI: 10.1126/science.aao3048

https://www.sciencedaily.com/releases/2018/08/180831175032.htm

Veracyte Gets Draft Medicare Local Coverage OK for Pulmonary Fibrosis Test

Veracyte said after the close of the market on Thursday that it has received a draft Medicare local coverage determination through MolDx for its Envisia Genomic Classifier test, which uses RNA sequencing and machine learning technology to diagnose idiopathic pulmonary fibrosis.

The Wisconsin Physicians Service Insurance Corporation posted its draft LCD online and Veracyte said it anticipates that three other Medicare Administrative Contractors — CGS, Noridian Health Solutions, and Palmetto GBA — would follow suit.

“The evidence supporting use of the Envisia classifier met MolDx’s high bar for coverage and strongly positions us to expand commercialization of the test in 2019,” Veracyte CEO Bonnie Anderson said in a statement.

The draft policy is open to a 45-day comment period and could potentially go into effect in early 2019, according to Veracyte.

Envisia is intended for patients with interstitial lung disease who physicians suspect may have idiopathic pulmonary fibrosis, but do not have a definitive usual interstitial pneumonia pattern. Veracyte launched an early access program for the assay in May, following a clinical validation study that it published last year, and plans to launch it more broadly in 2019.

https://www.genomeweb.com/molecular-diagnostics/veracyte-gets-draft-medicare-local-coverage-determination-envisia-test

Enzo to expand LI facilities

Enzo Biochem said this week that it has entered an agreement to purchase a nearly 36,000-square-foot commercial facility in Farmingdale, New York, that it anticipates will enhance its ability to produce and distribute a growing portfolio of molecular, immunohistochemistry, immunoassay, and immune-oncology products and services.

The building, adjacent to the company’s Long Island campus, expands the infrastructure needed to produce and distribute its expanding diagnostic platform products and related services, including automation-compatible reagent systems and associated products for sample collection and processing through analysis. The new facility also provides more space for production of its development-stage clinical candidates, including Enzo’s proprietary sphingosine kinase 1 inhibitor, SK1-I, which is being investigated for potential applications in oncology and autoimmune diseases.

In connection with the acquisition of the new facility, the Town of Babylon Industrial Development Agency has committed to providing multi-year tax abatements and additional incentives, Enzo said.

https://www.genomeweb.com/brief-week-enzo-biochem-caris-life-sciences-human-longevity-more

Hospital built to draw millennial customers

Technology and real-time communication at Dayton Children’s Hospital optimize the patient and family experience for a new generation.

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KEY TAKEAWAYS

Technology and real-time communication are essential to millennials.

Look outside the healthcare industry for ideas to enhance the patient experience.

Find vendors that will evolve their technology to meet your patients’ needs.

Easy wins include reliable wireless network and phone chargers.

As health systems move toward more consumer-centric practices, children’s hospitals are the leading edge of serving millennials, a tech-savvy generation with different expectations than the age groups preceding it.

With a new patient tower opening last year, Dayton Children’s Hospital in Ohio, which serves more than 300,000 children a year in more than 50 specialties, presents a case study in designing a patient and family experience for this generation.

While its administrators acknowledge that many factors and processes influence patient satisfaction, the infrastructure now exists to optimize the patient experience.

In 2012 Deborah Feldman joined Dayton Children’s as president and CEO. The next year she debuted a vision for 2020, which included plans for the new facility, which opened in 2017.

Those plans took a deep dive into the needs and behaviors of millennials—the generation of parents whose children are now treated there—and included a commitment to offer best-in-class technology as part of the up-front investment.

THE MILLENNIAL FACTOR

“As a children’s hospital, our consumers are increasingly millennials,” says Kelly Kavanaugh, vice president of marketing and strategic planning at Dayton Children’s 178-bed inpatient facility.

During the planning process for the new patient tower, “I compiled research about millennials and how they think about care, but more importantly, how they behave in the rest of their life, which really influences how they think about healthcare,” she says.

Among the most essential findings were a need for technology that enables real-time, two-way communication, and processes to instantly address needs and provide instant gratification.

While these concepts are hard to find in healthcare settings, they are well-refined in the world outside of hospitals where Amazon, Apple, and Google operate and are now becoming players in the healthcare arena. These brands are respected by millennials and ones that Dayton Children’s wanted to emulate.

For inspiration, the team’s project manager, a nurse who is now retired, visited hospitals around the country, gathering information about best practices and names of preferred vendors.

SATISFYING A DRIVING NEED FOR TECHNOLOGY

Nikkia Whitaker, MSN, RN, CCRN, clinical technology integration manager, later joined the team, serving as the liaison between the IT department and end users. Rather than letting vendors drive the process, she further refined plans by asking patients and families what features and benefits were most appealing.

“There was a lot of involvement with our patient ambassadors and our family advisory board,” says Whitaker. “We asked what things were important to them, and then reached out to vendors and asked, ‘How can you make this happen?’ ”

In the end, Whitaker was responsible for launching a dozen new systems with interconnectivity between many of them. Among those were:

• GetWellNetwork, a patient engagement software system that works through the patient’s television
• Vocera, a wearable smartphone device for nurses
• Hill-Rom Nurse Call, bedside call technology

While a few of the systems were piloted ahead of time, remarkably, Whitaker decided to go live with all technology simultaneously. Even more remarkably, the launch went smoothly and continues to operate efficiently. Here’s why:

• Before the launch date, Whitaker organized six groups of “super users” and conducted training with 12 vendors over a two-day period
• During the following six weeks, the super users trained staff members on their units
• After the launch, training continues as the hospital enhances the technology, and vendors issue updates
• Every other week, Whitaker conducts a four-hour technology training class for all new nurses and PCAs

“We’re using technology to the fullest capability of what IT says we can do with it and what nurses say they want to do with it,” says Whitaker.

PATIENT EXPERIENCE FEATURES

The new patient tower not only houses state-of-the-art patient care equipment, it also showcases technology and features that appeal to millennials. Among the highlights:

Some of the updates were not complex, but had a significant impact, according to the hospital’s marketing executive. Ideas other hospitals could emulate without a huge technology overhaul include:

• Bedside buttons that allow patients to speak directly with their nurses, no matter where the nurses are located in the hospital
• Whiteboards built into the television system that enable patients and family members to register real-time complaints and compliments
• Electronic name badges that track hospital personnel throughout the floor and will soon project their picture and identity onto the patient’s television screen when they enter the room
• A coded lighting alert system outside each patient room that enables staff members to determine key information at a glance, for example, if a patient is a fall risk or a procedure is in process
• Electronic signage outside each door embedded into a tablet that lists patient precautions, as well as welcoming messages
• A video-based patient education system that tracks programs watched and documents viewings into the EMR
• Interconnectivity between many of the devices, such as smart bed monitors and vital sign monitors that feed directly into the EMR
• A reliable wireless network for millennials who arrive at the hospital with their own devices. They use the network to continue working and stay connected to family and friends.
• Parents of patients admitted through the emergency department often have their phones, but not their chargers. Keeping a variety of chargers available is an easy solution and a “huge win,” says Kavanaugh.
• Installing larger television sets in patient rooms. Interestingly, says Kavanaugh, this was one of the greatest sources of complaints in the old facility. Patient rooms in the new tower offer two televisions: a 40-inch monitor and keyboard for patients, and a 20-inch television in the parents’ area of the room—a much-desired diversion from kid’s programming, she says.
• The ability to order meals via the television, a measure that also created efficiencies for the dietary department

NEW WAYS TO MEASURE IMPACT

While patient scores have not changed dramatically due to these upgrades, as measured by traditional survey mechanisms, Dayton Children’s now has new ways to capture feedback and data:

• Each day, two survey questions are pushed out via the GetWellNetwork, appearing on patients’ television screens. On a 10-point scale, with 10 being the highest grade, 90% of respondents consistently rate satisfaction at nine or above.
• Staff members now respond immediately to concerns patients and family members raise.
• “If there’s a negative response to a daily survey question or a complaint is received, it immediately triggers a message to our nurse leaders who then deal with it in real time,” says Cindy Burger, MS, RN, vice president of patient and family experience.
• In addition, families or patients now have an easy way to provide positive feedback. Each month about 60 employees are recognized for outstanding service.

“We have an industry that’s slow to respond to new things,” says Burger, “but [our hospital is serving] a whole new generation that has very different expectations. We’re seeing it now; the adult hospitals will see it soon, when more of their patients are millennials.”

https://www.healthleadersmedia.com/innovation/hospital-built-enhance-millennial-experience

For nursing home patients, breast cancer surgery may do more harm than good

Surgery is a mainstay of breast cancer treatment, offering most women a good chance of cure.

For frail nursing home residents, however, breast cancer surgery can harm their health and even hasten death, according to a study published Wednesday in JAMA Surgery.

The results have led some experts to question why patients who are fragile and advanced in years are screened for breast cancer, let alone given aggressive treatment.

The study examined the records of nearly 6,000 nursing home residents who had inpatient breast cancer surgery the past decade. It found that 31 to 42 percent died within a year of the procedure. That’s significantly higher than the 25 percent of nursing home residents who die in a typical year, said Dr. Victoria Tang, lead author and an assistant professor of geriatrics and hospital medicine at the University of California-San Francisco.

Although her study doesn’t include information about the cause of death, Tang said she suspects that many of the women died of underlying health problems or complications related to surgery, which can further weaken older patients. Patients who were the least able to take care of themselves before surgery, for example, were the most likely to die within the following year. Dementia also increased the risk of death.

It’s unlikely that many of the deaths were due to breast cancer, which often grows slowly in the elderly, Tang said. Breast cancers often take a decade to turn fatal.

“When someone gets breast cancer in a nursing home, it’s very unlikely to kill them,” said study co-author Dr. Laura Esserman, director of the UCSF breast cancer center. “They are more likely to die from their underlying condition.”

Yet most patients in the study got sicker and less independent in the year following breast surgery.

Among patients who survived at least one year, 58 percent suffered a serious downturn in their ability to perform “activities of daily living,” such as dressing, bathing, eating, using the bathroom or walking across the room.

Women in the study, who were on average 82 years old, suffered from a variety of life-threatening health problems even before being diagnosed with breast cancer. About 57 percent suffered from cognitive decline, 36 percent had diabetes, 22 percent had heart failure, 17 percent had chronic lung disease, and 12 percent had survived a heart attack.

The high mortality rate in the study is striking because breast surgery is typically considered a low-risk procedure, said Dr. Deborah Korenstein, chief of general internal medicine at New York’s Memorial Sloan Kettering Cancer Center.

The paper provided an example of how sick, elderly people can suffer from surgery. An 89-year-old woman with dementia who underwent a mastectomy became confused after surgery and pulled off all her bandages. Health care workers had to restrain her in bed to prevent her from pulling off the bandages again. The woman died 15 months later of a heart attack.

Surgery late in life is more common than many realize. One-third of Medicare patients undergo surgery in the year before they die, according to a 2011 study in The Lancet. Eighteen percent of Medicare patients have surgery in their final month of life and 8 percent in their final week.

Nearly 1 in 5 women with severe cognitive impairment, such as Alzheimer’s disease, get regular mammograms, according to a study in the American Journal of Public Health.

The new study leaves some important questions unanswered.

The paper didn’t include healthier nursing home residents who are strong enough to undergo outpatient surgery, said Dr. Heather Neuman, a surgeon and associate professor at the University of Wisconsin School of Medicine and Public Health. These women may fare better than those who are very ill.

Esserman and Tang said their findings suggest doctors need to treat breast cancer differently in very frail patients.

“People think, ‘Oh, a lumpectomy is nothing,'” Esserman said. “But it’s not nothing in someone who is old and frail.”

In recent years, doctors have tried to scale back breast cancer therapy to help women avoid serious side effects. In June, for example, researchers announced that sophisticated genetic tests can help predict which breast cancers are less aggressive, a finding that could allow 70 percent of patients to avoid chemotherapy.

The Medicare database used in this study didn’t mention whether any of the patients had chemotherapy, radiation or other outpatient care. So the UCSF researchers acknowledged that they can’t rule out the possibility that some of the women suffered complications due to these other therapies. In general, however, authors noted that only 6 percent of nursing home residents with cancer are treated with chemotherapy or radiation.

The authors said doctors should give very frail patients the option of undergoing less aggressive therapy, such as hormonal treatments. In other cases, doctors could offer to simply treat symptoms as they appear.

The new study raises questions about the value of screeningnursing home residents for breast cancer, Korenstein said. Although the American Cancer Society hasn’t set an upper age limit for breast cancer screening, it advises women to be screened as long as they’re in good health and expected to live at least another decade.

Residents of nursing homes generally can’t expect to live long enough to benefit from breast screening, Korenstein said.

“It makes no sense to screen people in nursing homes,” Korenstein said. “The harms of doing anything about what you find are far going to outweigh the benefits.”

https://www.healthleadersmedia.com/clinical-care/nursing-home-patients-breast-cancer-surgery-may-do-more-harm-good-0

Private Medicaid firm that left Iowa has yet to pay thousands of medical bills

A Medicaid company that terminated its Iowa contract almost a year ago has yet to pay as much as $14.6 million for medical care provided to disabled, poor and elderly Iowans, a Des Moines Register investigation shows.

AmeriHealth Caritas’ outstanding bills include nearly 6,000 individual charges totaling more than $1 million at the University of Iowa Hospitals and Clinics and $541,000 at Broadlawns Medical Center, public records obtained by the Register show.

Several private and nonprofit medical groups told the Register they have tens of thousands of dollars in outstanding bills that they say are hamstringing their operations and efforts to provide medical care.

“I’ve talked with the governor and she said $1 unpaid is a $1 too much,” said Julie Tow, owner of Comfort Home Health Care in Cedar Rapids. “And she has tried to coordinate meetings with these people, and she does, but then nothing happens.”

At the directive of then-Gov. Terry Branstad, AmeriHealth was one of three for-profit businesses that Iowa hired in 2016 to take over management of the state’s $5 billion annual program.

Last year, after 18 months and multiple failed attempts to negotiate higher payments for its Medicaid work, AmeriHealth announced on Halloween that it would terminate its Iowa contract. Its services continued until Nov. 30.

Until the termination, AmeriHealth was Iowa’s largest Medicaid company, managing the care of more than a third of the 600,000 Iowans in the program.

One of AmeriHealth’s chief responsibilities was to pay medical professionals who provide services to their clients. Doctors have up to a year to submit claims for payment to the company.

AmeriHealth and other Medicaid managers generally are expected to make payment for legitimate and correctly filed claims within 30 days to meet the federal definition of “timely processing.”

But medical executives such as Tow — who says her company is owed at least $30,000 — say payments have languished for months, describing situations in which AmeriHealth has either lost claims or information crucial to resolving the unpaid disputes.

AmeriHealth’s latest report June 30 to the Iowa Insurance Division shows it has $14,624,276 in unpaid claims. A review of the report was first published by the community blog “Bleeding Heartland” earlier this week.

AmeriHealth spokesman Joshua Brett responded to a request for an interview with a written statement that said the company is complying with its Iowa contract.

“AmeriHealth Caritas Iowa continues to diligently work to adjudicate provider claims,” Brett said.

Kimberly Weber, an executive of Iowa Home Care in Des Moines, estimates her business is owed more than $222,000 by AmeriHealth.

She said she has reached out to Iowa Medicaid Director Mike Randol and Iowa Department of Human Services Director Jerry Foxhoven several times.

“What cannot happen is they act like they don’t know,” Weber said. “We’ve been forthright about the problem.”

Brenna Smith, a spokeswoman for Gov. Kim Reynolds, issued a one-sentence statement when asked what steps the governor may take to resolve the issue:

“The governor expects AmeriHealth to fulfill the contract, and that includes paying any providers who are entitled to be paid.”

Matt Highland, a spokesman for the Iowa Department of Human Services, said AmeriHealth’s final payments likely will not be made until 2020 because of filing standards.

Iowa has a payment “withhold” of 2 percent to Medicaid companies, which can amount to tens of millions of dollars should Human Services determine the company has not met goals or acted appropriately.

That decision will be made late this year, Highland said.

Before AmeriHealth terminated its work with the state last year, Iowa’s Human Services had assessed more than $1 million in penalties against the company.

AmeriHealth also was a subject of a Des Moines Register investigation published earlier this year about the denial of care to disabled Iowans.

https://uw-media.desmoinesregister.com/embed/video/109568906?sitelabel=reimagine&placement=snow-smallarticleinlinehtml5&keywords=iowa-medicaid-privatization%2Cmedicaid%2Ccontract-issue-healthcare%2Cpublic-records%2Chealth-insurance%2Cdesire%2Coverall-positive&simpleTarget=&simpleExclusion=&pagetype=story&cst=news%2Ffeatures_investigations&ssts=news%2Finvestigations&series=

AmeriHealth’s Dr. Brian Morley testified that it wasn’t necessary for an in-home care patient to receive daily assistance to clean himself after bowel movements. Read the full investigation: features.desmoinesregister.com/news/medicaid-denials/

Ed Brown, the CEO of the Iowa Clinic, said his staff is aggressive in challenging billing practices from the Medicaid companies it believes to be unfair.

AmeriHealth owes the Iowa Clinic less than $20,000, an amount he described as “not trivial but also not of a magnitude that I have to hold my nose.”

Brown said the state’s desire to better manage Medicaid and save money — the key reasons Iowa hired for-profit corporations to manage the program — is worthy, but continuing operational issues make it difficult to achieve that goal.

“It’s unfortunate, but this has turned into a political football,” Brown said. “And this is not something to play political football with.”

https://www.desmoinesregister.com/story/news/investigations/2018/08/30/iowa-privatized-medicaid-company-amerihealth-caritas-thousands-unpaid-medical-bills-broadlawns/1137484002/