Blue Cross Blue Shield (BCBS) has seen double-digit growth in the number of planned knee and hip replacements among its commercially-insured members, the company said in a report published Wednesday.
From 2010 to 2017, the number of annual elective knee and hip replacements rose by 17% and 33%, respectively, contributing to a 44% increase in spending on orthopaedic procedures.
Growth was strongest in the 55- to 64-year-old age group, but BCBS also saw upticks in the numbers of procedures performed on younger people.
Elective knee and hip replacements are on the rise. The biggest increase in the data analyzed by BCBS was in planned hip replacements in people aged 55 to 64, the oldest demographic included in the report. From 2010 to 2017, the number of hip replacements performed in this group jumped 42%, resulting in almost four out of every 1,000 BCBS members undergoing the procedure in 2017.
The number of hip replacements in younger people is increasing, too. BCBS reported a 25% increase in the 45 to 54 age group and a 14% uptick in the 35 to 44 demographic. Those increases came off low 2010 base figures, though, meaning the procedures remain relatively rare in younger people.
BCBS identified similar trends in the data on planned knee replacements. These procedures were more common than hip replacements in 2010 and remained so in 2017, despite undergoing less dramatic increases over the analyzed period. The strongest growth was seen in the 55 to 64 group, where an 18% increase brought the procedure rate per 1,000 people up above seven.
Health insurer BCBS looked into the data as spending on treatments for orthopedic pain conditions makes up a significant part of total healthcare budgets. Among commercially-insured BCBS members, spending on these conditions totaled $54 billion in 2017. That represented 14% of overall healthcare spending in the population.
Elective orthopedic procedures alone cost around $25 billion in 2017, making it a big part of the total healthcare budget and therefore a potential opportunity to cut costs.
This scope for cost cutting is unrelated to the price of the devices used. Rather, it relates to the large variations in the cost of procedures between different facilities in the same location, and to evidence that it is better and cheaper to do knee and hip replacements in outpatient settings. Still, the overwhelming majority of procedures still take place in inpatient settings.
Massachusetts General Hospital is planning a $1 billion addition to its campus in downtown Boston, The Boston Globe reports.
The proposed construction — thought to be the largest ever undertaken by a hospital in the state — includes two connected 12-story towers with private patient rooms, a cardiac center, cancer center, operating rooms and other clinical space.
The entire project will add 1 million square feet and allow Mass General to treat an additional 100 to 200 patients. The project, which requires local and state approvals, is expected to take seven years to complete, putting the grand opening in 2026.
The project comes as many hospitals are scaling back on construction projects in the face of financial headwinds. Fewer inpatients, lower reimbursements and rising labor and operating costs are hitting hospitals and health systems where it hurts, and not just earnings but credit ratings have suffered.
A 2018 Health Facilities Management survey indicated that renovations rather than new construction are a continuing hospital trend, as well as the construction of more outpatient than inpatient facilities. For instance, New York City Health + Hospitals/Coney Island Hospital is underway with a $738 million renovation and expansion in Brooklyn.
This is the second $1 billion expansion for a Boston hospital announced in the past few years. The $1.2 billion Boston Children’s Hospital expansion, which is underway now, had to overcome opposition from some groupsthat were concerned that the capital project would drive up the costs of services at the hospital and that also objected to the demolition of an existing garden used by patients and their families.
A recent Fitch Ratings report showed a mixed bag for not-for-profit hospitals and health systems in the 2018 third quarter, with 11 security rating upgrades and 11 downgrades. Among the downgrades were Dignity Health and MedStar Health, which each slipped from A to A-.
Amid these concerns and uncertainty about the economy generally, some hospital projects that are planned are facing greater scrutiny over concerns the costs could be passed onto patients and consumers. Mass. General was prepared to file preliminary plans for its twin towers project with the city of Boston this week, according to the Globe.
Still, hospitals are moving ahead with construction to meet patient demand and stay competitive.
Mayo Clinic currently has about $1.6 billion tied up in various construction and expansion projects spanning the next three to five years. The projects include about $908 million for construction related to patient care, research and education, as well as a $648 million expansion of its Phoenix campus. The five-year Arizona project will add new clinical space, support services and infrastructure, plus 2,000 new jobs, including 200 physicians.
BJC Healthcare opened a 12-story inpatient tower and St. Louis Children’s Hospital expansion one year ago, part of a $1 billion transformation to modernize and improve patient care. And Banner Health disclosed in financial reports last summer that it will invest $61.4 million to build three new inpatient rehabilitation hospitals and expand its outpatient business.
Even a slight improvement in your heart/lung fitness could reduce your risk of a heart attack, a new study reveals.
Between 2006 and 2008, researchers assessed the cardiorespiratory (heart/lung) fitness of just over 4,500 men and women in Norway. None had heart disease, high blood pressure or cancer, and most were considered at low risk for heart disease over the next 10 years.
By 2017, however, 147 of the study participants had suffered a heart attack or developed angina, conditions caused by narrowing or blockage of heart arteries.
More investigation showed that the risk of heart attack and angina steadily declined as cardiorespiratory fitness increased.
“We found a strong link between higher fitness levels and a lower risk of heart attack and angina pectoris over the nine years following the measurements that were taken,” said Bjarne Nes of the Cardiac Exercise Research Group (CERG) at the Norwegian University of Science and Technology in Trondheim.
“Even among people who seem to be healthy, the top 25 percent of the most fit individuals actually have only half as high a risk as the least fit 25 percent,” he said in a university news release.
The study used a fitness calculator developed at CERG, which measures the body’s capacity to transport and use oxygen during exercise. It found that for each increase of 3.5 fitness points, the risk of heart attack and angina decreased by 15 percent.
The findings suggest that even a small improvement in cardiorespiratory fitness can benefit heart health, the researchers said.
The study was recently published in the European Heart Journal.
Study first author Jon Magne Letnes said, “Our results should encourage people to use training as preventive medicine. A few months of regular exercise that gets you out of breath can be an effective strategy for reducing the risk of cardiovascular disease.” Letnes is a doctoral candidate in the university’s department of circulation and medical imaging.
Sanjay Sharma, a leading expert in sports and heart disease, wrote an editorial that accompanied the study.
“There is apparently no upper limit for training when it comes to the beneficial effects for the heart,” Sharma wrote. In addition to serving as medical director of the London Marathon, he is a professor of cardiology at St. George’s, University of London.
More information
CERG offers a fitness calculator that can be found here.
Are you burned out from trying to be well? It’s hard work these days, what with all the yoga and meditation and elixirs and focusing on your breath without thinking about the mountain of life admin you have piling up.
Of course, there is no doubt that regular wellness and self care practices—as obnoxious as those terms have come to sound—can help us face the hard work of being human. But here’s the thing: Sometimes what you feel like doing is lying down and doing nothing. And in those moments, the idea of engaging in a high-minded spiritual practice or dragging yourself out the door for an endorphin-boosting workout can cause more stress than it will alleviate.
In times like these, it can be helpful to have a practice that doesn’t contribute to the problem it’s trying to solve, but still feels restorative. For me, that’s viparita karani, or legs up the wall.
I first discovered this pose several years ago, when a running injury meant I had, for months, what felt like a permanently tight hamstring (it was actually a connective tissue injury). An osteopath suggested I make time to spend five to 10 minutes a day with my legs up the wall, my body forming an L shape, with my back on the floor. Sure, I’d done this in yoga class once or twice, but once I started treating it as a daily practice, the nature of the pose changed for me.
Far beyond the point when my injury healed, I found myself craving a few minutes in viparita karani at the end of my day. In addition to unwinding my tight hamstrings without over-stretching them—which is why my osteopath recommended it—it calms my nerves, releases my lower back, drains blood from my legs, and somehow makes it much, much easier to quiet my ever-churning brain, even if for just a few minutes.
When I added a bit of weight—in the form of yoga bolsters (a heavier pillow will also do)—across my belly and on my feet, it created the altogether delightful feeling of melting me into the floor. These days I find myself doing the pose after a day on my feet, a long flight, and especially when I haven’t been sleeping well.
But are these benefits real, or just the effect of wellness wishful thinking? Studies have proven yoga’s effect on vagus nerve, the longest of our cranial nerves, which runs from our brains through our lungs to our gut. It’s responsible for both our sympathetic nervous system—the one that puts us in “fight or flight” mode at the first sign of danger—as well as the parasympathetic nervous system, the one that tells us to “rest and digest” so to speak.
High “vagal tone” means your body is good at switching between these states; in other words, you’re able to come down from your constant state of alert once in while. And studies have shown that regular yoga practice increases vagal tone. Though the mechanism is not well understood, yoga practice can lead to “parasympathetic dominance and enhanced cardiac function, mood, and energy states.”
Within the practice of yoga, inversions—any pose where your heart is higher than your head—are believed to stimulate the vagal nerve. While legs up the wall isn’t quite as ambitious as a headstand, is still counts as an inversion. Sometimes if your brain can’t relax—you can get your body can do it for you.
You can do viparita karani anywhere, from a hotel room or a gym to your bedroom or at the base of a tree. It’s the literal opposite of sitting, which can’t be bad, and offers the grounding effect maybe urbanites crave. Personally, I also find that inverting my literal point of view for a few minutes can have the curious effect of changing my perspective about something else I’m thinking about.
To do it, lay a blanket or yoga mat out, or lie on a carpet, and sit sideways against the wall. Swing your legs up against the wall while rotating your hips, and lie back. At this point you may have to wiggle to get your sit bones flush with the wall. Your hamstrings shouldn’t feel strained, so if they do, put a little distance between your behind and the wall. If your lower back needs support, you can put a pillow underneath your lower pelvis, as a variation. If it’s comfortable for your head, the blanket you’re lying on should end at your shoulders, so your head lies directly on the floor; the slight elevation of your heart will enhance the inversion’s effects.
Put your hands over your head and do nothing. Repeat.
The saying goes that nothing in this world is certain except for death and taxes.
And rightfully so, the inevitability of death is a prominent fear for many humans around the world. After all, death is universal, mysterious, immutable, and sometimes sudden – and it can shake up life in ways that no other event can.
But is how we perceive death, along with its common portrayal in media, something that is accurate?
PERCEPTIONS VS. REALITY
Like anything that is shrouded in mystery, death has accumulated its fair share of myths and half-truths that get baked into our stories, perceptions, and societies.
Even further, high-profile and tragic events like terrorist attacks, murders, and suicides dominate many aspects of the news cycle. As a result, the causes of death that media outlets are the most fixated on couldn’t be further from actual causes of human death as shown through statistics.
The following animation, which comes from Aaron Penne, compares three data sets to show that our worries and media coverage have become quite disproportionate from the actual data. The animation looks at the following:
Which causes do we worry the most about? (Google Search data)
Which causes are talked about in the media? (NYT and Guardian headlines)
What are actual causes of death in the U.S.? (CDC data)
And as you’ll see, the data is quite different for each source.
We worry about cancer 10x more than we worry about heart disease, but in reality both diseases kill roughly the same amount of people. Meanwhile, the media is fixated on terrorism, homicides, and cancer, but heart disease – which kills more than all put together – receives almost no coverage.
MORE DATA ON DEATH
Actual causes of death are quite different from personal and media perceptions, but this data is not absolute either. After all, how someone may die depends greatly upon other factors like age.
Here are causes of human death in the U.S. graphed by age group:
The data shows that accidents are the leading cause of death for most ages up until 45 years old, at which case cancer and heart disease take over.
While the topic of death is grim, the above data and statistics can arguably help provide a more realistic outlook regarding one of life’s certainties. It also shows that humans and media are not necessarily rational about this topic, so it’s important to think about it independently if at all possible.
Raise your hand if you’re sick of hearing that life begins at the edge of your comfort zone. I know I am.
It is impossible to escape the gurus and influencers on social media who preach that choosing safety is self-sabotage. That without getting uncomfortable on a daily basis, I’ll never get anywhere in life, my lack of courage realized. “It’s never as scary as it looks,” the Stanford grad student Yubing Zhang chants in a widely viewed TEDx talk, Life Begins at the End of Your Comfort Zone – one of several talks on this theme that the influential conference has given a platform to. When you stay in your comfort zone, “you maintain flawed beliefs about yourself or you hold on to guilt and self-doubt”, the bestselling leadership writer and motivational speaker Jack Canfield says. “A comfort zone is a beautiful place, but nothing grows there” is a popular graphic post on Instagram. And Eleanor Roosevelt’s most-touted quote, “Do one thing every day that scares you”, adorns everything from office coffee mugs to wallpaper.
I believed these quotes once. My experience, however, taught me something different. When I pushed my comfort zone relentlessly, as the leadership experts advise, it led me straight into burnout. I learned the hard way to define – and, more importantly, to honor – the boundaries of my comfort zone. Since then, it has been a huge asset that has helped me make big strides.
Rewind just a few years and you’d find me crammed on a bus heading out of New York City, at the height of rush hour, with a two-hour commute ahead. On most mornings, stress-induced cortisol was the only thing keeping me from collapsing in exhaustion. Up to this point in my life, I had been driven by a mentality of pushing harder: straight As in school, top of my class in college, and now a demanding job in Manhattan. On the outside, everything looked peachy – as if I were a picture of success. On the inside, I was feeling defeated and helpless. In accordance with the self-improvement mindset, I rationalized these feelings as stemming from my own inadequacy. If I felt I was juggling more than I possibly could, I clearly had to hustle more. “I just need to work harder,” I told myself. “I’m out of my comfort zone. It’ll get better. I’ll adjust.”
But as the months went on, my sense of dread grew. Every day was a cocktail of fear. What crisis would crop up? What new project would be dropped into my lap this morning? My health was crumbling. Facing my fear should have allowed me to grow, as I understood the motivational slogans. Instead, in my mid-twenties, I found myself laid up in bed, so tired I could barely move, and suffering from heart palpitations and nightmares. By pushing myself in the name of getting uncomfortable, I had self-sacrificed to the point of exhaustion. In the end, I left the job and accepted that my boundaries were there to keep me safe.
Literally, the comfort zone refers to an optimal temperature. But psychologically speaking, it is a state where a person feels at ease and in control of their environment. How overcoming this state became the obsession of the self-optimization movement is curious. An early reference was made in a 1907 research paper by the American psychologist Robert Mearns Yerkes, who found that in mice, “anxiety improves performance until a certain optimum level of arousal has been reached”. (Yerkes was also a proponent of eugenics and his work is considered to be tainted by a racialist bias.)
The idea of using anxiety to enhance performance gained traction in the face of the economic deregulation of the 1990s and the resulting competitive pressures. In 2009, the well-known British management theorist Alasdair White repeated established wisdom when he wrote that “in understanding and managing performance, the key is the management of the stress” and described anxiety as a tool to assist in performance management. Yet a 2017 paper at the University of Leicester found that there was no empirical evidence to support this idea. “Nevertheless,” the author wrote, “despite all the evidence to the contrary, the notion that stress is ‘good’ for performance is still being peddled by management textbooks”.
Contrast all this with what the early 20th-century developmental psychologist Lev Vygotsky calls the “zone of proximal development”. This conceptual space, which is near the comfort zone, allows for healthy and gradual growth, the way children naturally learn new skills. To me, it means taking on challenges deliberately, but only after having thought long and hard about my qualifications and carefully laying out each step. It means playing to my strengths.
Having pushed myself to the point of illness, I now know what I’m no longer willing to tolerate. By recognizing and respecting my comfort zone, I can identify when a situation threatens my wellbeing. And by asserting my boundaries, I can get back from anxiety to a place where I feel psychologically safe and secure.
In a world of increasing demands on our time and attention, our comfort zones act as predictable spaces of mastery where we can seek refuge when the stress becomes too much. They act as containers to shore up confidence, gain momentum, and think clearly. When we spend less time grappling with discomfort, we can focus more on what matters most. If the people who routinely push themselves past their comfort zones are metaphorically skydiving out of airplanes, those of us who choose to operate from within our comfort zones are serenely laying bricks, creating a home we can thrive in.
There may be no more powerful word in the English language than cancer.
No matter how carefully that word is qualified or communicated to patients, it is a term that is bound to unnerve or even terrify them.
Whether the language should change when it comes to describing indolent tumors that are of low risk of threatening a patient’s long-term survival is the subject of a debate in TheBMJ.
“It is a compelling argument that ethics alone require us to use a strict definition of the word to avoid unnecessary harm to our patients — psychological, physical, and financial — from unnecessarily invasive investigation and treatment,” said Laura Esserman, MD, of the University of California San Francisco, writing in favor of removing the word cancer when appropriate. “A condition that is indolent or rarely metastasizes is not a cancer as clearly defined.”
She pointed out that cancer diagnoses cover a wide range of conditions and include high-risk tumors that have a greater than 75% chance of progressing over a 1- or 2-year period, as well as ultra-low-risk cancers that have a less than 5% chance of progressing over a 20-year period.
Using the word cancer is unhelpful when physicians should be trying to “de-escalate” treatment of certain ultra-low-risk tumors (e.g., certain breast lesions or Gleason 6 prostate) by offering active surveillance instead of active treatment, Esserman argued, but this has proved difficult to accomplish.
“This is because it is difficult to encourage patients to wait and watch once they have been told they have cancer,” she said.
Changing the nomenclature of cancer will also change what researchers investigate and report. In the case of breast cancer, Esserman noted, this will put more of a focus on conditions “that directly affect women’s health and reduce the considerable toll from breast cancers, which lead to more than 40,000 deaths a year in the U.S. alone.”
In arguing against changing the nomenclature, Murali Varma, MD, of University Hospital of Wales, pointed out that while a tumor may be low risk, it “is impossible to determine the natural course of any low-risk tumor because excision for definitive diagnosis alters its natural course, precluding knowledge of how the tumor would have behaved if left untreated. This uncertainty could also lead to underestimation of the frequency of overdiagnosis as some ‘cured cancers’ would not have progressed even if untreated.”
More education about the meaning of a cancer diagnosis is a better option, he suggested.
For example, a 0.5 cm papillary thyroid cancer is likely to be harmless if removed, but dangerous if untreated. In that sense, he explained, it could be akin to an infection like bacterial pneumonia, which is usually easily cured when treated, but carries a higher risk of mortality if left untreated.
“Creating new entities risks confusion, so public education about the nature of cancer must be the priority,” Varma wrote, explaining that it might be better to categorize some very low-risk cancers as benign, and educate the public that a benign cancer signifies low risk rather than no risk, thereby avoiding “anxiety-inducing labels.”
In a patient commentary accompanying the article, Birte Twisselmann, PhD, who is an editor at the journal and had two lesions removed over the course of a year, suggested that it is not only the word cancerthat can be problematic.
After having a lesion removed from her foot that had been described as “mildly cancerous,” her discharge letter described it as a “mildly atypical dysplastic acral lentiginous nevus.”
This kind of language seemed as if “it had a hidden meaning not intended for the patient to understand,” she wrote. “This opacity was another trigger for anxiety.”
This argument about cancer nomenclature is not a new one. An article last year suggested that describing low-risk tumors as cancer leads to overdiagnosis and overtreatment, and that doctors should stop using the word cancer if a patient is unlikely to be harmed by these kinds of tumors.
