'Undetected Cognitive Impairment in Primary Care'

 Undetected cognitive impairment in primary care continues to be a nationwide problem, recent studies showed.

"Unrecognized cognitive impairment and dementia is a major problem in the U.S. and has consequences for patients, families, and the healthcare system," said Ambar Kulshreshtha, MD, PhD, of Emory University in Atlanta, who presented new research on the topic at the 2024 American Geriatrics Societyopens in a new tab or window (AGS) scientific meeting.

"Delayed diagnosis of cognitive impairment and dementia means that patients are identified in later stages when their symptoms are worse, and they already have complications leading to hospitalizations and challenges with placement," Kulshreshtha pointed out.

"As a result of this, some of the resources and newer treatment options that could have potentially slowed the disease are not received," he added. "We lose a critical window when we could have helped the patient and their families with lifestyle intervention, aggressive control of risk factors, and medication management."

Federally Qualified Health Centers

At the 2024 AGS meeting, Kulshreshtha reviewed highlights from a cross-sectional study that assessed unrecognized cognitive impairment and dementia in five federally qualified health centersopens in a new tab or window (FQHCs) in Indiana that were primary care clinics for low-income people. One in 12 people in the U.S. rely on FQHCs for care, Kulshreshtha said.

The group studied 204 patients ages 65 and older. Mean age was 70 years, 62.3% were women, and 52.9% were Black.

No study participant had a pre-existing diagnosis of mild cognitive impairment or dementia, a prescription for a cholinesterase inhibitor or memantine, serious mental illness, or permanent residence in a nursing facility. All had at least one health provider visit in the last 12 months and 3 years of available data.

Cardiovascular risk factors and conditions were highly prevalent in the cohort; 93% had hypertension, 52% had diabetes, 23% had heart disease, and 10% had a history of cerebrovascular disease.

After a comprehensive diagnostic assessment -- including structured patient and study partner interviews, medical record review, neurological examination, and neuropsychological testing -- a neurologist, geriatrician, and neuropsychologist produced one of three diagnoses: normal cognition, mild cognitive impairment, or dementia.

Unrecognized cognitive impairment and dementia were ubiquitous in FQHCs, Kulshreshtha said. "Overall, 62% of patients met criteria for mild cognitive impairment, 12% for dementia, and 26% had no cognitive impairment," he reported. In the subgroup of participants with dementia, 24% had cerebrovascular disease.

Overall, Black patients had higher odds of undetected mild cognitive impairment or dementia compared with white patients (OR 2.58, 95% CI 1.35-5.06, P=0.024), which persisted after adjusting for covariates.

The burden of dementia in the U.S. falls disproportionately on Black older adults, Kulshreshtha noted. Many prevalence studies suggest that Black older adults are twice as likelyopens in a new tab or window to have Alzheimer's disease or related dementias as white older adults.

"Undetected cognitive impairment is also a problem for non-English speaking people, immigrants, and people living in remote geographic locations where access to healthcare is limited," he pointed out.

"There continues to be prevailing stigma and misinformation in communities, and primary care providers struggle with a lack of time, resources, and referral options," Kulshreshtha added. "Late diagnosis also puts an undue burden on caregivers when they have to cope with the financial challenges and advanced-care planning, as some patients have progressed to lacking decision-making capacity."

General Primary Care

The FQHC findings supported those of a recent study that examined the cognitive performance of adults in general primary care clinics in two U.S. cities.

In a 2023 paper published in the Journal of General Internal Medicineopens in a new tab or window, Alex Federman, MD, MPH, of the Icahn School of Medicine at Mount Sinai in New York City, and colleagues evaluated 872 English-speaking adults ages 55 or older without known cognitive impairment.

Participants were recruited from primary care practices in New York City and Chicago. Their mean age was about 67 years, 44.7% were men, and 32.9% were Black.

Undiagnosed cognitive impairment was defined by age- and education-adjusted z-scores on the Montreal Cognitive Assessment (MoCA) compared with published normsopens in a new tab or window.

The researchers identified undiagnosed cognitive impairment in 20.8% of study participants. Impairment was mild in 10.5% and moderate-to-severe in 10.3%.

Rates of undiagnosed cognitive impairment of any severity were markedly higher for Black patients (26.8%) and Latinx patients (28.2%) than for white patients (6.9%).

Patients with depression were more than twice as likely as those without it to have moderate or severe cognitive impairment, Federman and colleagues added.

Several factors may be driving high rates of undiagnosed impairment. While advocacy groups like the Alzheimer's Associationopens in a new tab or window call for routine cognitive screening, the practice remains controversial. The Centers for Medicare & Medicaid Services supports cognitive screening by including it in the Medicare annual wellness visitopens in a new tab or window but the U.S. Preventive Services Task Force does not endorse screeningopens in a new tab or window for older adults without signs or symptoms of cognitive impairment.

In 2020, a working group of Alzheimer's researchers proposed a framework to refine cognitive evaluations and promote early diagnoses of mild cognitive impairment in primary care. The ongoing MyCog trialopens in a new tab or window also is testing iPad assessments based on the NIH Toolbox in 45,000 primary care patients to improve cognitive deficit detectionopens in a new tab or window in underserved communities.

Disclosures

Kulshreshtha reported no conflicts of interest.

Federman's work was supported by the National Institute on Aging. He reported no conflicts on interest.

https://www.medpagetoday.com/spotlight/ags-alzheimers-disease-mci/110157

Over 400 Physicians From Delaware's ChristianaCare Organize Via SEIU

 More than 400 physicians from Delaware's Christiana Hospital, Wilmington Hospital, and Middletown Free-standing Emergency Department -- all part of the ChristianaCare health system -- filed to unionize with Doctors Council SEIU Local 10MD.

"If successful, this will be the first physician union in Delaware and the first union of any kind at ChristianaCare," Doctors Council SEIU said in an announcement of the filing, which pointed to the ongoing corporatization of medicine as driving the physicians' efforts.

Some of the specific concerns that physicians detailed in regard to their filing included understaffing and inadequate resources, corporate influence on medical decision making, limited input in matters affecting patient care and physician safety and autonomy, and moral injury caused by pressure to place profit over patients.

Roshan Modi, MD, a radiologist at ChristianaCare, told MedPage Today that he believes "the theme has really been profits before patients across all departments. We're just being asked to do more and more with less and less."

"Physician morale is at an all-time low because we want to care for our neighbors, we want to care for our community, but we're not given the opportunity or the adequate resources to do so appropriately," Modi said.

That sentiment is hardly an isolated one amid a nationwide movement that continues to grow.

Just this week, some 150 primary care providers from Oregon-based Legacy Health announced that they are planning to unionizeopens in a new tab or window with the Pacific Northwest Hospital Medicine Association, a hospitalist-specific labor union affiliated with the American Federation of Teachers.

Earlier this month, a group of about 150 physicians and advanced practice providers at Washington, D.C.'s Unity Health Care, who unionized with the Union of American Physicians and Dentists last December, gathered to announce the filing of unfair labor practice chargesopens in a new tab or window against Unity with the National Labor Relations Board.

Other recent efforts have included a strike by emergency medicine physiciansopens in a new tab or window contracted through the private equity-backed staffing firm TeamHealth to work at Ascension St. John Hospital in Detroit following their unionization last year.

Overall, physicians at ChristianaCare and other facilities are part of a growing comradeship aimed at improving patient care and working conditions through a resurgence in organizing effortsopens in a new tab or window.

"We're hoping that we can be a blueprint for other hospitals," Modi said. "This is not unique with ChristianaCare. We all are experiencing the same things, and as a result, patients are experiencing the same things."

"This is a movement that needs to happen in medicine to push back against the corporatization of healthcare," he noted.

A spokesperson for ChristianaCare said in an emailed statement that, "we are proud of our physicians, who deliver world-class care while serving our patients and our community with love and excellence."

"We believe that continuing to have a direct relationship with physicians is an essential component of our continued shared success," the spokesperson added. "We have received the petition from Doctors Council SEIU Local 10MD and recognize the right of all employees to vote on whether or not they want a union to represent them."

https://www.medpagetoday.com/special-reports/features/110144

Whitehouse, Cassidy eye bipartisan primary care payment reform, seek industry feedback

 U.S. Sens. Sheldon Whitehouse and Bill Cassidy, M.D., want to reform how primary care providers get paid through Medicare, and they also want to hear from the healthcare industry about the best way to do it.

Whitehouse, a Democrat from Rhode Island, and Cassidy, a physician and Republican from Louisiana, introduced a bipartisan bill, the Pay PCPs Act (S. 4338), Wednesday to better support and improve pay for high-quality primary care providers. 

The legislation serves as a marker for future primary care legislation and is intended to solicit feedback on a number of important policy questions, the lawmakers said.

The Pay PCPs Act would task the Centers for Medicare & Medicaid Services (CMS) with establishing hybrid payments to reward primary care providers who provide the best care to their patients—care that reduces patients’ emergency visits, hospitalizations, excess specialist services and other big cost drivers, according to a press release. 

The bill would provide Medicare beneficiaries with reduced cost-sharing for certain primary care activities and service and would also create a new technical advisory committee to help CMS more accurately determine Fee Schedule rates.

The proposed legislation would encourage CMS to accelerate its existing efforts to support value-based primary care and improve the adequacy of pay for primary care providers in Medicare, according to the lawmakers.

Whitehouse and Cassidy also issued a request for information (PDF) for feedback on policy questions. Feedback can be submitted to physician_payment@cassidy.senate.gov until July 15, 2024.

In the RFI, the lawmakers outline the legislative proposal by outlining that the Medicare Physician Fee Schedule currently is comprised of activities and services that are ill suited to support primary care.

"Primary care requires ongoing care coordination and relies upon routine activities that are under- or non-reimbursed in the Fee Schedule. This legislation encourages CMS to adopt 'hybrid payments' for primary care providers in the Fee Schedule, accelerating ongoing efforts in CMMI models," the lawmakers wrote in the RFI.

"Hybrid payments give primary care providers in Medicare steady, upfront, and value-based payments for under-reimbursed activities, while maintaining some traditional FFS payments for certain services. Hybrid payments allow primary care providers to innovate and more easily integrate diverse care activities to improve care quality and reduce costs," they wrote.

“Primary care is a critical part of the health care equation.  Overwhelming evidence shows that primary care both improves health outcomes for patients and drives down health costs.  There are many issues to address in primary care, and we look forward to receiving feedback on our legislation through the RFI to make a meaningful difference to health care success,” said Sen. Whitehouse and Dr. Cassidy in a joint statement.

The U.S. spends more on healthcare as a share of its GDP than peer countries, but U.S. life expectancy is below that of its peer nations—and falling.  

For decades, the U.S. has underinvested in primary care, spending only 5 to 7 cents of every healthcare dollar on primary care. Other high-income countries spend 13 cents per dollar.

The U.S. primary care system suffers from "chronic lack of adequate support," according to a 2023 scorecard report.

Three in 10 people report not having a usual source of primary care, and reports find the U.S. will face a shortage of between 17,000 and 45,000 primary care doctors over the next decade, the lawmakers laid out.

Primary care groups immediately cheered the legislation.

Susan Dentzer, president and CEO of America's Physician Groups, which represents about 360 organizations, said the plan proposed by the lawmakers for a hybrid form of Medicare payment would combine prospective, per-member-per-month payments with fee-for-service. 

“This approach will enable many smaller physician practices not only to survive the current headwinds facing primary care, but also to build the infrastructure that they will need to thrive in value-based models—the direction in which the nation's health care system must continue to move," Dentzer said in a statement. "We also applaud the move to reduce copayments from Medicare beneficiaries for vitally important care coordination services.  America's patients, doctors, and the nation as a whole would be better off with this overall approach, and we look forward to working with policy makers to embed it in law and see it flourish in practice.”

Many primary care providers strive to provide patient-centered, coordinated healthcare that is accountable for costs and quality, she noted. "We can't achieve this goal without a strong basis in advanced primary care, and outside of value-based payment models, the current structure of Medicare fee-for-service physician payment doesn't adequately support the model, and in fact, undermines it," Dentzer said.

“We’re heartened to see Senator Whitehouse and Senator Cassidy’s bipartisan commitment to improving seniors’ access to comprehensive primary care by proposing legislation that would offer hybrid payment (a mix of Fee-for-Service and prospective payment) to Medicare primary care practices," said Ann Greiner, president and CEO of the Primary Care Collaborative, in a statement issued Wednesday.

https://www.fiercehealthcare.com/providers/senators-both-sides-aisle-propose-primary-care-payment-reform-seek-industry-feedback

'White House's Brainard says China's exports can undermine investments in US'

 White House National Economic Adviser Lael Brainard said on Thursday China's industrial capacity and exports in certain sectors are so large, they can undermine the viability of investments in the United States.

"China is now simply too big to play by its own rules," Brainard said during remarks at the Center for American Progress, a liberal think tank.

"China's industrial capacity and exports in certain sectors are now so large, they can undermine the viability of investments in the U.S. and other countries," she said.

President Joe Biden unveiled steep tariff increases on an array of Chinese imports including electric vehicle (EV) batteries, computer chips and medical products earlier this week.

China vowed retaliation for the tariff decision. Its commerce ministry said Beijing was opposed to the U.S. tariff hikes and would take measures to defend its interests.

Brainard also warned a new cycle of Chinese policy-driven overcapacity and export surges could have adverse consequences for American workers, undermine market-based innovation and competition and America's supply chain resilience.

"We have learned from the past. There can be no second China Shock here in America," she said.

She also said the United States will work with Mexico to address concerns that some Chinese steel and auto exports could flow in through Mexico.

https://www.yahoo.com/news/white-houses-brainard-says-chinas-155438913.html

Walmart CFO says 'many consumer pocketbooks' being stretched as high inflation persists

 While Walmart's earnings topped Wall Street expectations, CFO John David Rainey said that "many consumer pocketbooks are still stretched." 

"We see the effect of that in our business specs as they're spending more of their paychecks on non-discretionary categories and less on general merchandise," Rainey told analysts on the first-quarter earnings call Thursday. 

Rainey said that particular merchandise mix is still a headwind to margins, but Walmart U.S. is in the midst of executing strategies aimed at improving general merchandise sales and increasing the visibility of the e-commerce brand assortments in fashion, home and electronics, according to Rainey.  

"We have the opportunity to grow general merchandise sales in stores with our first party e-commerce assortment and especially with our marketplace," he said. 

Walmart reported revenue of $161.51 billion for the three-month period ending April 30, beating analyst expectations of $159.5 billion. The Arkansas-based retailer also reported adjusted earnings of 60 cents per share, topping Wall Street's estimate of 52 cents. 

In the midst of a year marked by uncertainty and persisting inflation, the company raised its full-year forecast. 

In April, inflation climbed 3.4% from the same time last year, down from the 3.5% reading in March. While inflation has fallen considerably from a peak of 9.1%, progress has largely flatlined since the summer. Inflation remains well above the Fed's 2% target.

In turn, it's created severe financial pressures for most U.S. households, which are forced to pay more for everyday necessities like food and rent. However, these price hikes are particularly devastating for lower-income Americans, because they tend to spend more of their already-stretched paycheck on necessities.

Walmart

To help, Walmart CEO Doug McMillon said the company is working with suppliers to lower prices and its "rollback count is up." 

Walmart U.S. CEO John Furner said the company has almost 7,000 rollbacks which the company noted is "resonating" with consumers. Rollbacks refer to temporary price reductions on goods. 

https://www.foxbusiness.com/lifestyle/walmart-cfo-says-many-consumers-are-being-stretched-high-inflation-persists

'US says experimental studies show cooking hamburgers kills bird flu virus'

 The U.S. Department of Agriculture said on Thursday that experimental studies found no H5N1 bird flu virus in ground beef cooked to 145 degrees Fahrenheit (63 degrees Celsius) or 160 degrees Fahrenheit, following an outbreak of the disease in dairy cattle.

The USDA previously said 30 samples of ground beef from retail outlets tested negative for H5N1 virus and that the meat supply is safe.

Hamburgers cooked to 120 degrees Fahrenheit in experimental studies showed the virus was present at reduced levels, the USDA said.

https://www.yahoo.com/news/us-says-experimental-studies-show-155105100.html

Police take back building from protesters at University of California, Irvine

 Police on Wednesday took back a lecture hall from pro-Palestinian protesters who for hours occupied the building at the University of California, Irvine, then cleared a student encampment that stood for more than two weeks, witnesses said.

Officers from about 10 nearby law-enforcement agencies converged on the campus after university officials requested help because protesters had occupied the lecture hall, leading the school to declare it a "violent protest," police and university officials said.

About four hours later, police had ejected the protesters from both the lecture hall and the plaza that had been the site of the encampment, according to the university and Reuters witnesses.

"The police have retaken the lecture hall," UC Irvine spokesperson Tom Vasich said by telephone from the scene. "The plaza has been cleared by law-enforcement officers."

Vasich said there were a "minimal number of arrests" and characterized the protesters as "begrudgingly cooperative."

Hours before midnight, the university said police activity had concluded on the campus and all classes would be held remotely on Thursday, asking employees not to come to campus.

The demonstration at Irvine, about 40 miles (65 km) south of Los Angeles, is the latest in a series of campus protests across the United States over the war in Gaza in which activists have called for a ceasefire and the protection of civilian lives while demanding universities divest from Israeli interests.

UC Irvine protesters had established an encampment adjacent to the lecture hall on April 29 similar to those at other universities that have led to mass arrests and clashes with police elsewhere in the country.

In a letter posted later in the day, University Chancellor Howard Gillman said: "My concern now is not the unreasonableness of their demands. It is their decision to transform a manageable situation that did not have to involve police into a situation that required a different response. I never wanted that. I devoted all of my energies to prevent this from happening."

On Wednesday 200 to 300 protesters took over the lecture hall at a time when no classes were in session, Vasich said.

Police responded in riot gear and formed a barricade while an officer on a loudspeaker warned the crowd that they had formed an unlawful assembly and risked arrest if they remained, the Orange County Register reported.

Students chanted slogans, banged drums and hoisted banners, with rows of police standing nearby, Reuters witnessed. One banner hung from the building declared the site "Alex Odeh Hall," in honor of a Palestinian activist who was killed in a 1985 office bombing in the nearby city of Santa Ana.

Four adjacent research buildings with potentially hundreds of people inside were locked down, and those inside were instructed to shelter in place, Vasich said, though the university later altered that instruction and instead advised them to leave.

Shortly before nightfall, police moved in on the lecture hall, then engaged in a tense standoff with protesters at the encampment.

Helmeted police wielding batons formed a line against protesters. Police gradually moved forward, pushing the students back every few minutes, until the officers rushed the crowd and made more arrests.

Before long most demonstrators had retreated, police held the otherwise empty plaza strewn with trash, and a few onlookers remained at the periphery.

Since the day the encampment began, Gillman said the university has been in talks with students but has been unable to reach an agreement to find an "appropriate and non-disruptive" alternative site.

Gillman has said the university cannot selectively decide not to enforce rules against the illegal encampment and that "The University of California has made it clear it will not divest from Israel."

"Encampment protesters have focused most of their demands on actions that would require the university to violate the academic freedom rights of faculty, the free speech rights of faculty and fellow students, and the civil rights of many of our Jewish students," Gillman said on Monday.

https://www.yahoo.com/news/police-called-protesters-building-university-002254176.html