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Spending Dips On Health Care For The Medicare Elderly

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Health care spending among the Medicare population age 65 and older has slowed dramatically since 2005, and as much as half of that reduction can be attributed to reduced spending on cardiovascular disease, a new Harvard study says.

Led by David Cutler, the Otto Eckstein Professor of Applied Economics, a team of researchers found that by 2012 those reductions saved the average person nearly $3,000 a year. Across the entire elderly population, those savings add up to a whopping $120 billion, with about half of those savings coming from Medicare. The study is described in a Feb. 4 paper published in Health Affairs.

“This is the first time, to my knowledge, anyone has shown that some forms of medical care can save money,” Cutler said.

“You see that claim all the time. But in terms of widespread preventive care saving money … we’ve never had that example before.”

And though it can make intuitive sense that if you prevent people from falling ill, they’ll spend less on health care, the view among many economists was the opposite.

“The received wisdom has been that prevention doesn’t save money, it only saves lives,” Cutler said.

“Of course that’s something we want to do. But the argument was that you shouldn’t expect your prevention to save you money.”

Part of the reason why, he said, can be boiled down to simple numbers. Prevention programs must include huge numbers of people to be effective, making them expensive, and there is no guarantee they will work. As an example, Cutler pointed to smoking cessation.

“If you stop smoking and then you don’t have a heart attack, you save the money you’d spend on treating the heart attack,” he said.

“But the argument has been that, because very few people will manage to stop smoking, you have to intervene with a lot of people, so the number you need to treat is large. And then the second reason is that maybe you don’t die of a heart attack, but you’re going to die of something, and that will still be expensive … so it’s largely a wash.”

Cutler’s study upends those arguments, saying that even relatively modest investments in preventive care can produce significant savings.

“When we looked at the trend in per-capita spending by the elderly, in 2005 is where we began to see the increases slowing,” Cutler said.

“And a large part of that is due to cardiovascular health, because what used to disable people were heart disease and strokes, and those have declined immensely … so about half of the decline we saw was related to cardiovascular issues.”

By 2012, Cutler said, the slowdown in health care spending was beginning to add up.

“It was almost $2,900 a year, per person — that’s a lot of money,” he said.

“Toward the end of Obama’s first term, you may recall that there was a great deal of talk about debt reduction. But when a deal didn’t get made, the issue just faded away. One reason why is because Medicare costs came in less rapidly than we thought … and this study shows one reason why.”

Deciphering what was behind the slowdown in health care spending was not easy.

“There were three main technical challenges in this paper,” Cutler said.

“The hardest one, where we spent the most time, was in trying to de-compose the spending by disease. That turns out to be very difficult because if someone goes to the doctor for a cardiovascular condition, but they also have a history of mental illness, how do you separate the spending on those items?”

The solution, Cutler said, came when he and colleagues compared a random sample of billing records of people with similar diagnoses.

“We did an analysis of everyone who has X, we compared them to people who look just like them, but they don’t have X,” Cutler said.

“And then we can ask how much more did people with X spend?”

The next challenge, Cutler said, came in teasing apart how much of the spending slowdown was due to fewer cases of cardiovascular disease and how much to each case simply costing less. What researchers found was that there were both fewer first-time illnesses and fewer cases where a patient had a problem, like a heart attack, and later experienced additional problems.

Finally, Cutler said, the team faced the challenge of gauging the impact of medications on spending. To do that, he said, they created a combined measure of how various drugs lower the risk for cardiovascular disease. When the team compared the predicted drop in disease to the actual drop, it found about half of the dip could be attributed to medications.

While the study found that significant cost savings came from improvements in cardiovascular health, Cutler said there is still room for improvement.

“Even now, only half the people with high cholesterol have their cholesterol brought down to guideline levels,” he said.

“And it’s the same for people with high blood pressure, so there’s still a way to go.”

Going forward, Cutler hopes to expand the study to include the near-elderly, in an effort to understand how earlier intervention can reduce health care spending.

“There’s no reason to think this would be limited to the elderly,” he said.

“And in fact, getting people who are 58 now to take medications could save Medicare a lot of money because they will be healthier when they enter that population.”

Ultimately, Cutler said, the study provides important evidence that preventive care not only can help people live healthier lives for longer, but also can have a positive impact on their pocketbooks.

“For the first time, we can see savings from it, which is very gratifying, because very often when you think about saving money in medical care, it brings up unpleasant topics, like who should be rationed from chemotherapy or which services are not necessary,” he said.

“We’ve always known in principle that if people are healthy, you wouldn’t need to spend money on them … but no one ever had a way to show it. That’s what makes me particularly excited about this.”

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Children Carry Evidence Of Toxins From Home Flooring And Furniture

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Children living in homes with all vinyl flooring or flame-retardant chemicals in the sofa have significantly higher concentrations of potentially harmful semi-volatile organic compounds (SVOCs) in their blood or urine than children from homes where these materials are not present, according to a new Duke University-led study.

The researchers presented their findings Sunday, Feb. 17 at the annual meeting of the American Association for the Advancement of Science in Washington, D.C.

They found that children living in homes where the sofa in the main living area contained flame-retardant polybrominated diphenyl ethers (PBDEs) in its foam had a six-fold higher concentration of PBDEs in their blood serum.

Exposure to PBDEs has been linked in laboratory tests to neurodevelopmental delays, obesity, endocrine and thyroid disruption, cancer and other diseases.

Children from homes that had vinyl flooring in all areas were found to have concentrations of benzyl butyl phthalate metabolite in their urine that were 15 times higher than those in children living with no vinyl flooring.

Benzyl butyl phthalate has been linked to respiratory disorders, skin irritations, multiple myeolma and reproductive disorders.

“SVOCs are widely used in electronics, furniture and building materials and can be detected in nearly all indoor environments,” said Heather Stapleton, an environmental chemist at Duke’s Nicholas School of the Environment, who led the research.

“Human exposure to them is widespread, particularly for young children who spend most of their time indoors and have greater exposure to chemicals found in household dust.”

“Nonetheless, there has been little research on the relative contribution of specific products and materials to children’s overall exposure to SVOCs,” she noted.

To address that gap, in 2014 Stapleton and colleagues from Duke, the Centers for Disease Control & Prevention, and Boston University began a three-year study of in-home exposures to SVOCs among 203 children from 190 families.

“Our primary goal was to investigate links between specific products and children’s exposures, and to determine how the exposure happened — was it through breathing, skin contact or inadvertent dust inhalation,” Stapleton said.

To that end, the team analyzed samples of indoor air, indoor dust and foam collected from furniture in each of the children’s homes, along with a handwipe sample, urine and blood from each child.

“We quantified 44 biomarkers of exposure to phthalates, organophosphate esters, brominated flame retardants, parabens, phenols, antibacterial agents and perfluoroalkyl and polyfluoroalkyl substances (PFAS),” Stapleton said.

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Your Home Is A Hidden Source Of Air Pollution

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Cooking, cleaning and other routine household activities generate significant levels of volatile and particulate chemicals inside the average home, leading to indoor air quality levels on par with a polluted major city, University of Colorado Boulder researchers have found.

What’s more, airborne chemicals that originate inside a house don’t stay there: Volatile organic compounds (VOCs) from products such as shampoo, perfume and cleaning solutions eventually escape outside and contribute to ozone and fine particle formation, making up an even greater source of global atmospheric air pollution than cars and trucks do.

The previously underexplored relationship between households and air quality drew focus today at the 2019 AAAS Annual Meeting in Washington, D.C., where researchers from CU Boulder’s Cooperative Institute for Research in Environmental Sciences (CIRES) and the university’s Department of Mechanical Engineering presented their recent findings during a panel discussion.

“Homes have never been considered an important source of outdoor air pollution and the moment is right to start exploring that,” said Marina Vance, an assistant professor of mechanical engineering at CU Boulder.

“We wanted to know: How do basic activities like cooking and cleaning change the chemistry of a house?”

In 2018, Vance co-led the collaborative HOMEChem field campaign, which used advanced sensors and cameras to monitor the indoor air quality of a 1,200-square-foot manufactured home on the University of Texas Austin campus. Over the course of a month, Vance and her colleagues conducted a variety of daily household activities, including cooking a full Thanksgiving dinner in the middle of the Texas summer.

While the HOMEChem experiment’s results are still pending, Vance said that it’s apparent that homes need to be well ventilated while cooking and cleaning, because even basic tasks like boiling water over a stovetop flame can contribute to high levels of gaseous air pollutants and suspended particulates, with negative health impacts.

To her team’s surprise, the measured indoor concentrations were high enough that that their sensitive instruments needed to be recalibrated almost immediately.

“Even the simple act of making toast raised particle levels far higher than expected,” Vance said.

“We had to go adjust many of the instruments.”

Indoor and outdoor experts are collaborating to paint a more complete picture of air quality, said Joost de Gouw, a CIRES Visiting Professor. Last year, de Gouw and his colleagues published results in the journal Science showing that regulations on automobiles had pushed transportation-derived emissions down in recent decades while the relative importance of household chemical pollutants had only gone up.

“Many traditional sources like fossil fuel-burning vehicles have become much cleaner than they used to be,” said de Gouw.

“Ozone and fine particulates are monitored by the EPA, but data for airborne toxins like formaldehyde and benzene and compounds like alcohols and ketones that originate from the home are very sparse.”

While de Gouw says that it is too early on in the research to make recommendations on policy or consumer behavior, he said that it’s encouraging that the scientific community is now thinking about the “esosphere,” derived from the Greek word ‘eso,’ which translates to ‘inner.’

“There was originally skepticism about whether or not these products actually contributed to air pollution in a meaningful way, but no longer,” de Gouw said.

“Moving forward, we need to re-focus research efforts on these sources and give them the same attention we have given to fossil fuels. The picture that we have in our heads about the atmosphere should now include a house.”

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Diet Drinks May Be Associated With Strokes Among Post-Menopausal Women

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Among post-menopausal women, drinking multiple diet drinks daily was associated with an increase in the risk of having a stroke caused by a blocked artery, especially small arteries, according to research published in Stroke, a journal of the American Heart Association.

This is one of the first studies to look at the association between drinking artificially sweetened beverages and the risk of specific types of stroke in a large, racially diverse group of post-menopausal women. While this study identifies an association between diet drinks and stroke, it does not prove cause and effect because it was an observational study based on self-reported information about diet drink consumption.

Compared with women who consumed diet drinks less than once a week or not at all, women who consumed two or more artificially sweetened beverages per day were:

  • 23 percent more likely to have a stroke;
  • 31 percent more likely to have a clot-caused (ischemic) stroke;
  • 29 percent more likely to develop heart disease (fatal or non-fatal heart attack); and
  • 16 percent more likely to die from any cause.

Researchers found risks were higher for certain women. Heavy intake of diet drinks, defined as two or more times daily, more than doubled stroke risk in:

  • women without previous heart disease or diabetes, who were 2.44 times as likely to have a common type of stroke caused by blockage of one of the very small arteries within the brain;
  • obese women without previous heart disease or diabetes, who were 2.03 times as likely to have a clot-caused stroke; and
  • African-American women without previous heart disease or diabetes, who were 3.93 times as likely to have a clot-caused stroke.

“Many well-meaning people, especially those who are overweight or obese, drink low-calorie sweetened drinks to cut calories in their diet. Our research and other observational studies have shown that artificially sweetened beverages may not be harmless and high consumption is associated with a higher risk of stroke and heart disease,” said Yasmin Mossavar-Rahmani, Ph.D., lead author of the study and associate professor of clinical epidemiology and population health at the Albert Einstein College of Medicine in the Bronx, New York.

Researchers analyzed data on 81,714 postmenopausal women (age 50-79 years at the start) participating in the Women’s Health Initiative study that tracked health outcomes for an average of 11.9 years after they enrolled between 1993 and 1998. At their three-year evaluation, the women reported how often in the previous three months they had consumed diet drinks such as low calorie, artificially sweetened colas, sodas and fruit drinks. The data collected did not include information about the specific artificial sweetener the drinks contained.

The results were obtained after adjusting for various stroke risk factors such as age, high blood pressure, and smoking. These results in postmenopausal women may not be generalizable to men or younger women. The study is also limited by having only the women’s self-report of diet drink intake.

“We don’t know specifically what types of artificially sweetened beverages they were consuming, so we don’t know which artificial sweeteners may be harmful and which may be harmless,” Mossavar-Rahmani said.

The American Heart Association recently published a science advisory that found there was inadequate scientific research to conclude that low-calorie sweetened beverages do – or do not – alter risk factors for heart disease and stroke in young children, teens or adults. The Association recognizes diet drinks may help replace high calorie, sugary beverages, but recommends water (plain, carbonated and unsweetened flavored) as the best choice for a no calorie drink.

“Unfortunately, current research simply does not provide enough evidence to distinguish between the effects of different low-calorie sweeteners on heart and brain health. This study adds to the evidence that limiting use of diet beverages is the most prudent thing to do for your health,” said Rachel K. Johnson, Ph.D., R.D., professor of nutrition emeritus, University of Vermont and the chair of the writing group for the American Heart Association’s science advisory, Low-Calorie Sweetened Beverages and Cardiometabolic Health.

“The American Heart Association suggests water as the best choice for a no-calorie beverage. However, for some adults, diet drinks with low calorie sweeteners may be helpful as they transition to adopting water as their primary drink. Since long-term clinical trial data are not available on the effects of low-calorie sweetened drinks and cardiovascular health, given their lack of nutritional value, it may be prudent to limit their prolonged use” said Johnson.

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