Health for life

Prenatal folic acid supplements appear to reduce the risk for autistic spectrum disorders, according to a study published today (February 13) in the Journal of the American Medical Association (JAMA).

The Centers for Disease Control and Prevention estimate that about 1 in 88 children in the U.S. have been identified with an Autism Spectrum Disorder (ASD). ASDs are amongst the most heritable of mental disorders, but little is known about how the disorder develops. Consequently, methods for diagnosis, prevention, and treatment are limited.

Folic acid (Vitamin B9) is required for DNA synthesis and repair in the human body, and its naturally occurring form—folate—is found in leafy vegetables, peas, lentils, beans, eggs, yeast, and liver. Taking folic acid supplements during early pregnancy is known to protect against spina bifida and other neural tube defects in children. In the United States, Canada, and Chile, folic acid is added to flour, so as to automatically provide these supplements to consumers. Norway does not enrich its flour, and since 1998, the Norwegian Directorate of Health has recommended that all women planning to become pregnant take a daily supplement of folic acid from one month before the start of pregnancy through the first trimester.

Despite this policy, studies from North America and Europe have shown that many pregnant women have a lower dietary intake of folate than what is necessary to prevent neural tube defects.

The report in JAMA emerged from the Norwegian Mother and Child Cohort Study (MoBa) and its sub-study of autism, the Autism Birth Cohort (ABC) Study. This international collaboration (see list of members below) comprises the largest prospective birth cohort devoted to the investigation of gene-environment interactions and biomarker discovery for neuropsychiatric disorders.

A total of 85,176 MoBa babies—born from 2002-2008—and their parents participated in the study. Prenatal dietary habits were recorded, and families were regularly surveyed for 3-10 years to measure the development of autism spectrum disorders. A total of 270 cases of autism spectrum disorders were identified in the study population (114 autistic disorder; 56 Asperger syndrome; 100 atypical or unspecified autism; i.e., pervasive developmental disorder not otherwise specified, PDD-NOS).

Mothers who took folic acid supplements in early pregnancy had a 40% reduced risk of having children with autistic disorder compared with mothers who did not take folic acid. The reduction in risk was observed in those who took folic acid during the time interval from 4 weeks before to 8 weeks after the start of pregnancy. Autistic disorder is the most severe form of autism spectrum disorders in children. No reduction in risk was observed for PDD-NOS. For Asperger syndrome, the number of children was too low to obtain sufficient statistical power in the analyses.

The use of folic acid in early pregnancy increased substantially from 2002 to 2008 among women who participated in MoBa. In 2002, 43% of mothers took folic acid supplements; by 2008, 85% of mothers did. However, many women began taking folic acid later than recommended, and only half started before the beginning of pregnancy.

The timing of a mothers intake of folate appears to be a critical factor. Her childs risk of autism was reduced only when the supplements were taken between 4 weeks before to 8 weeks after the start of pregnancy.

"We examined the rate of autism spectrum disorders in children born to mothers who did or did not take folic acid during pregnancy. There was a dramatic reduction in the risk of autistic disorder in children born to mothers who took folic acid supplements," says Pål Surén, first author and epidemiologist at the Norwegian Institute of Public Health (NIPH).

The researchers also analyzed whether the risk of autistic disorder was influenced by the use of other dietary supplements. They did not find any association between the mothers use of fish oil supplements (cod liver oil and omega-3 fatty acids) in early pregnancy and the risk of autistic disorder, and no association for the mothers use of other vitamins and minerals.

In recent years, researchers have started to investigate whether folic acid has other beneficial effects on the development of the fetus brain and spinal cord. A study of language development from MoBa, published in 2011, showed that children whose mothers took folic acid supplements in early pregnancy had only half the risk of severe language delay at age three years compared with other children. A separate 2011 study from the University of California, Davis, demonstrated a lower risk of autism spectrum disorders in children of mothers who had used prenatal vitamin supplements during pregnancy. Prenatal vitamin supplements contain folic acid in combination with other vitamins and minerals.

Joint senior author Ezra Susser, professor of Epidemiology at Columbia Universitys Mailman School of Public Health and professor of Psychiatry at the College of Physicians and Surgeons, stated, "Our findings extend earlier work on the significance of folate in brain development and raise the possibility of an important and inexpensive public health intervention for reducing the burden of autism spectrum disorders."

"This elegant work illustrates the power of the ABC cohort for not only chipping away at the riddle of what causes autism, but for developing new methods for early recognition, prevention and treatment," says W. Ian Lipkin, John Snow Professor of Epidemiology at the Mailman School of Public Health and principal investigator of the ABC cohort.

It thought the fundamental purpose of teachers was to teach. Yet, when it considers that the hours that a child spends in school is an opportunity to catch problems that may be missed by parents and docs alike, the idea that schools can be a first line of defense in the early detection of mental illness has some merit.

 For your consideration when youre grappling with your local school taxes:

Tim is the son of Paul Gionfriddo, who is a former Connecticut politician and current mental health advocate.  As the parent of a child with schizophrenia, he knows what hes writing about.

When Mr. Gionfriddo was starting out as a legislator, he was only just becoming aware of Tims difficulties in school. What followed was heartbreaking tale of inflexible school officials arranging for the wrong evaluations, wrong diagnoses, inadequate care and wasted attempts to help a deeply troubled child. Teachers were unable to cope, the parents were often blamed and Tim got shuffled around an unresponsive school system.  Despite "good" insurance, coverage fell short and many services involved onerous co-pays and limitations. And once he reached adulthood, an unwillingness to accept services moved Tim to the margins of society, leading to repeated hospitalizations and incarcerations. He now lives in squalor somewhere in San Francisco.

Tims story is not unique. According to Mr. Gionfriddo, a well meaning policy that moved hundreds of thousands of mentally ill out of decaying inpatient psychiatric hospitals in the 1980s was followed by

1) schools being unable to handle children with mental illness,

2) underfunding of community agencies, and

3) the siloing of the resources that did exist, resulting in little collaboration among physicians, law enforcement, community services or the mental health community.

Among Mr. Gionfriddos recommendations?  In addition to better screening by pediatricians during the well child visit, insurance orm and better housing options, state legislators should support the following:
 
1. The U.S. public school system should be prepared to offer mental health services in addition to basic education;

2. Every teacher should receive training in recognizing mental illness and how to handle it;

4. Once mental illness is  discovered, meaningful support should be included in a childs individualized education planning.

Image from Wikipedia

Chest pain is not a frequent early warning symptom of a heart attack in women.

But what is?

In a study funded by the NIH that appeared in the journal Circulation in 2003,¹ the most frequent early warning symptom of heart attack in women was unusual fatigue ... not a tiredness that you might link to overwork or stress, but a fatigue so severe some women gave the example of not being able to make a bed without resting.

Most Women Have Early Warning Symptoms

Of the 515 women studied, 95% of them reported experiencing symptoms a month or more before a heart attack.

The most frequent symptoms reported were:

• unusual fatigue (70.7% of women experienced)
  
• sleep disturbances (47.8%)
  
• shortness of breath (42.1%)
  
• indigestion (39.4%)
  
• anxiousness (35.5%)

The minority of women who did report chest discomfort in the weeks leading up to a heart attack "used descriptors such as aching, tightness, or pressure, not pain" to explain it.

Even during a heart attack, 43% of women in this study "did not experience any type of chest discomfort."

The lead author of the study, Jean C. McSweeney, PhD:²

"McSweeney said her best advice is for women who have risk factors for heart disease such as smoking, high blood pressure, high cholesterol, diabetes or a family history of heart disease and who are experiencing [early warning] symptoms should contact their doctor before seeking emergency treatment."

________
¹ For the study (full free access):
Women’s Early Warning Symptoms of Acute Myocardial Infarction

² For a summary, provided by Yale-New Haven Health:
Signs Of Impending Heart Attacks Among Women

According to the White House, the health insurance exchange glitches are a symptom of high demand from a grateful citizenry eager to embrace Obamacare. While articles like this and this suggest that sloppy and amateurish programming is really behind the website crashes, the Disease Management Care Blog is concerned that early high demand - if it exists - could be an early sign of a coming insurance death spiral.

"Death spirals" occur when persons with high levels of risk disproportionately enter an insured population.  When that happens, premiums have to rise to match the increased expenses. That, in turn, causes persons with lower risk to drop their insurance, leading to an even higher proportion of high risk individuals, who drive prices even higher.

The DMCB intuitively doubts that the early high demand described by the White House is the result of healthy latte-sipping millenials and young invincibles having nothing better to do with their web-surfing time.  Rather, the persons most likely to be in a rush to get into the web site are persons who really need insurance.  Those would be the ones facing huge health care bills.
 
Another indication is the relative lack of the standard individual anecdote or "ledes" in media reports that hook the reader into paying attention.  Used by politicians and journalists alike, ledes put a "human face" on a narrative by bridging the personal and the policy.   

Supporters of exchanges would probably like to see something ledes along the lines of...

For years, 25 year old Ivanna Ceeadoc could only lurk outside the local health clinic and watch helplessly as her friends from the coffee shop down the street got free health communications from the nurse practitioners within.  But after using the health insurance exchange....

or

Until he signed up in the health insurance exchange, part-time jazz drummer and retail specialist Hank Erinfersumburgers never had to see a health care provider. Previously unaware of a bleak future of fast food and tight clothes, Hanks zero dollar co-pay now lets him see a dietician and have enough money left over for a lunch......

Young Ivanna and Hank havent made an appearance in the national health insurance exchange narrative because they probably arent part of the story.  More likely, its persons in their 50s and early 60s who have been hold they need a joint replacement, an angioplasty or back surgery....

 Ima Medeesazter was looking at a stack of medical bills a mile high.  Her surgeons plans included weeks in a hospital costing her hundreds of thousands of dollars. Ima put things off, but now that she used the exchange, she can look forward to getting to know her ICU nurses really well.......

Even more worrisome: this astonishing statement by HHS Administrator Kathleen Sebelius that she "doesnt know" how many have enrolled in health insurance since the October 1 opening date.  If the experts running the shop are unaware the Insurance 101 principle of knowing who and why persons are signing up for health insurance, they have no idea about the spiral threat.

Image from Wikipedia

Im baaaaack!

When persons are admitted to a hospital, insurers payment rates are based on the diagnosis, not the number of days in the hospital (known as a "length of stay").  As a result, once the admission is triggered, the hospital has important economic incentive to discharge the patient as quickly as possible.  The Disease Management Care Blogs physician colleagues used to refer to this as "treat, then street."

Unfortunately, discharging patients too soon can result in readmissions.  Thats why the DMCB has agreed with others that diagnosis-based payment systems and a policy of "no pay" for readmissions were working at cross purposes.  Unified bundled payment approaches like this seem to be a good start.

But thats all theoretical.  Whats the science have to say?

Peter Kaboli and colleagues looked at the push-pull relationship between diagnosis-based payment incentives  and the likelihood of readmissions in a scientific paper just published in the Annals of Internal Medicine. 

The authors used the U.S. Veterans Administration (VA) Hospitals "Patient Treatment Files" to examine length of stay versus readmissions in 129 VA hospitals.  The sample consisted of over 4 million admissions and readmissions (defined as within 30 days and not involving another institution) from 1997 to 2010. The mean age started out at 63.8 years and increased to 65.5 years, while the proportion of persons aged 85 years or older increased from 2.5% to 8.8%. Over the years, admissions also grew more complicated with a higher rate of co-morbid conditions, such as diseases of the kidney (from 5% to 16%).

As length of stay went down, readmissions should have gone up, right?

The answer was yes and no.

Yes, if the data were trended over time: Over the 14 year period of observation, the number of days in the hospital (length of stay or LOS) decreased from 6.0 days to 4.3 days.  Yet, as LOS decreased, readmissions also decreased from 16.6% to 15.2%. 

The decreases held up when the LOS was risk-adjusted for hospital and patient characteristics.  There was also no increase in mortality rates

No, if hospitals were compared to each other:  Hospitals with risk-adjusted low lengths of stay had higher readmission rates compared to their average peers.  In that group, each day of saved LOS was associated with a 6% increased rate of 30-day readmissions.

It gets even more complicated.  As the LOS increased beyond the average, each additional day in the hospital was associated with a 3% increased rate of 30-day readmissions.

What should the DMCB learn from these data?  Keeping in mind that the VA is not necessarily generalizable to the typical community medical center,

1. Over 14 years of worth of VA data for 129 hospitals suggest it is possible to have your cake (a lower LOS) and eat it too (lower readmissions).  Thats the good news.

2. While overall performance improved over the years, between hospital comparisons showed there is a "U" shaped relationship between days in the hospital and the likelihood of readmission.  The DMCB agrees with the authors: premature discharge before the patient is ready is associated with an 6% per day readmission rate, while patients who are very sick and have to stay a few extra days in the hospital are also at risk to the tune of 3% per day.  Thats the sobering news.

What are the implications?

Overzealous efforts to discharge patients can backfire with readmissions.  It appears theres an optimum length of stay that minimizes, but will never eliminate, readmissions.

Patients who do go home "too soon" or need extra days in the hospital appear to be at special risk.  Accountable care organizations and population health management service providers should use this information to target patients at special risk of "treat, street and... repeat."