Posts tagged #public health

Did you know hospitals hire "secret shoppers" to understand the patient experience of care?

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A nurse walked in with a loaded syringe. “Can you lift your gown?” she asked.

The woman on the gurney held the scratchy emergency room blanket closer to her chin. “What’s in the syringe?” she asked.

The nurse frowned. “Don’t you want the medicine your doctor ordered?”

The woman took a deep breath and kept asking questions. She had more than just self-interest on the line.

She was a “secret shopper,” a consultant pretending to be a patient in order to evaluate the quality and culture of care in a hospital.

TO learn more, check out my article at The New York Times.

Posted on August 2, 2019 .

Will New Hampshire open safe sites for people who inject drugs?

New Hampshire is still in the throes of one of the worst opioid epidemics in the country. Deaths are mounting, and mostly in young people.

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As hospitals around the nation and our fair state scale up to provide medication assisted therapy and other evidence-based ways to help, safe injection sites remain controversial.

Based on data from Vancouver's Insite program showing lower public drug use, less needle sharing, and prevention of infectious diseases like HIV, I think it's time for us to get over our hangups and act to save lives.

It was fun and illuminating to talk with Laura Knoy's and guests on NHPR's Exchange. For a stream of the hour-long show, click here

What's the best way to incentivize immunizations?

Vaccination saves lives.

Yet, resistance to immunization has become entrenched in some sociodemographic strata. Wealthy, educated liberals who care about organic food and "natural" products among them. 

Under-immunization of school-aged children in turn has led to outbreaks of measles and other transmissible infections, and contributes to  thousands of preventable influenza deaths in children each year. 

It's not enough to tout the benefits of vaccines, and then stand back with syringe in hand. Potential vaccines want to know vaccines are safe, and hear misconceptions about the low risks of vaccines. A seminal article by my Dartmouth colleague Brendan Nyhan showed that trying to disabuse vaccine skeptics of their misconception too may fail. 

Many states and countries are piloting various incentive programs designed to enhance immunization rates without engaging in potentially polarizing debate. From making immunizations mandatory to attend school to linking welfare benefits to vaccine receipt and even straight up cash incentives, lots of experiments are happening. Some of them even work.

Check out this great article by Susan Scutti of CNN and its accompanying video. I was proud to be quoted in it.

Let Opioid Users Inject in Hospitals

It is a new world in health care as America grapples with an epidemic of opioid drug abuse. The Centers for Disease Control and Prevention reported that opioid overdoses killed over 28,000 people nationwide in 2014, more than ever before.

From heart-valve infections to drug overdoses, the casualties of this epidemic wash up in our hospitals. It has changed my hospital service significantly. Almost every day, we try to save a young person dying from infectious complications of injection drug use.

Addicted patients usually bond with their providers over the shared goal of healing. Yet these interactions, which often bridge divides of class, culture and personal psychology, can break down. When addicted patients inject drugs in the hospital, doctors and nurses can find themselves cast in the role of disciplinarians, even jailers.

Confining patients to their rooms, restricting their activities and posting guards is expensive. It may also compromise a patient’s well-being: Ambivalent providers may visit less often, educate patients less avidly and spend less time devising the best treatments.

The worst effect of confining addicted patients in the hospital may be the damage to the patient-provider bond. 

To read more, including my proposal to let opioid users inject in the hospital, check out my new op-ed at The New York Times

Also, check out my new 8-minute radio spot about the topic at for Word of Mouth by Virginia Prescott at NHPR. It was also a trip to appear on Sirius XM's widely-syndicated Michael Smerconish show, although a recording has not been archived. The controversy the post created was nicely covered in Concord's Union Leader.

Vaccines just aren't as easy to discover as they used to be

Edward Jenner had it easy. Swab some cowpox in 1796, scratch the nastiness into the arm of a little kid (see below), and, PRESTO, instant immortality. 

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Vaccine success after vaccine success followed. Measles, mumps, rubella, polio... one after another global scourge quaked before the mighty pipettes of vaccine researchers.

I admit, the stalwarts who discovered those vaccines did more than transfer cow-pus to an un-consented minor research subject prior to doing a victory lap around the farm. Rather, they earned their laurels by working hard, and by being brilliant.

But ease wrought hubris, and as deadly viral menaces fell in succession, you could forgive one noted twentieth century sage, US Surgeon General William Stewart (pictured below), for saying, "It’s time to close the books on infectious diseases, declare the war against pestilence won, and shift national resources to such chronic problems as cancer and heart disease."

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Whoops!

These early triumphs gave way to a long, hard slog. Vaccines against HIV, tuberculosis, herpes, staphylococci, and hepatitis C, among others, have proven far more elusive. Amid small successes, and spectacular failures, we have discovered an uncomfortable fact: we don't really know what makes a good vaccine tick. 

This week I was glad to contribute both heat and noise to the mix. In an op-ed in the Health Affairs blog, I write about the dangers of dogmatism and the lessons learned on the road to a new HIV vaccine. And, we also published preclinical data this week on a new scalable version of our tuberculosis vaccine. Data from our Phase 1 trial of the same vaccine should come out soon!

Who knows if all this will lead to glory. Probably not! Either way, it's been a pleasure to try. 

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Posted on December 21, 2016 .

Will legislators defuse the ticking time bomb of dirty needle use?

For years, Indiana had slowly dismantled its public health system, and needle exchange programs lacked both funding and legal safeguards. Then an HIV outbreak exploded into public view, and Republican Governor Mike Pence had to do some fancy footwork to undo the damage done. He allowed needle exchange programs to operate and provided some long overdue prevention funding. In the meantime, dozens of young Indianans were infected with hepatitis C and HIV. It was a sad case of politics overturning science and common sense.

Now, New Hampshire and other states are in the same boat: politically-minded legislators bloviate about punitive anti-drug stances while the opiate epidemic rages. Complications of injection drug use are on the rise, and it's only a matter of time before a new HIV outbreak comes to town. Needle exchange programs, proven over and again to prevent infections and thus to save lives, languish in the legal shadows.

Fortunately, new legislation is being considered to change help catch New Hampshire up to the 21st Century, and maybe save some lives in the process. I was proud to be quoted here about this overdue change.

Swipe right to connect young people to HIV testing

Midway through her sophomore year of high school, my patient told her parents that she had missed two periods and was worried she might be pregnant.

Stunned to learn that she was sexually active, her parents took her to the pediatrician, who had another surprise: She wasn’t pregnant but she did have H.I.V.

To learn more - including how my patient could have been protected from late H.I.V. diagnosis by a cool mobile app - check out my new post up at The New York Times. Many thanks to support from Dartmouth Public Voices Fellowship, a chapter of the Op-ed Project.

 

Will this new diagnostic test help us prevent antibiotic misuse?

Clinicians seeing a miserable patient with the sniffles or a cough commonly face a challenging choice: give them antibiotics on the off chance they help, or educate a patient who feels gross why those antibiotics won't work. More of than not, clinicians take the easy way out and reach for the prescription pad. 

The problem of course is that this leads to millions of unnecessary antibiotic prescriptions every year. It's one major driver of epidemic antibiotic resistance, and also why the epidemiology of the antibiotic-associated infection C diff is worse than ever. 

This problem doesn't persist because clinicians are stupid or uncaring. Rather, it is their best intentions that lead them astray. Faced with a concrete potential benefit for the patient in front of them versus an abstract risk down the road, often times clinicians choose that concrete potential benefit over a hard-to-imagine intangible risk like antibiotic resistance or future C diff. Even if the risks FAR outweigh any potential benefits.

A point-of-care test that could tell both docs and patients that those symptoms are definitively from a virus could really change that whole dynamic. And, it could save us from a lot of antibiotic misuse.

A new study out today brings us closer to that reality. Researchers out of Duke found gene expression combinations that were nearly unique to viral vs bacterial vs non-infectious illnesses. To learn more, check out this new post by Eric Boodman in STATnews. I was proud to be quoted in it. See also this very thoughtful post by the ever- excellent Judy Stone at Forbes.

This is not the first test to try to tell bacterial and viral respiratory infections apart. Other similar tests have tried the same thing, and seemed promising at the outset but ultimately flamed out. Take procalcitonin testing, for instance. The reason so many tests have failed before is that the promising diagnostic data found in early studies conducted amid artificially distinct clinical populations and implausibly controlled lab circumstances looked much worse once applied to the messy real world of clinical medicine. That's the next hurdle this new technology has to surmount: to show convenient quick utility in real patients in the real world.

I have my fingers crossed that this new technology will be better!

Why we shouldn't over-hype the use of PrEP to prevent HIV transmission

Recently we got great news from a real-world study of HIV pre-exposure prophylaxis (PrEP).

Researchers at San Francisco's Kaiser Permanente Medical Center reported on the real-world experience of 657 people who started PrEP between 2012 and 2015. Over 99% were men who have sex with men, 84% reported multiple sexual partners, and 30% had HIV-positive partners. Together they were observed for over 388 person-years of PrEP use.

The big news: Exactly zero patients contracted HIV infection! That's huge.

The problem is, the popular conversation about it has been over the top. From The Washington Post to FoxNews and the Huffington Post, people have been saying it's "100% effective" and lots of other undeserved superlatives.

PrEP works, this study was great, but there is real danger in all of this over-hype.

Read more in my new post over at TheBodyPro

Posted on September 19, 2015 .