Achieving prevention and health, rather than more healthcare

Rutgers is researching a new health care model that emphasizes primary care and prevention over emergency care in underserved communities

Peer-Reviewed Publication

RUTGERS UNIVERSITY

If more people have access to health insurance, we have to be sure the death rates of those with certain chronic conditions are decreasing.

This is one of the statements Gregory Peck, an acute care surgeon and associate professor at Rutgers Robert Wood Johnson Medical School, will be researching on behalf of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) at the National Institutes of Health.

Funded by NIH grants totaling more than $1 million through a recent two-year award from the New Jersey Alliance for Clinical and Translational Science (NJ ACTS), a Rutgers hub of the National Center for Advancing Translational Sciences, and now a four-year award from the NIDDK, Peck is on average one of just two critical care surgeons funded nationally annually creating new models of health for NIH consideration.

Peck recently published two studies investigating death rates for gallstone disease, a disease of the abdomen that causes right-sided belly pain after eating, which share risk factors with other deadly diseases. His study, published in Gastro Hep Advances, found that between 2009 and 2018 the number of deaths of people in New Jersey with diagnosed gallstone disease (1,580) remained steady and did not improve, and that deaths in Latinos ages 65 and older potentially increased.

His study in the Journal of Surgical Research found that after Medicaid expansion in 2014 as compared to before, the amount of emergency surgery to remove the gallbladders for gallstone disease decreased in the state overall, but increased in people with Medicaid. While fatality from gallbladder removal surgery decreased for those 65 or older, there was increased death from surgery in the younger population and a trend of more death in the population with Medicaid. Further, the relatively decreased amount of gallbladder removal surgery occurring in ambulatory outpatient care centers did not necessarily help this.

 

Peck discusses the implications of the findings on a new shift in healthcare to prevention model.

Why did you focus on gallstone disease?

As a metabolic disease, gallstone disease is also linked to heart disease, cancer, diabetes, obesity and a sedentary lifestyle. In fact, heart disease, which is the No. 1 killer in America, and gallstone disease, which is the No. 1 digestive disease requiring surgery in America, share the risk factors of high levels of bad cholesterol type and obesity.

How do these studies inform public policy?

The amount of people dying with gallstone disease – most of whom require surgery – over the past decade has not gotten better. That’s 160 people a year who still are dying from a preventable death such as gallstone disease. Making progress is what this type of epidemiologic study focuses on, and concerningly, we might not have made good progress.

If Medicaid expansion didn’t positively affect the death rate of people with gallstone disease and we see it increase specifically in older Latino populations, we need to be asking if we are helping people of color and those who live in communities with lower socioeconomic status improve health or treating them sooner to prevent emergency surgery and especially decreasing death from emergency surgery. Insurance expansion is certainly needed, but we have to ensure the action specific pieces of policy impact the population requiring surgery in a patient-centered way.

The real goal is preventing the disease from even occurring. When we pass public health policy, we need to advocate for preventive care that reaches people through their community. Right now, the findings show that we might just be providing people with insurance cards who find themselves still needing to use the emergency department. Instead, that insurance should help them visit their primary care doctor, who can help them make changes like decreasing their bad cholesterol levels, which contribute to gallstone disease, and help them access care in ambulatory surgery centers sooner.

We need to cultivate preventive healthcare rather than ballooning the investment in emergency healthcare, which does not solve current inequities.

What other steps to improve access to care should be taken?

We propose a novel population health approach that shifts from the reactive treatments of emergency disease to proactive prevention. One place to start is increasing access to appropriate outpatient elective healthcare for underrepresented groups with barriers to preventive care, such as by increasing health insurance that incentivizes the behaviors toward improved health. A first step for my research group is to focus on diseases that currently require as much emergency as elective care, such as gallstone disease, and understand this by understanding who presents to the hospital, as to dial this back into the community level, to decrease hospital care.

In addition, in primary care, laboratory, radiology or ambulatory care settings we need to improve communication with people with low English proficiency – especially how well prevention is explained in a patient’s primary language. Language barriers might also prevent them from understanding the importance of cholesterol or blood pressure control over the one, two and three decades of life, or how they find access to diagnostic tests or treatment needed earlier.

How is Rutgers working to increase primary care knowledge in underserved communities?

Shawna Hudson, the co-director of community engagement for NJ ACTS, and my research mentor, is researching how representatives rooted in the community can help healthcare providers and researchers better understand how we can use community engagement to involve people in a communities’ preventive care as to decrease risk factors for chronic disease before they need hospital-based care and, more importantly, emergency surgery.

One initiative is the Community Engagement Virtual Salons, which help researchers and health care providers at NJ ACTS engage with patients and community members about how biomedical and clinical research leads to action through understanding disease and then enacting policy. In these sessions, the public serves as experts to provide feedback from a community perspective. This allows the medical profession to build relationships with community partners and increase the culturally sensitive participation of hard-to-reach populations.

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JOURNAL

Journal of Surgical Research

DOI

10.1016/j.jss.2023.03.006 

METHOD OF RESEARCH

Data/statistical analysis

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Decreased Emergency Cholecystectomy and Case Fatality Rate, Not Explained by Expansion of Medicaid

ARTICLE PUBLICATION DATE

14-Apr-2023

COI STATEMENT

Gregory L. Peck, DO, MPH, FACS was first author in the intellectual content and writing of the manuscript to take public responsibility for it. He has reviewed the final manuscript, believe it represents valid work, and approves it for submission. He is currently supported by the NIH National Center for Advancing Translational Sciences’ (NCATS) Rutgers Clinical Translational Science KL2 Career Development Award (CTSA 5 KL2 TR003018-4). He reports no proprietary or commercial interest in any product mentioned or concept discussed in this article and has no potential conflicts of interest. Yen-Hong Kuo, PhD participated sufficiently in the intellectual content and writing of the manuscript to take public responsibility for it. He has reviewed the final manuscript, believes it represents valid work, and approves it for submission. He reports no proprietary or commercial interest in any product mentioned or concept discussed in this article and has no potential conflicts of interest. Shawna V. Hudson, PhD participated sufficiently in the intellectual content and writing of the manuscript to take public responsibility for it. She has reviewed the final manuscript, believes it represents valid work, and approves it for submission. She reports no proprietary or commercial interest in any product mentioned or concept discussed in this article and has no potential conflicts of interest. Vicente H. Gracias, MD, FACS participated sufficiently in the intellectual content and writing of the manuscript to take public responsibility for it. He has reviewed the final manuscript, believes it represents valid work, and approves it for submission. He reports no proprietary or commercial interest in any product mentioned or concept discussed in this article and has no potential conflicts of interest. Jason A. Roy, PhD participated sufficiently in the intellectual content and writing of the manuscript to take public responsibility for it. He has reviewed the final manuscript, believes it represents valid work, and approves it for submission. He reports no proprietary or commercial interest in any product mentioned or concept discussed in this article and has no potential conflicts of interest. Brian L. Strom, MD, MPH participated sufficiently in the intellectual content and writing of the manuscript to take public responsibility for it. He has reviewed the final manuscript, believes it represents valid work, and approves it for submission. He reports no proprietary or commercial interest in any product mentioned or concept discussed in this article and has no potential conflicts of interest.

Growing number of states provide coverage for outpatient hemodialysis for undocumented immigrants

AMERICAN COLLEGE OF PHYSICIANS   

NEWS RELEASE 24-APR-2023

Annals of Internal Medicine Tip Sheet @Annalsofim Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent. ---------------------------- 1. Growing number of states provide coverage for outpatient hemodialysis for undocumented immigrants Abstract: https://www.acpjournals.org/doi/10.7326/M23-0202 Editorial: https://www.acpjournals.org/doi/10.7326/M23-0838 URL goes live when the embargo lifts A brief research report has found that, due to increased advocacy and awareness of outcomes, a growing number of states have implemented policies that provide statewide coverage for undocumented persons with kidney failure to receive outpatient hemodialysis. The report is published in Annals of Internal Medicine. Currently, undocumented immigrants cannot receive federal health insurance and most state Medicaid programs. In many states, undocumented immigrants with kidney failure rely on emergency hemodialysis (dialysis only after presenting critically ill to an emergency department) as mandated by the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA), which requires hospitals to provide emergency care regardless of ability to pay. Emergency hemodialysis is associated with a 14-fold higher mortality rate at 5 years and increased psychosocial burden for patients, caregivers, and clinicians. In 2019, only 12 states and the District of Columbia provided statewide coverage of outpatient hemodialysis by including kidney failure as a qualifying condition under Emergency Medicaid. Researchers from the University of Colorado and University of California San Francisco assessed policy between March and October 2022 by 1) review of state Medicaid and Emergency Medicaid policy manuals for covered diagnosis codes “kidney failure,” “dialysis,” and “transplantation” and inclusion of undocumented immigrants and 2) brief interviews with clinicians with experience working with undocumented immigrants in every state. The authors found that as of 2022, twenty states and Washington, DC provide statewide coverage for standard outpatient hemodialysis for undocumented immigrants. Seventeen of those states provide outpatient hemodialysis through Emergency Medicaid, the remainder through Medicaid or state insurance pools. Five states also provide coverage for kidney transplantation. According to the authors, the expansion of dialysis coverage may be due to increasing awareness of poor outcomes with emergency hemodialysis and heightened advocacy efforts. An accompanying editorial by authors from Harvard Medical School highlights the significant burden of lack of access to kidney replacement therapy care faced by undocumented residents experiencing kidney failure. The authors call for a humane national solution to abandon emergency dialysis as the only option for undocumented immigrants and instead pursue a move toward covering outpatient dialysis in all 50 states. They also call on legislators and policymakers to support a pathway for non-U.S. citizens living in the United States, including undocumented immigrants, to be able to purchase affordable insurance. Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Katherine Rizzolo, MD, please email Katherine.rizzolo@cuanschutz.edu. ---------------------------- 2. A cash transfer temporarily alleviates functional impairments for older adults Abstract: https://www.acpjournals.org/doi/10.7326/M22-2496 URL goes live when the embargo lifts A randomized controlled trial of more than 1,100 people aged 55 years and older found that among older people living alone, a small cash transfer was effective in alleviating short-term functional impairment, but the effects were not sustained after 3 months. The findings are published in Annals of Internal Medicine. As many as 16 percent of older adults worldwide live alone, and the proportion is expected to grow over time. The resulting isolation is of significant policy concern, as loneliness is associated with depression, cognitive decline, and reduced well-being. Given the low number of trained therapists in developing countries and the financial constraints their governments face, delivery of cognitive behavioral therapy (CBT) over the phone could be a promising intervention to improve the well-being of older persons living alone. Similarly, cash transfers could have a direct impact on food security and could also affect mental health or day-to-day functioning. Researchers from Dartmouth College, MIT, Sangath, and IIT Madras studied 1,120 adults living alone in Tamil Nadu, India aged 55 and older to determine whether phone-based CBT or a cash transfer reduce functional impairment, depression, or food insecurity in this population. Participants received phone-based CBT, a one-time cash transfer of 1,000 rupees ($12 USD), or both. The outcomes were measured at baseline and at 2 rounds of follow-up phone surveys, 3 weeks and 3 months after the end of CBT. Overall, the small cash transfer reduced short-term (3 weeks) functional impairment and resulted in a small but not clinically or statistically significant reduction in depression in the short term. Cash had no effect on short-term food security. There were no short-term effects from CBT or the 2 interventions together. None of the interventions showed any effect at 3 months. Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Esther Duflo, please email eduflo@mit.edu. -------------------------------- 3. Hypotensive-avoidance strategies not associated with decrease in postoperative hypotension or adverse outcomes Abstract: https://www.acpjournals.org/doi/10.7326/M22-3157 Editorial: https://www.acpjournals.org/doi/10.7326/M23-0745 URL goes live when the embargo lifts A randomized trial of more than 7,000 people found that hypotension-avoidance strategies were not associated with a decrease in postoperative hypotension or adverse outcomes compared with hypertension-avoidance strategies. The findings are published in Annals of Internal Medicine. Hypotension is common during and after noncardiac surgery. It is also associated with an increased risk for death and cardiovascular complications at 30 days after noncardiac surgery. Similarly, postoperative hypertension is associated with vascular complications after noncardiac surgery. Half of adults having major noncardiac surgery have a history of hypertension, and most use antihypertension medication. Uncertainty remains about what intraoperative blood pressure to target and how to manage long-term antihypertensive medications perioperatively. Researchers from Population Health Research Institute conducted a partial factorial randomized trial of 7,490 people using two perioperative blood pressure management strategies. Patients using the hypotension-avoidance strategy did not take angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin-receptor blockers (ARBs) from the night before surgery through postoperative day 2, resuming them 3 days after surgery. Patients using the hypertension-avoidance strategy received all their usual antihypertensives preoperatively, including on the morning of surgery, and postoperatively. The authors found that fewer patients using the hypotensive-avoidance strategy experienced clinically significant hypotension compared with patients using the hypertensive-avoidance strategy. However, there was no difference between strategies related to vascular death and nonfatal myocardial injury, stroke, or cardiac arrest. According to the authors, further research is needed to identify and evaluate perioperative interventions that can modify hemodynamics to an extent and in the direction that will lead to a favorable effect on major clinical outcomes. An accompanying editorial from authors at the University of Nebraska Medical Center and Cleveland Clinic Lerner College of Medicine highlights that the decision about whether to hold selected antihypertensive medications for surgery remains a nuanced, individualized decision. They emphasize that the degree and possibly the duration of hypotension experienced by patients in this study may have been inadequate to affect the outcomes that were studied. The authors also call for future studies to examine both intraoperative and postoperative management strategies, identify other patient risk factors for poor outcomes, and ensure the clarity of surrogate versus patient-relevant clinical outcomes. Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author P.J. Devereaux, MD, PhD, please email PJ.Devereaux@phri.ca. -------------------------------- Also published in this issue: Infectious Diseases: What You May Have Missed in 2022 Rand Al Ohaly, MBBS*; Marie-Eve Benoit, MD*; and Mindy Schuster, MD, MSCE Special Article Abstract: https://www.acpjournals.org/doi/10.7326/M23-0757

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JOURNAL

Annals of Internal Medicine

DOI

10.7326/M23-0202 

METHOD OF RESEARCH

Data/statistical analysis

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Access to Kidney Care for Undocumented Immigrants Across the United States

ARTICLE PUBLICATION DATE

25-Apr-2023