In a series of reports on emergency care in the U.S., the Institute of Medicine (IOM; Washington) has concluded that the nation’s emergency system “as a whole is overburdened, underfunded and highly fragmented,” and the IOM is calling for federal funds to correct the inadequacies it found in the system.

The studies found that while demand for emergency room (ER) services has been growing rapidly – emergency department (ED) visits growing by 26% from 1993 to 2003 – the actual number of EDs declined by 425 over the same period. The number of hospital beds declined by 198,000, which has led to a situation whereby patients are simply “boarded,” or held in the ED until the hospital can find a bed for the patient. Another finding was that children make up 27% of all ED visits, but only 6% of EDs in the U.S. have all of the supplies necessary for treating them. Therefore, most children get emergency care in ERs established for the general population.

The series of studies found that the ED system, which is in most cases operating above capacity, is “ill-prepared to handle surges from disasters such as hurricanes, bombings, or disease outbreaks.” And the committee is calling on Congress to create a “coordinated, regionalized, accountable system,” which would involved allocating $88 million over five years for a demonstration project “to encourage states to identify and test alternative strategies for achieving” that vision.

The group is asking the federal government to create a single body to be in charge of emergency services, a responsibility which is now “scattered among multiple agencies.” In addition, the committee said that the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO; Oak Brook, Illinois) should “reinstate strong standards for ED boarding and diversion.”

“Most of us need emergency services only rarely, but we assume that the system will be able to provide us rapid, skilled care when we do,” said committee chair Gail Warden, president emeritus, Henry Ford Health System (Detroit). “Unfortunately, the system’s capacity is not keeping pace with the increasing demands being placed on it. We need a comprehensive effort to shore up America’s emergency medical care resources and fix problems that can threaten the health and lives of people in the midst of a crisis.”

One of the major problems cited is that ERs are in large part responsible for treatment of most of the uninsured patients, which causes hospitals to lose money overall. To remedy this, Congress should allocate $50 million for “hospitals that provide large amounts of uncompensated emergency and trauma care.” That leads to a problem with many specialists who are critical to emergency care, such as neurosurgeons, often work uncompensated for the care they provide. That funding would also be used to cover personal protective equipment, training and planning for both emergency medical services (EMS) and hospital-based staff.

Another recommendation is that the Department of Health and Human Services should conduct a study of the research needs and gaps in emergency care, and once those gaps are determined, perhaps establish a center or institute specifically devoted to the study and improvement of emergency care.

In its key findings, the IOM said: “As a result, the regional flow of patients is poorly managed, leaving some EDs empty while others are overcrowded.” The report also noted that EMS often operate on different radio frequencies and lack common procedures for emergencies. Futhermore, the studies found that there are no nationwide standards for the training and certification of EMS personnel.

The committee found that “many drugs and medical devices have not been adequately tested on, or dosed properly for, children. It also said that while children are the most vulnerable to disasters due to their tendency to become dehydrated more quickly, that “disaster planning has largely overlooked their needs.” As a result, the committee is calling again on Congress to increase funding for the Emergency Medical Services for Children Program to $37.5 million per year for five years, which would include the study of appropriate medical technologies and devices to meet the specific needs of children.

Group blasts study as discouraging screening

A group focused on reducing the mortality from lung cancer has issued a statement attacking a recent report by the National Cancer Institute (NCI) of the National Institutes of Health (NIH; Bethesda, Maryland), saying that the report does a disservice by discouraging early screening for the disease. Laurie Fenton, president of Lung Cancer Alliance (Washington), said, “For the third time in three months, the NCI has tried to debunk the grim mortality statistics on lung cancer and ignore the critical need for earlier detection on the nation’s No. 1 cancer killer. The question that begs to be answered is ‘why?’”

Fenton was referring to an article published in the June issue of the Journal of the National Cancer Institute, claiming that lung cancer screening can lead to over-diagnosis, finding tumors that might not otherwise have been found during a person’s lifetime and wasting healthcare resources. The study also suggests that the additional testing and treatment that results may lead to substantial toxicity and even premature death.

Pamela Marcus, PhD, of the NCI, and colleagues surveyed 7,118 participants in the Mayo Lung Project for information on their lung cancer diagnosis, health and smoking history, and chest scan results after the study’s initial follow-up in July 1983. The patients in the initial project had been randomly placed in two groups, one of which underwent multiple screening chest X-rays and spectrum tests used to identify lung cancer.

The authors identified a total of 585 cancers in the patients in the screened arm and 500 cancers in the group that was not screened. They report that the 85 more cancers found in screened patients suggests that screening can lead to over-diagnosis of the disease.

The authors characterized the number of over-diagnoses with this method “modest,” but said that “the very real and deleterious role that over-diagnosis plays in mass screening can not be discounted. The newest imaging technologies can detect very small lung abnormalities, but these abnormalities may be clinically unimportant. The question remains as to whether early detection of lung cancer through mass screening results in a net benefit to the public’s health.”

Fenton, however, said that this conclusion is “exactly what was said by the opponents of mammography screening 30 years ago, yet this is even more ludicrous. First of all, the study they refer to is 40 years old and was so badly designed that it has already been repudiated by the experts years ago.”

She also said that the study focused on the use of X-ray for the screening, “not CT [computed tomography] scans which, it is widely agreed, more accurately detect lung cancer tumors. I do not know why NCI would spend badly needed funding to rehash an old, meaningless study when so much needs to be done on lung cancer.”

She noted that lung cancer continues to have a higher per-year mortality rate than the combined deaths from breast, prostate, colon, kidney, melanoma and liver cancers. “Over-diagnosis is not killing people,” she said. “Lung cancer is – about 440 people a day, one person every three minutes – and three-quarters of them were already at lethal stages when diagnosed.”

Fenton added: “Three months ago, the NCI announced that all cancer mortality was dropping, ignoring the statistics on lung cancer. Last month, NCI said that non-smoking women should feel relieved that their lung cancer mortality rate is slightly less than non-smoking men, ignoring the fact that women of the United States have the second highest lung cancer mortality rate in the world and don’t even know it. Now we have the NCI wasting more time and money on anti-lung cancer screening PR.

“Again we call on NCI to address the biggest cancer killer with a sense of urgency and commitment, and to assist those dedicated professionals who have been working so hard to make early detection a reality.”

The Lung Cancer Alliance describes itself as the only national non-profit organization solely dedicated to patient support and advocacy for people living with lung cancer and those at risk for the disease. In January, LCA issued the first-ever Report Card on Lung Cancer, an assessment of progress being made in the battle against the disease. “The majority of grades received were failing,” the organization said.

Earlier CMS pay for diabetes urged ...

Sixty million Americans, nearly one-third of the U.S. adult population, are pre-diabetic. A study published in the June issue of the journal Diabetes Care said it has found that it would be cost effective for Medicare to pay for diabetes prevention at age 50 rather than to deny prevention benefits until age 65 when many individuals will have already developed the disease.

”Diabetes is growing with the increasing rate of obesity and has reached epidemic proportions in this country,” says Ronald Ackermann, MD, assistant professor of medicine at the Indiana University School of Medicine (Indianapolis) and first author of the study.

”Prepaying benefits before the onset of diabetes might prevent millions of individuals from developing the disease and would prevent the very high future costs of treating the disease once it occurs.”

In 2002, a large clinical trial, known as the Diabetes Prevention Program, determined diet and exercise sharply reduced the chances that a person with pre-diabetes would develop diabetes. This study did not address the issue of how diet and exercise programs would be financed.

“Cost-sharing strategies to offer lifestyle interventions to help individuals between the ages of 50 and 64 keep their weight down and to develop realistic individualized exercise programs would be a win-win situation for both pre-diabetic patients and for the private and governmental funders of their health care,” said Ackermann.

Sharing the costs of efforts to help the huge number of pre-diabetics in their 50s and early 60s alter their lifestyles would not cost private insurance companies or Medicare more than they would eventually have to pay for treatment for the large number of pre-diabetics who will develop diabetes after age 65 if no preventive treatment is supported.

It is not the norm in this country for private insurance companies and the federal government to pay for preventive treatments for a chronic disease. However, the new study by Ackermann and colleagues concludes that if individuals with pre-diabetes and their employers contribute only modest co-payments for a diabetes prevention benefit, this would allow private health insurers and Medicare to cover these programs, and the economic impact, as well as the health and social implications of obesity and diabetes, would decline.

... as diabetes balloons worldwide

During the last 20 years the total number of people with diabetes worldwide has risen from 30 million to 230 million, according to the International Diabetes Federation. It reports China and India having the most diabetes sufferers in the world.

Today, out of the top 10 countries with diabetes sufferers, seven are developing countries. The Caribbean and the Middle East have regions where the percentage of adults with diabetes has reached 20%. In certain parts of Africa developing diabetes can mean a short route to death. While patients in developed countries, with access to proper treatment, can expect to live for several decades, in countries such as Mali and Mozambique developing diabetes often means a life expectancy of one or two years.

The International Diabetes Federation released its data at the 66th Scientific Sessions of the American Diabetes Association (Alexandria, Virginia).

Among other statistics released by the organization:

  • Top five countries with the most diabetes sufferers in 2003 were: India (35.5 million, China 23.8 million, U.S. 16 million, Russia 9.7 million and Japan 6.7 million.
  • The top five countries with the highest percentage of adults with diabetes in 2003 were: Nauru 30.2 %, United Arab Emirates 20.1 %, Qatar 16%, Bahrain14.9%, and Kuwait 12.8%.
  • There are 6 million new diabetes sufferers in the world each year.
  • The number of diabetes sufferers by 2025 is expected to double in Africa, the Eastern Mediterranean and Middle East, and South-East Asia; and rise by 20% in Europe, 50% in North America, 85% in South and Central America and 75% in the Western Pacific.
  • Diabetes is now the fourth-biggest cause of death worldwide.
  • Half of all diabetes sufferers around the globe do not know they have it. In some parts of the world 80% of sufferers don’t know.
  • Diabetes raises the sufferer’s risk of developing a cardiovascular disease two to four times. Cardiovascular disease, the cause of death in the industrial world, will soon be the No.1 cause of death globally.
  • Diabetes accounts for 5% to 10% of most nati-ons’ health budgets.
  • One-quarter of all the countries in the world have made no specific provision for diabetes care in their health plans.