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2012: Moments to Note in a Year in Health

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In 2012, healthcare saw dramatic changes on major fronts: advances in patient care, important scientific discoveries, and -- perhaps most dramatically -- in policy. Among the many studies published, there was research challenging conventional wisdom on: nutrition; the causes of the world’s most serious health problems; and how to treat hot flashes.

What science didn’t challenge, new laws taking effect ultimately will, prompting changes for healthcare providers and consumers alike -- and, we all hope, resulting in care that is more effective, more affordable and more available than ever before.

Let’s take a selective glimpse at some of 2012’s key health stories:

Upheld: the Affordable Care Act. You could say that the Affordable Care Act — which mandates healthcare coverage and should result in health insurance coverage for about 30 million more Americans — faced two tough challenges in 2012. First, it survived Supreme Court scrutiny, with the high court ruling 5-4 that the law is constitutional.

Second, it survived the presidential election, with GOP challenger Mitt Romney making a promise to repeal the law a centerpiece of his failed bid to oust President Barack Obama. The law, set to be in full effect in 2014, also will eliminate lifetime limitations and exclusion policies, provides cost-effective prescription plans for seniors, allows children to remain on their parents’ plans until age 26 and requires insurance companies to provide certain preventative health measures at no additional cost.

Center stage: end-of-life care. Surveys show that 86 percent of us would rather spend our last days at home — not in a hospital or nursing home. Yet, 80 percent of Americans die in these kinds of institutions. Part of that is due, as I’ve written before, to our delay in making end-of-life plans and making our wishes known to our doctors and family.

Death may be an unpleasant topic to ponder, but we must do so to for our own sake and for our families — and as we try to make the best choices for our strapped healthcare system. A third of all our healthcare resources are spent in the last year of life, with a large chunk going to futile treatments. Too many patients with advanced cancer undergo chemotherapy to no benefit in the last year of life. Too many with terminal disease die in the intensive care unit. Too few receive palliative care or hospice services that would provide the sustained, quality-of-life treatment people say they want in their last days.

While more than 80 percent of Californians surveyed say it’s important that they put their end-of-life wishes in writing, fewer than a quarter complete an advance directive, according to a 2012 California Healthcare Foundation survey. Nationally, only a third of people fill out such directives. Click here to start yours. A Physician Orders for Life-Sustaining Treatment is another step that patients — before they become seriously ill — may wish to discuss and fill out with their physicians to make their healthcare wishes known in advance. When the POLST is filled out, studies show, treatment is consistent with the patients’ wishes more than 90 percent of the time for resuscitation, medical interventions and antibiotics.

Gaining ground: evidence-based medicine. Throughout 2012, physician professional societies and government task forces took a hard look at the evidence and found excessive testing occurring without benefit to patients. Eliminating this kind of waste will take on increasing importance as healthcare providers seek to offer care that is less costly and provides better results. There has been a marked shift in attitudes toward testing, treating and over-diagnosis.

Last spring, a coalition of nine physician specialty societies, working with the ABIM Foundation and its “Choosing Wisely” campaign, identified 45 tests or procedures that are common but often unnecessary. The campaign provides specific, evidence-based recommendations to guide patients and physicians to make the most appropriate care choices based on the individual’s situation.

Eliminating costly, unnecessary tests should not only result in savings but also should reduce patients’ stress, time and exposure to unnecessary risk. For example, a survey of nearly 1,200 healthy Consumer Reports readers found that 44 percent had received screening tests for heart disease that were rated unlikely or very unlikely to have benefits that outweigh the risks. As part of “Choosing Wisely,” the American College of Cardiology recommends that patients and physicians question the necessity of stress-imaging tests for annual checkups. For otherwise healthy adults without cardiac symptoms, these tests rarely provide results that lead to meaningful changes in their care.

In May, the U.S. Preventive Services Task Force recommended that doctors stop using the PSA test to screen healthy men for prostate cancer, concluding that many men are harmed as a result of the screening and few benefit.

Epidemic spread: obesity as global health woe. Epidemic levels of obesity and diabetes posed major health concerns, with two-thirds of Americans considered overweight or obese and roughly 25 million Americans diagnosed with Type 2 diabetes — increasing their heart disease risk by up to 2½ times. Obesity isn’t just an American malaise. A study just published in The Lancet indicates obesity now is a more serious world health crisis than hunger. Every country outside of sub-Saharan Africa faces alarming obesity rates — an increase of 82 percent globally in the past two decades. For the first time, non-communicable diseases like diabetes, stroke and heart disease topped the list of leading causes of years spent sick or injured.

As to understanding why, part of it is our sedentary lifestyle. A 2012 study showed that sitting still for three hours a day can shave two years off your life. The truth is, while the basic equation of weight loss is to burn more calories than consumed, that doesn’t add up to easy answers. Obesity’s causes are complex and treatments few. A large federal study of whether diet and weight loss can prevent heart attacks and strokes in the overweight and obese with Type 2 diabetes ended two years ahead of schedule because the intensive program wasn’t helping.

Small steps, as I’ve written, are starting to make a big difference. New York City banned sale of large sodas and other sugary drinks at restaurants, street carts and movie theaters — the first restriction of its kind in the country. New York set a previous trend that led calorie-peddling giants like McDonalds to ban trans-fats; a 2008 NYC rule forced chain restaurants to post calorie counts — a great practice that California has picked up.

Re-examined: nutrition’s conventional wisdom. When you compare apples to organic apples, nutritionally you will find they are the same — though you might find fewer pesticides on the organic fruit, a Stanford study published this year found. The meta-analysis of 237 earlier studies found that, while organic foods have lower levels of pesticides, conventionally grown foods contain levels that fall at or below federal safety standards. There were no significant differences in the vitamin content in produce. Researchers found no significant difference in fat or protein content in dairy foods, though organic milk boasted higher levels of those coveted, healthy Omega-3 fatty acids. So, as I have noted, consumers on tight budgets may want to think hard about the cost-benefits in their personal situation and whether foods labeled as organics are such a health must.

Studies also showed us this year that, perhaps, we shouldn’t count on all those vitamins and supplements and we’d be better off getting them the old-fashioned way: from foods we eat. A study in the June issue of the medical journal Heart found, for example, that regular users of calcium supplements had an 86 percent increased heart attack risk compared to those who didn’t use supplements. Meanwhile, there was a 30 percent reduction in risk among adults with a moderately high intake of calcium from food itself. While it’s not proven why, researchers think it might be because supplements can cause quick spikes in blood calcium levels, while calcium from food is absorbed more slowly.

Maybe that’s why they say an “apple a day can keep the doctor away,” and not a multivitamin supplement a day ...

Re-evaluated: women and HRT. The benefits of hormone-replacement therapy outweigh the risks for women who begin near menopause, a re-evaluation of the Women’s Health Initiative data concludes. Climacteric, the journal of the International Menopause Society, ran a series of articles in its June issue that corrected the widespread notion left by the women’s initiative a decade ago. After that study suggested women taking estrogen and progestin replacement had higher rates of heart disease, stroke and breast cancer than those on placebo, millions of women and their doctors were frightened away from hormone-replacement therapy. Now experts agree that, while hormone replacement therapy may not be right for every woman, it does have significant benefits and the initial warnings from the women’s initiative were over-generalized.

Reappraisals have suggested that women who start hormone replacement therapy around the time of menopause have a lower risk of heart disease and overall mortality than those who start hormone therapy after age 60. The studies also found that across the board, hormone replacement therapy patients have a lower risk of colorectal cancer and bone fractures. Also, the women’s initiative greatly underestimated the benefits of the therapy to a woman’s quality of life.

New role: for me. In 2013, healthcare can expect to continue to undergo rapid and drastic change. I’ll be making a few changes myself. After 26 years as chair of the Department of Medicine at Cedars-Sinai, I will focus my full attention on my new role as vice president for Clinical Innovation. This means I’ll get to spend even more time grappling with many of the issues that shaped the year’s biggest stories, and helping our patients and our institution rise to the challenges they present. I look forward to sharing what we learn with you in 2013. Hope you enjoy a happy and healthy new year!