News & Analysis
speed with which patients are treated. A recent Michigan study found that even once stroke patients had arrived at the hospital and their brains had been imaged, there were delays before they received tPA (Sauser K et al. JAMA Neurol. 2014; 71[9]:1155-1161). A recent study in Germany, which also has a low rate of tPA use, found that specially equipped ambulances could administer tPA en route to the hospital without an increase in adverse events (Ebinger M et al. JAMA. 2014;311[16]:16221631). Compounding the problem of delayed treatment is the fact that 20% of strokes occur on awakening, although they might have started during sleep, making it tricky to determine whether the window of opportunity for treatment with tPA is still open, Sacco said. For that reason, he said, onset of such strokes is considered to be
either when the person went to bed or the last time they were well, both likely to be outside the 4.5-hour window of opportunity for tPA. Ovbiagele echoed Sacco. Even with the designated stroke centers, “we’ve barely moved the needle at all” when it comes to treating patients with tPA, he said. “There are so many things we can’t do about it.” Many patients simply don’t realize that they’ve had a stroke, Ovbiagele said, noting that while stroke can cause confusion, it doesn’t typically cause pain like a heart attack. Much can be done to prevent stroke, however, he said. On October 28, the AHA/ASA published updated guidelines for primary prevention of stroke, which were endorsed by neurology and neurosurgery professional groups as well as an association of cardiovascular nurses
(Meschia JF et al. Stroke. doi:10.1161/STR .0000000000000046 [published online October 28, 2014]). The authors of the guidelines cite an international case-control study of 6000 individuals that found that 10 potentially modifiable risk factors explained 90% of the risk of stroke (O’Donnell et al. Lancet. 2010; 376[9735]:112-123). Well-documented modifiable risk factors include hypertension, diabetes, atrial fibrillation, physical inactivity, obesity, excessive salt intake, and high alcohol consumption, the authors write. “Many times, we think of stroke from the standpoint of the devastating consequences that are personal and familial,” said Ovbiagele, who wasn’t involved in updating the prevention guidelines. But in addition, the costs from a societal standpoint “are huge,” he said. “It really beholds us to optimize prevention,” he said.
The JAMA Forum
Health Care and Poverty Joshua M. Sharfstein, MD
2200
performing educational system. From this perspective, it’s possible to see interventions in health care settings as “too little, too late” in addressing underlying inequity. But the discussion challenged both of these shades of skepticism. Edin, who has spent years interviewing individuals and families in extreme poverty, noted the breakdown of many community institutions that existed to provide information and help to families in need of resources. “If you look at the poorest of the American poor…only half of this group gets anything from [food stamps]. It’s really stunning,” Edin said. “Only a tiny portion gets a housing subsidy. But most everybody has some sort of health care, either for their children or for themselves. So if you want an institutional point of connection for these families, it is the health care industry.…It’s such a marvelous point of contact.” She noted that families may never learn about opportunities for assistance with food or energy bills outside of a medical setting. Onie spoke about the college students’ passion for helping connect low-
Joshua M. Sharfstein, MD
income families to resources. Health Leads tracks the thousands of times that students have identified eligibility for assistance and then assured that patients receive it. The students then teach the medical students, residents, and physicians in the clinic about the social needs of their patients, leading them to refer families for assistance back to the students in the future. Onie said she frequently heard
JAMA December 3, 2014 Volume 312, Number 21
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a CAMBRIDGE UNIVERSITY LIBRARY User on 08/10/2015
jama.com
Maximilian Franz/The Daily Record
I
recently had the opportunity to moderate a fascinating discussion at the Johns Hopkins Bloomberg School of Public Health on the role of the health care system in addressing poverty. One of the 2 speakers was Kathryn Edin, PhD, a sociologist who has written extensively about the lives of the poor in the United States. The other was Rebecca Onie, JD, a MacArthur Fellow who began a national effort called Health Leads, which brings teams of college students to medical clinics to connect patients with social services and resources. Should there be an expectation for health care institutions to take on entrenched social inequality? It’s a fair question. Some would point out that just getting health care right is hard enough, and good health care alone helps people and families to remain productive and stay out of poverty. Others would note that in recent years, an overdue focus on the social determinants of health has led to a greater focus on “upstream” contributors to poor health, such as substandard housing, few employment opportunities, and an under-
News & Analysis
and food insecurity are associated with obesity because of the reliance on cheap sources of calories. Patients, too, have sensed the difference in clinics that ask about their social needs. “Our patients now come in expecting to be able to talk to their physician about whether or not they have food at home,” one doctor told Onie. “That’s pretty powerful,” Onie remarked. “It’s a really profound shift in Some would point out that just getting boththepatient’s health care right is hard enough, and understanding of what health good health care alone helps people and care can be and families to remain productive and stay also the providout of poverty. er’s identity in that system.” started to see confronting poverty as part Of course, helping patients in a health of the job. And the students themselves, care setting alone will not reduce rates of many of whom have gone on to medical violence, control pollution, expand school, start with a practical understand- healthy food offerings, improve failing ing of the relationship between poverty schools, or add new jobs—at least not and health. Both have learned from expe- directly. But breaking down the wall rience that addressing poverty—even in between poverty and health care is a part—can make a huge difference in health step in the right direction. It leads to a outcomes. Homes without electricity do greater understanding of the full set of not keep refrigerated medications. Hunger challenges and potential solutions to from physicians that they never asked about social needs, because they had no idea how to address them. The root cause of avoiding questions of poverty was not cynicism, but rather ignorance. With assistance from a student team, many physicians began to regularly talk to patients about their needs and work to address them. These clinicians have
jama.com
those challenges. It also opens the door to different kinds of collaborations with communities. And the timing could not be better. New payment incentives for better health outcomes are creating opportunities for new and innovative partnerships. At the end of the session, students flocked to Edin and Onie to ask questions, talk over ideas, and ask how to get involved. It was a fitting end to a discussion about a future vision for health care. Author Affiliation: Secretary of the Maryland Department of Health and Mental Hygiene, Baltimore. Corresponding Author: Joshua M. Sharfstein, MD ([email protected]). Published online September 24, 2014, at http: //newsatjama.jama.com/category/the -jama-forum/. Disclaimer: Each entry in The JAMA Forum expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. Additional Information: Information about The JAMA Forum is available at http://newsatjama.jama .com/about/. Information about disclosures of potential conflicts of interest may be found at http: //newsatjama.jama.com/jama-forum -disclosures/.
JAMA December 3, 2014 Volume 312, Number 21
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a CAMBRIDGE UNIVERSITY LIBRARY User on 08/10/2015
2201
speed with which patients are treated. A recent Michigan study found that even once stroke patients had arrived at the hospital and their brains had been imaged, there were delays before they received tPA (Sauser K et al. JAMA Neurol. 2014; 71[9]:1155-1161). A recent study in Germany, which also has a low rate of tPA use, found that specially equipped ambulances could administer tPA en route to the hospital without an increase in adverse events (Ebinger M et al. JAMA. 2014;311[16]:16221631). Compounding the problem of delayed treatment is the fact that 20% of strokes occur on awakening, although they might have started during sleep, making it tricky to determine whether the window of opportunity for treatment with tPA is still open, Sacco said. For that reason, he said, onset of such strokes is considered to be
either when the person went to bed or the last time they were well, both likely to be outside the 4.5-hour window of opportunity for tPA. Ovbiagele echoed Sacco. Even with the designated stroke centers, “we’ve barely moved the needle at all” when it comes to treating patients with tPA, he said. “There are so many things we can’t do about it.” Many patients simply don’t realize that they’ve had a stroke, Ovbiagele said, noting that while stroke can cause confusion, it doesn’t typically cause pain like a heart attack. Much can be done to prevent stroke, however, he said. On October 28, the AHA/ASA published updated guidelines for primary prevention of stroke, which were endorsed by neurology and neurosurgery professional groups as well as an association of cardiovascular nurses
(Meschia JF et al. Stroke. doi:10.1161/STR .0000000000000046 [published online October 28, 2014]). The authors of the guidelines cite an international case-control study of 6000 individuals that found that 10 potentially modifiable risk factors explained 90% of the risk of stroke (O’Donnell et al. Lancet. 2010; 376[9735]:112-123). Well-documented modifiable risk factors include hypertension, diabetes, atrial fibrillation, physical inactivity, obesity, excessive salt intake, and high alcohol consumption, the authors write. “Many times, we think of stroke from the standpoint of the devastating consequences that are personal and familial,” said Ovbiagele, who wasn’t involved in updating the prevention guidelines. But in addition, the costs from a societal standpoint “are huge,” he said. “It really beholds us to optimize prevention,” he said.
The JAMA Forum
Health Care and Poverty Joshua M. Sharfstein, MD
2200
performing educational system. From this perspective, it’s possible to see interventions in health care settings as “too little, too late” in addressing underlying inequity. But the discussion challenged both of these shades of skepticism. Edin, who has spent years interviewing individuals and families in extreme poverty, noted the breakdown of many community institutions that existed to provide information and help to families in need of resources. “If you look at the poorest of the American poor…only half of this group gets anything from [food stamps]. It’s really stunning,” Edin said. “Only a tiny portion gets a housing subsidy. But most everybody has some sort of health care, either for their children or for themselves. So if you want an institutional point of connection for these families, it is the health care industry.…It’s such a marvelous point of contact.” She noted that families may never learn about opportunities for assistance with food or energy bills outside of a medical setting. Onie spoke about the college students’ passion for helping connect low-
Joshua M. Sharfstein, MD
income families to resources. Health Leads tracks the thousands of times that students have identified eligibility for assistance and then assured that patients receive it. The students then teach the medical students, residents, and physicians in the clinic about the social needs of their patients, leading them to refer families for assistance back to the students in the future. Onie said she frequently heard
JAMA December 3, 2014 Volume 312, Number 21
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a CAMBRIDGE UNIVERSITY LIBRARY User on 08/10/2015
jama.com
Maximilian Franz/The Daily Record
I
recently had the opportunity to moderate a fascinating discussion at the Johns Hopkins Bloomberg School of Public Health on the role of the health care system in addressing poverty. One of the 2 speakers was Kathryn Edin, PhD, a sociologist who has written extensively about the lives of the poor in the United States. The other was Rebecca Onie, JD, a MacArthur Fellow who began a national effort called Health Leads, which brings teams of college students to medical clinics to connect patients with social services and resources. Should there be an expectation for health care institutions to take on entrenched social inequality? It’s a fair question. Some would point out that just getting health care right is hard enough, and good health care alone helps people and families to remain productive and stay out of poverty. Others would note that in recent years, an overdue focus on the social determinants of health has led to a greater focus on “upstream” contributors to poor health, such as substandard housing, few employment opportunities, and an under-
News & Analysis
and food insecurity are associated with obesity because of the reliance on cheap sources of calories. Patients, too, have sensed the difference in clinics that ask about their social needs. “Our patients now come in expecting to be able to talk to their physician about whether or not they have food at home,” one doctor told Onie. “That’s pretty powerful,” Onie remarked. “It’s a really profound shift in Some would point out that just getting boththepatient’s health care right is hard enough, and understanding of what health good health care alone helps people and care can be and families to remain productive and stay also the providout of poverty. er’s identity in that system.” started to see confronting poverty as part Of course, helping patients in a health of the job. And the students themselves, care setting alone will not reduce rates of many of whom have gone on to medical violence, control pollution, expand school, start with a practical understand- healthy food offerings, improve failing ing of the relationship between poverty schools, or add new jobs—at least not and health. Both have learned from expe- directly. But breaking down the wall rience that addressing poverty—even in between poverty and health care is a part—can make a huge difference in health step in the right direction. It leads to a outcomes. Homes without electricity do greater understanding of the full set of not keep refrigerated medications. Hunger challenges and potential solutions to from physicians that they never asked about social needs, because they had no idea how to address them. The root cause of avoiding questions of poverty was not cynicism, but rather ignorance. With assistance from a student team, many physicians began to regularly talk to patients about their needs and work to address them. These clinicians have
jama.com
those challenges. It also opens the door to different kinds of collaborations with communities. And the timing could not be better. New payment incentives for better health outcomes are creating opportunities for new and innovative partnerships. At the end of the session, students flocked to Edin and Onie to ask questions, talk over ideas, and ask how to get involved. It was a fitting end to a discussion about a future vision for health care. Author Affiliation: Secretary of the Maryland Department of Health and Mental Hygiene, Baltimore. Corresponding Author: Joshua M. Sharfstein, MD ([email protected]). Published online September 24, 2014, at http: //newsatjama.jama.com/category/the -jama-forum/. Disclaimer: Each entry in The JAMA Forum expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. Additional Information: Information about The JAMA Forum is available at http://newsatjama.jama .com/about/. Information about disclosures of potential conflicts of interest may be found at http: //newsatjama.jama.com/jama-forum -disclosures/.
JAMA December 3, 2014 Volume 312, Number 21
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a CAMBRIDGE UNIVERSITY LIBRARY User on 08/10/2015
2201
