Reuters Health

SHANGHAI (Reuters) - Li Tiantian, a Chinese doctor turned tech entrepreneur, is a leading light of the country's much-trumpeted healthcare reform drive. His medical networking platform DXY.com links two million doctors across China and has attracted funding from tech giants like Tencent.

DXY is exactly what Beijing has said it's looking to support after it pinpointed remote healthcare, Internet and technology as drivers to solve its healthcare woes in a 5-year roadmap in March.

The reality is rather different: DXY is curbing plans to work with public hospitals to help connect doctors and patients online because of a lack of support by Beijing and obstacles working with China's huge, fragmented public healthcare sector.

"We've heard a lot of good stories from the top - Internet +, driving force, policy changing - but see nothing happen at the bottom," Li told Reuters. "It's not about market, capital or even tech - these things are already developed very well ... rather it's the regulations, laws and systems of support."

Li's position reflects wider obstacles to healthcare reforms in technology, online drug sales, hospital privatization and doctors' pay, drivers that are a major lure for investors and firms betting billions of dollars on China opening up a market set to be worth around $1.3 trillion by 2020.

"(Investors) always ask: is there actually a macro tailwind, and is the government and regulatory environment - which is very important in China - supportive of this?" said Alexander Ng, associate principal at McKinsey & Co.

"If there's a lot of negative voices it might make investors back off or calculate a much higher risk premium."

REFORM RHETORIC

China has ramped up its healthcare reform rhetoric, touting greater access for foreign investors to healthcare services, a bigger role for technology and pushing drug sales from mostly state-run hospitals towards the retail market.

This has helped draw in close to $30 billion worth of healthcare merger and acquisition investment so far this year, a fivefold leap from the same period in 2014, according to Reuters data. Healthcare M&A already leapt last year.

But, despite the government's longer-term ambitions, industry insiders say reforms are being held up because of technical issues such as crumbling and fragmented IT systems to in-fighting between regulators and push-back from the state-run firms who dominate the sector - and don't want change.

"With so many vested interests - dealers, hospitals, insurance departments and others - reform is not very fast," said Frank Zhao, chief financial officer at China Jo Jo Drugstores Inc.

Privately, some health policy advisers admit reforms are falling behind, while the public line is that reform has "hit up against the Yangtze River," a reference to the obstacle famously overcome by Mao Zedong's Communist forces in 1949.

The healthcare ministry did not respond to faxed queries seeking comment for this article.

Zhao points to the expected approval for online prescription drug sales, which he and other industry insiders say has been delayed this year due to regulatory concerns and opposition from state-run hospitals and distributors.

These hold-ups are a frustration for pharmacy chains like Jo Jo as it looks to increase its business online, but also for tech giants like Alibaba Group Holding Ltd, which wants to get into the online prescription drug space.

OPEN MARKET?

One big draw for investors has been China's privatization drive of healthcare services - touted as key to revamping an unpopular healthcare system, blighted by crowded hospitals, corruption and simmering tension between patients and staff.

But, despite the fast growth of private investment in hospitals, the public sector still dominates around 90% of all patient visits, according to a Deutsche Bank 2015 healthcare report. Investors cite issues with insurance schemes, access to Chinese doctors and a still tightly-controlled market.

"With things still not market-led, organizations like ours are facing huge challenges and difficulties," Hu Lan, President and Director of hospital investment firm AMCARE Corporation, said at a conference in Shanghai in June.

Healthcare spending as a slice of China's GDP also remains small at around 6% in 2013 compared to 17% in the United States, World Health Organization (WHO) data show.

Reforms to reduce hospitals' reliance on drug sales also faces a revolt from doctors who argue this will take away a key revenue stream at a time when medical staff are overworked, underpaid and often violently abused by angry patients.

"Every few days you hear about a doctor being beaten or even killed. This situation is a huge mental burden for doctors," said Wu Xiaobo a doctor at the Wangjing Hospital in Beijing in a recent viral video campaign for doctors' rights.

As for DXY's Li, his firm now plans to change tack and set up an offline clinic in the eastern city of Hangzhou this year to pilot potential healthcare reforms - outside the state sector.

"We were hoping we could leverage changing policy and do something on mobile and digital," Li said. "We found it's just too slow, so the only way to do it is out on our own."

SHANGHAI (Reuters) - Li Tiantian, a Chinese doctor turned tech entrepreneur, is a leading light of the country's much-trumpeted healthcare reform drive. His medical networking platform DXY.com links two million doctors across China and has attracted funding from tech giants like Tencent.

DXY is exactly what Beijing has said it's looking to support after it pinpointed remote healthcare, Internet and technology as drivers to solve its healthcare woes in a 5-year roadmap in March.

The reality is rather different: DXY is curbing plans to work with public hospitals to help connect doctors and patients online because of a lack of support by Beijing and obstacles working with China's huge, fragmented public healthcare sector.

"We've heard a lot of good stories from the top - Internet +, driving force, policy changing - but see nothing happen at the bottom," Li told Reuters. "It's not about market, capital or even tech - these things are already developed very well ... rather it's the regulations, laws and systems of support."

Li's position reflects wider obstacles to healthcare reforms in technology, online drug sales, hospital privatization and doctors' pay, drivers that are a major lure for investors and firms betting billions of dollars on China opening up a market set to be worth around $1.3 trillion by 2020.

"(Investors) always ask: is there actually a macro tailwind, and is the government and regulatory environment - which is very important in China - supportive of this?" said Alexander Ng, associate principal at McKinsey & Co.

"If there's a lot of negative voices it might make investors back off or calculate a much higher risk premium."

REFORM RHETORIC

China has ramped up its healthcare reform rhetoric, touting greater access for foreign investors to healthcare services, a bigger role for technology and pushing drug sales from mostly state-run hospitals towards the retail market.

This has helped draw in close to $30 billion worth of healthcare merger and acquisition investment so far this year, a fivefold leap from the same period in 2014, according to Reuters data. Healthcare M&A already leapt last year.

But, despite the government's longer-term ambitions, industry insiders say reforms are being held up because of technical issues such as crumbling and fragmented IT systems to in-fighting between regulators and push-back from the state-run firms who dominate the sector - and don't want change.

"With so many vested interests - dealers, hospitals, insurance departments and others - reform is not very fast," said Frank Zhao, chief financial officer at China Jo Jo Drugstores Inc.

Privately, some health policy advisers admit reforms are falling behind, while the public line is that reform has "hit up against the Yangtze River," a reference to the obstacle famously overcome by Mao Zedong's Communist forces in 1949.

The healthcare ministry did not respond to faxed queries seeking comment for this article.

Zhao points to the expected approval for online prescription drug sales, which he and other industry insiders say has been delayed this year due to regulatory concerns and opposition from state-run hospitals and distributors.

These hold-ups are a frustration for pharmacy chains like Jo Jo as it looks to increase its business online, but also for tech giants like Alibaba Group Holding Ltd, which wants to get into the online prescription drug space.

OPEN MARKET?

One big draw for investors has been China's privatization drive of healthcare services - touted as key to revamping an unpopular healthcare system, blighted by crowded hospitals, corruption and simmering tension between patients and staff.

But, despite the fast growth of private investment in hospitals, the public sector still dominates around 90% of all patient visits, according to a Deutsche Bank 2015 healthcare report. Investors cite issues with insurance schemes, access to Chinese doctors and a still tightly-controlled market.

"With things still not market-led, organizations like ours are facing huge challenges and difficulties," Hu Lan, President and Director of hospital investment firm AMCARE Corporation, said at a conference in Shanghai in June.

Healthcare spending as a slice of China's GDP also remains small at around 6% in 2013 compared to 17% in the United States, World Health Organization (WHO) data show.

Reforms to reduce hospitals' reliance on drug sales also faces a revolt from doctors who argue this will take away a key revenue stream at a time when medical staff are overworked, underpaid and often violently abused by angry patients.

"Every few days you hear about a doctor being beaten or even killed. This situation is a huge mental burden for doctors," said Wu Xiaobo a doctor at the Wangjing Hospital in Beijing in a recent viral video campaign for doctors' rights.

As for DXY's Li, his firm now plans to change tack and set up an offline clinic in the eastern city of Hangzhou this year to pilot potential healthcare reforms - outside the state sector.

"We were hoping we could leverage changing policy and do something on mobile and digital," Li said. "We found it's just too slow, so the only way to do it is out on our own."

SHANGHAI (Reuters) - Li Tiantian, a Chinese doctor turned tech entrepreneur, is a leading light of the country's much-trumpeted healthcare reform drive. His medical networking platform DXY.com links two million doctors across China and has attracted funding from tech giants like Tencent.

DXY is exactly what Beijing has said it's looking to support after it pinpointed remote healthcare, Internet and technology as drivers to solve its healthcare woes in a 5-year roadmap in March.

The reality is rather different: DXY is curbing plans to work with public hospitals to help connect doctors and patients online because of a lack of support by Beijing and obstacles working with China's huge, fragmented public healthcare sector.

"We've heard a lot of good stories from the top - Internet +, driving force, policy changing - but see nothing happen at the bottom," Li told Reuters. "It's not about market, capital or even tech - these things are already developed very well ... rather it's the regulations, laws and systems of support."

Li's position reflects wider obstacles to healthcare reforms in technology, online drug sales, hospital privatization and doctors' pay, drivers that are a major lure for investors and firms betting billions of dollars on China opening up a market set to be worth around $1.3 trillion by 2020.

"(Investors) always ask: is there actually a macro tailwind, and is the government and regulatory environment - which is very important in China - supportive of this?" said Alexander Ng, associate principal at McKinsey & Co.

"If there's a lot of negative voices it might make investors back off or calculate a much higher risk premium."

REFORM RHETORIC

China has ramped up its healthcare reform rhetoric, touting greater access for foreign investors to healthcare services, a bigger role for technology and pushing drug sales from mostly state-run hospitals towards the retail market.

This has helped draw in close to $30 billion worth of healthcare merger and acquisition investment so far this year, a fivefold leap from the same period in 2014, according to Reuters data. Healthcare M&A already leapt last year.

But, despite the government's longer-term ambitions, industry insiders say reforms are being held up because of technical issues such as crumbling and fragmented IT systems to in-fighting between regulators and push-back from the state-run firms who dominate the sector - and don't want change.

"With so many vested interests - dealers, hospitals, insurance departments and others - reform is not very fast," said Frank Zhao, chief financial officer at China Jo Jo Drugstores Inc.

Privately, some health policy advisers admit reforms are falling behind, while the public line is that reform has "hit up against the Yangtze River," a reference to the obstacle famously overcome by Mao Zedong's Communist forces in 1949.

The healthcare ministry did not respond to faxed queries seeking comment for this article.

Zhao points to the expected approval for online prescription drug sales, which he and other industry insiders say has been delayed this year due to regulatory concerns and opposition from state-run hospitals and distributors.

These hold-ups are a frustration for pharmacy chains like Jo Jo as it looks to increase its business online, but also for tech giants like Alibaba Group Holding Ltd, which wants to get into the online prescription drug space.

OPEN MARKET?

One big draw for investors has been China's privatization drive of healthcare services - touted as key to revamping an unpopular healthcare system, blighted by crowded hospitals, corruption and simmering tension between patients and staff.

But, despite the fast growth of private investment in hospitals, the public sector still dominates around 90% of all patient visits, according to a Deutsche Bank 2015 healthcare report. Investors cite issues with insurance schemes, access to Chinese doctors and a still tightly-controlled market.

"With things still not market-led, organizations like ours are facing huge challenges and difficulties," Hu Lan, President and Director of hospital investment firm AMCARE Corporation, said at a conference in Shanghai in June.

Healthcare spending as a slice of China's GDP also remains small at around 6% in 2013 compared to 17% in the United States, World Health Organization (WHO) data show.

Reforms to reduce hospitals' reliance on drug sales also faces a revolt from doctors who argue this will take away a key revenue stream at a time when medical staff are overworked, underpaid and often violently abused by angry patients.

"Every few days you hear about a doctor being beaten or even killed. This situation is a huge mental burden for doctors," said Wu Xiaobo a doctor at the Wangjing Hospital in Beijing in a recent viral video campaign for doctors' rights.

As for DXY's Li, his firm now plans to change tack and set up an offline clinic in the eastern city of Hangzhou this year to pilot potential healthcare reforms - outside the state sector.

"We were hoping we could leverage changing policy and do something on mobile and digital," Li said. "We found it's just too slow, so the only way to do it is out on our own."

NEW YORK (Reuters Health) - The American Board of Internal Medicine (ABIM) maintenance-of-certification (MOC) program could cost $5.7 billion in physicians' time and fees over the next decade, according to a new model study.

"We estimate that physicians will spend 33 million hours over 10 years to fulfill MOC requirements," Dr. Dhruv S. Kazi from the University of California, San Francisco, told Reuters Health by email.

"This is approximately equivalent to the total clinical work load of 1785 physicians over 10 years," Dr. Kazi said. "This demand on physician time comes during a period of expanding insurance coverage and anticipated physician workforce shortfalls; it may therefore adversely affect access to care, particularly elective care."

The ABIM's substantial expansion in 2014 of its MOC requirements for the more than 250,000 board-certified internists, hospitalists and internal medicine subspecialists ignited an intense debate about the societal value of the program, resulting in temporary suspension of some of the new requirements.

Dr. Kazi's team sought to quantify the costs of the 2015 version of the MOC program and compare them with the costs that would have been incurred had the 2013 version remained unchanged.

The new MOC requirements would cost board-certified internal medicine physicians an average of $23,607 over 10 years, including $2,349 in fees to the ABIM and $21,259 in time costs, the researchers report in Annals of Internal Medicine, online July 28.

Average costs would range from $16,725 for general internists to $40,495 for hematologists-oncologists.

The overall program would cost $5.7 billion ($561 million in fees to ABIM and $5.1 billion in time costs) over the next 10 years, an increase of $1.2 billion over the previous MOC program.

"The ABIM has previously suggested that participation in MOC will cost $200 to $400 per year," the researchers note. "This is a substantial underestimate precisely because it overlooks time costs."

"While we had anticipated that physician time would be an important driver of costs of the program, we were surprised to see that 9 out of every 10 dollars in MOC costs were related to the program's demands on physician time," Dr. Kazi said. "In fact, every additional hour spent by physicians on MOC increased the costs of the program by approximately 13 million dollars."

"The internal medicine community has embraced the principle of evidence-based medicine in clinical practice; expensive policy interventions such as MOC should be held to the same evidentiary standards," Dr. Kazi concluded.

"Instead of piecemeal evaluations, the entire MOC program should be compared head-to-head with other policy interventions or health systems interventions that improve healthcare quality, thus providing an empirical basis for choosing MOC over alternative strategies for quality improvement," Dr. Kazi said.

"We hope that the high costs of MOC catalyze future studies examining the impact of MOC on the quality and economics of care delivered by board-certified physicians in the United States," Dr. Kazi added.

Dr. Robert B. Baron from the American Board of Internal Medicine told Reuters Health by email, "Their analysis is less about time and cost of doing MOC than it is about the time physicians take staying up-to-date. They estimate that it is about an hour a month, and about 40 hours to prepare for the exam every decade. While the researchers attribute that time to MOC, I suspect most physicians would be spending this time staying abreast of the latest developments in their field, with or without MOC. What MOC offers them is a structured framework to keep up and a marker for the public that they are."

"Our MOC program already recognizes so much of what physicians are doing in practice to stay up to date," said Dr. Baron, also of the University of California, San Francisco. "We can and should do more in that area. We are getting a lot of feedback from physicians about how we can improve MOC, and this feedback will help us shape what we know will be an evolving program."

"In conversations we have already had with the community, one thing physicians have shared loud and clear is that they deeply value staying current in their field," he added. "They believe they should spend time staying abreast of the latest updates in their discipline. We are talking with the community to assure that MOC gives them a structured way to stay current, and we all agree it is an important marker for patients that they have done so."

"The researchers make some claims about overall costs to the health care system," Dr. Baron said. "If you accept their methodology, which is a stretch, other research that appeared in JAMA in December showed greater overall savings - 30 times as much as the costs reported here - just in Medicare costs for physicians who participated in MOC. So maybe all those hours spent keeping up are worth it, not just for the physicians and the patients we take care of but for our entire health care system."

NEW YORK (Reuters Health) - The American Board of Internal Medicine (ABIM) maintenance-of-certification (MOC) program could cost $5.7 billion in physicians' time and fees over the next decade, according to a new model study.

"We estimate that physicians will spend 33 million hours over 10 years to fulfill MOC requirements," Dr. Dhruv S. Kazi from the University of California, San Francisco, told Reuters Health by email.

"This is approximately equivalent to the total clinical work load of 1785 physicians over 10 years," Dr. Kazi said. "This demand on physician time comes during a period of expanding insurance coverage and anticipated physician workforce shortfalls; it may therefore adversely affect access to care, particularly elective care."

The ABIM's substantial expansion in 2014 of its MOC requirements for the more than 250,000 board-certified internists, hospitalists and internal medicine subspecialists ignited an intense debate about the societal value of the program, resulting in temporary suspension of some of the new requirements.

Dr. Kazi's team sought to quantify the costs of the 2015 version of the MOC program and compare them with the costs that would have been incurred had the 2013 version remained unchanged.

The new MOC requirements would cost board-certified internal medicine physicians an average of $23,607 over 10 years, including $2,349 in fees to the ABIM and $21,259 in time costs, the researchers report in Annals of Internal Medicine, online July 28.

Average costs would range from $16,725 for general internists to $40,495 for hematologists-oncologists.

The overall program would cost $5.7 billion ($561 million in fees to ABIM and $5.1 billion in time costs) over the next 10 years, an increase of $1.2 billion over the previous MOC program.

"The ABIM has previously suggested that participation in MOC will cost $200 to $400 per year," the researchers note. "This is a substantial underestimate precisely because it overlooks time costs."

"While we had anticipated that physician time would be an important driver of costs of the program, we were surprised to see that 9 out of every 10 dollars in MOC costs were related to the program's demands on physician time," Dr. Kazi said. "In fact, every additional hour spent by physicians on MOC increased the costs of the program by approximately 13 million dollars."

"The internal medicine community has embraced the principle of evidence-based medicine in clinical practice; expensive policy interventions such as MOC should be held to the same evidentiary standards," Dr. Kazi concluded.

"Instead of piecemeal evaluations, the entire MOC program should be compared head-to-head with other policy interventions or health systems interventions that improve healthcare quality, thus providing an empirical basis for choosing MOC over alternative strategies for quality improvement," Dr. Kazi said.

"We hope that the high costs of MOC catalyze future studies examining the impact of MOC on the quality and economics of care delivered by board-certified physicians in the United States," Dr. Kazi added.

Dr. Robert B. Baron from the American Board of Internal Medicine told Reuters Health by email, "Their analysis is less about time and cost of doing MOC than it is about the time physicians take staying up-to-date. They estimate that it is about an hour a month, and about 40 hours to prepare for the exam every decade. While the researchers attribute that time to MOC, I suspect most physicians would be spending this time staying abreast of the latest developments in their field, with or without MOC. What MOC offers them is a structured framework to keep up and a marker for the public that they are."

"Our MOC program already recognizes so much of what physicians are doing in practice to stay up to date," said Dr. Baron, also of the University of California, San Francisco. "We can and should do more in that area. We are getting a lot of feedback from physicians about how we can improve MOC, and this feedback will help us shape what we know will be an evolving program."

"In conversations we have already had with the community, one thing physicians have shared loud and clear is that they deeply value staying current in their field," he added. "They believe they should spend time staying abreast of the latest updates in their discipline. We are talking with the community to assure that MOC gives them a structured way to stay current, and we all agree it is an important marker for patients that they have done so."

"The researchers make some claims about overall costs to the health care system," Dr. Baron said. "If you accept their methodology, which is a stretch, other research that appeared in JAMA in December showed greater overall savings - 30 times as much as the costs reported here - just in Medicare costs for physicians who participated in MOC. So maybe all those hours spent keeping up are worth it, not just for the physicians and the patients we take care of but for our entire health care system."

NEW YORK (Reuters Health) - The American Board of Internal Medicine (ABIM) maintenance-of-certification (MOC) program could cost $5.7 billion in physicians' time and fees over the next decade, according to a new model study.

"We estimate that physicians will spend 33 million hours over 10 years to fulfill MOC requirements," Dr. Dhruv S. Kazi from the University of California, San Francisco, told Reuters Health by email.

"This is approximately equivalent to the total clinical work load of 1785 physicians over 10 years," Dr. Kazi said. "This demand on physician time comes during a period of expanding insurance coverage and anticipated physician workforce shortfalls; it may therefore adversely affect access to care, particularly elective care."

The ABIM's substantial expansion in 2014 of its MOC requirements for the more than 250,000 board-certified internists, hospitalists and internal medicine subspecialists ignited an intense debate about the societal value of the program, resulting in temporary suspension of some of the new requirements.

Dr. Kazi's team sought to quantify the costs of the 2015 version of the MOC program and compare them with the costs that would have been incurred had the 2013 version remained unchanged.

The new MOC requirements would cost board-certified internal medicine physicians an average of $23,607 over 10 years, including $2,349 in fees to the ABIM and $21,259 in time costs, the researchers report in Annals of Internal Medicine, online July 28.

Average costs would range from $16,725 for general internists to $40,495 for hematologists-oncologists.

The overall program would cost $5.7 billion ($561 million in fees to ABIM and $5.1 billion in time costs) over the next 10 years, an increase of $1.2 billion over the previous MOC program.

"The ABIM has previously suggested that participation in MOC will cost $200 to $400 per year," the researchers note. "This is a substantial underestimate precisely because it overlooks time costs."

"While we had anticipated that physician time would be an important driver of costs of the program, we were surprised to see that 9 out of every 10 dollars in MOC costs were related to the program's demands on physician time," Dr. Kazi said. "In fact, every additional hour spent by physicians on MOC increased the costs of the program by approximately 13 million dollars."

"The internal medicine community has embraced the principle of evidence-based medicine in clinical practice; expensive policy interventions such as MOC should be held to the same evidentiary standards," Dr. Kazi concluded.

"Instead of piecemeal evaluations, the entire MOC program should be compared head-to-head with other policy interventions or health systems interventions that improve healthcare quality, thus providing an empirical basis for choosing MOC over alternative strategies for quality improvement," Dr. Kazi said.

"We hope that the high costs of MOC catalyze future studies examining the impact of MOC on the quality and economics of care delivered by board-certified physicians in the United States," Dr. Kazi added.

Dr. Robert B. Baron from the American Board of Internal Medicine told Reuters Health by email, "Their analysis is less about time and cost of doing MOC than it is about the time physicians take staying up-to-date. They estimate that it is about an hour a month, and about 40 hours to prepare for the exam every decade. While the researchers attribute that time to MOC, I suspect most physicians would be spending this time staying abreast of the latest developments in their field, with or without MOC. What MOC offers them is a structured framework to keep up and a marker for the public that they are."

"Our MOC program already recognizes so much of what physicians are doing in practice to stay up to date," said Dr. Baron, also of the University of California, San Francisco. "We can and should do more in that area. We are getting a lot of feedback from physicians about how we can improve MOC, and this feedback will help us shape what we know will be an evolving program."

"In conversations we have already had with the community, one thing physicians have shared loud and clear is that they deeply value staying current in their field," he added. "They believe they should spend time staying abreast of the latest updates in their discipline. We are talking with the community to assure that MOC gives them a structured way to stay current, and we all agree it is an important marker for patients that they have done so."

"The researchers make some claims about overall costs to the health care system," Dr. Baron said. "If you accept their methodology, which is a stretch, other research that appeared in JAMA in December showed greater overall savings - 30 times as much as the costs reported here - just in Medicare costs for physicians who participated in MOC. So maybe all those hours spent keeping up are worth it, not just for the physicians and the patients we take care of but for our entire health care system."

(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.

Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.

Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.

"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."

Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.

The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.

Of those who had not been referred, 1,795 attended at least one session.

Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.

Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.

Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.

"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.

Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.

Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.

"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.

Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.

Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.

"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."

(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.

Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.

Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.

"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."

Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.

The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.

Of those who had not been referred, 1,795 attended at least one session.

Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.

Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.

Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.

"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.

Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.

Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.

"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.

Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.

Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.

"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."

(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.

Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.

Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.

"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."

Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.

The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.

Of those who had not been referred, 1,795 attended at least one session.

Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.

Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.

Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.

"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.

Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.

Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.

"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.

Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.

Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.

"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."

NEW YORK (Reuters Health) - Young adult cancer survivors will continue to have high hospitalization rates over time, a Canadian study shows.

In five-year cancer survivors diagnosed between ages 20 and 44, hospitalization rates were elevated for at least 20 years, compared to rates in age- and sex-matched controls, according to Dr. Nancy N. Baxter at St. Michael's Hospital in Toronto and colleagues.

For all malignancies except melanoma and testicular cancer, the adjusted relative rate (ARR) of hospitalizations was significantly higher among survivors than controls.

"Late effects and complications of cancer treatments are experienced by many survivors for the rest of their lives," Dr. Baxter told Reuters Health in an e-mail.

The patients in this population-based study were treated from 1992-1999.

"Therapies have changed, she said. "In some cases there may be fewer late effects, but in others, they may be worse."

The study cohort included 20,275 survivors of young adult cancers who were recurrence-free for at least five years, and 101,344 controls. The authors observed survivors for a median of 9.93 years (range 0-16 years), according to their report online July 13 in the Journal of Clinical Oncology.

During this period, 34.3% had at least one hospitalization, vs. 27.3% for controls. The rate per 100 person-years was similar between male and female survivors.

Overall, the ARR of hospitalization in survivors compared with controls was 1.51.

At all time periods, survivors were more likely to be hospitalized than controls. The rate of hospitalization (per 100-person years) among survivors was 0.22 during years 5 to 8, 9 to11, and 12 to14. It decreased significantly during years 15 to 17 and 18 to 20, falling to 0.17 and 0.15, respectively (p

Among controls, the hospitalization rate was relatively constant during all time periods, ranging from 0.13 at 5 to 8 years to 0.12 at years 18 to 20.

The ARR of hospitalizations in survivors compared with controls was also relatively constant during for the first three3 time periods: 1.67, 1.55, and 1.57 at years 5 to 8, 9 to 11, and 12 to 14, respectively. It decreased to 1.36 at 15 to 17 years and 1.22 at years 18 to 20.

Those who survived gastrointestinal, urologic, colorectal, or brain cancers, or leukemia or lymphoma, had an ARR of hospitalization at least twice that of controls.

"We only looked at hospital admissions, not visits to the family doctor or medical conditions and disabilities that didn't require inpatient care," Dr. Baxter said, explaining that this likely underestimated the long-term impact of intense treatments that include surgery, chemotherapy, radiation, and hormonal therapy.

Lillie D. Shockney, Director of Cancer Survivorship Programs at the Sidney Kimmel Cancer Center at Johns Hopkins in Baltimore, said in an e-mail to Reuters Health that physical symptoms can be "guilty by association."

"If a patient had cancer, more tests, including inpatient procedures, might be done to rule out recurrence or the presence of a new malignancy," she said.

Studies such as this one could pave the way for more detailed research on the risk of treatment-related conditions that lead to more medical care, she said.

Shockney also said the report raises awareness of the need to pay special attention to cancer survivors; to consider survivorship as we would a chronic illness.

"Understanding the late effects of cancer treatment will help us design better treatments, counsel patients, and improve symptom management," said Dr. Baxter.

NEW YORK (Reuters Health) - Young adult cancer survivors will continue to have high hospitalization rates over time, a Canadian study shows.

In five-year cancer survivors diagnosed between ages 20 and 44, hospitalization rates were elevated for at least 20 years, compared to rates in age- and sex-matched controls, according to Dr. Nancy N. Baxter at St. Michael's Hospital in Toronto and colleagues.

For all malignancies except melanoma and testicular cancer, the adjusted relative rate (ARR) of hospitalizations was significantly higher among survivors than controls.

"Late effects and complications of cancer treatments are experienced by many survivors for the rest of their lives," Dr. Baxter told Reuters Health in an e-mail.

The patients in this population-based study were treated from 1992-1999.

"Therapies have changed, she said. "In some cases there may be fewer late effects, but in others, they may be worse."

The study cohort included 20,275 survivors of young adult cancers who were recurrence-free for at least five years, and 101,344 controls. The authors observed survivors for a median of 9.93 years (range 0-16 years), according to their report online July 13 in the Journal of Clinical Oncology.

During this period, 34.3% had at least one hospitalization, vs. 27.3% for controls. The rate per 100 person-years was similar between male and female survivors.

Overall, the ARR of hospitalization in survivors compared with controls was 1.51.

At all time periods, survivors were more likely to be hospitalized than controls. The rate of hospitalization (per 100-person years) among survivors was 0.22 during years 5 to 8, 9 to11, and 12 to14. It decreased significantly during years 15 to 17 and 18 to 20, falling to 0.17 and 0.15, respectively (p

Among controls, the hospitalization rate was relatively constant during all time periods, ranging from 0.13 at 5 to 8 years to 0.12 at years 18 to 20.

The ARR of hospitalizations in survivors compared with controls was also relatively constant during for the first three3 time periods: 1.67, 1.55, and 1.57 at years 5 to 8, 9 to 11, and 12 to 14, respectively. It decreased to 1.36 at 15 to 17 years and 1.22 at years 18 to 20.

Those who survived gastrointestinal, urologic, colorectal, or brain cancers, or leukemia or lymphoma, had an ARR of hospitalization at least twice that of controls.

"We only looked at hospital admissions, not visits to the family doctor or medical conditions and disabilities that didn't require inpatient care," Dr. Baxter said, explaining that this likely underestimated the long-term impact of intense treatments that include surgery, chemotherapy, radiation, and hormonal therapy.

Lillie D. Shockney, Director of Cancer Survivorship Programs at the Sidney Kimmel Cancer Center at Johns Hopkins in Baltimore, said in an e-mail to Reuters Health that physical symptoms can be "guilty by association."

"If a patient had cancer, more tests, including inpatient procedures, might be done to rule out recurrence or the presence of a new malignancy," she said.

Studies such as this one could pave the way for more detailed research on the risk of treatment-related conditions that lead to more medical care, she said.

Shockney also said the report raises awareness of the need to pay special attention to cancer survivors; to consider survivorship as we would a chronic illness.

"Understanding the late effects of cancer treatment will help us design better treatments, counsel patients, and improve symptom management," said Dr. Baxter.

NEW YORK (Reuters Health) - Young adult cancer survivors will continue to have high hospitalization rates over time, a Canadian study shows.

In five-year cancer survivors diagnosed between ages 20 and 44, hospitalization rates were elevated for at least 20 years, compared to rates in age- and sex-matched controls, according to Dr. Nancy N. Baxter at St. Michael's Hospital in Toronto and colleagues.

For all malignancies except melanoma and testicular cancer, the adjusted relative rate (ARR) of hospitalizations was significantly higher among survivors than controls.

"Late effects and complications of cancer treatments are experienced by many survivors for the rest of their lives," Dr. Baxter told Reuters Health in an e-mail.

The patients in this population-based study were treated from 1992-1999.

"Therapies have changed, she said. "In some cases there may be fewer late effects, but in others, they may be worse."

The study cohort included 20,275 survivors of young adult cancers who were recurrence-free for at least five years, and 101,344 controls. The authors observed survivors for a median of 9.93 years (range 0-16 years), according to their report online July 13 in the Journal of Clinical Oncology.

During this period, 34.3% had at least one hospitalization, vs. 27.3% for controls. The rate per 100 person-years was similar between male and female survivors.

Overall, the ARR of hospitalization in survivors compared with controls was 1.51.

At all time periods, survivors were more likely to be hospitalized than controls. The rate of hospitalization (per 100-person years) among survivors was 0.22 during years 5 to 8, 9 to11, and 12 to14. It decreased significantly during years 15 to 17 and 18 to 20, falling to 0.17 and 0.15, respectively (p

Among controls, the hospitalization rate was relatively constant during all time periods, ranging from 0.13 at 5 to 8 years to 0.12 at years 18 to 20.

The ARR of hospitalizations in survivors compared with controls was also relatively constant during for the first three3 time periods: 1.67, 1.55, and 1.57 at years 5 to 8, 9 to 11, and 12 to 14, respectively. It decreased to 1.36 at 15 to 17 years and 1.22 at years 18 to 20.

Those who survived gastrointestinal, urologic, colorectal, or brain cancers, or leukemia or lymphoma, had an ARR of hospitalization at least twice that of controls.

"We only looked at hospital admissions, not visits to the family doctor or medical conditions and disabilities that didn't require inpatient care," Dr. Baxter said, explaining that this likely underestimated the long-term impact of intense treatments that include surgery, chemotherapy, radiation, and hormonal therapy.

Lillie D. Shockney, Director of Cancer Survivorship Programs at the Sidney Kimmel Cancer Center at Johns Hopkins in Baltimore, said in an e-mail to Reuters Health that physical symptoms can be "guilty by association."

"If a patient had cancer, more tests, including inpatient procedures, might be done to rule out recurrence or the presence of a new malignancy," she said.

Studies such as this one could pave the way for more detailed research on the risk of treatment-related conditions that lead to more medical care, she said.

Shockney also said the report raises awareness of the need to pay special attention to cancer survivors; to consider survivorship as we would a chronic illness.

"Understanding the late effects of cancer treatment will help us design better treatments, counsel patients, and improve symptom management," said Dr. Baxter.

SAN FRANCISCO (Reuters) - A year and a half after the Affordable Care Act brought widespread reforms to the U.S. healthcare system, Chicago's Cook County Health & Hospitals System has made its first profit in 180 years.

Seven hundred miles south, the fortunes of Atlanta's primary public hospital, Grady Health System, haven't improved, and it remains as dependent as ever on philanthropy and county funding to stay afloat.

The disparity between the two "safety net" hospitals, both of which serve a disproportionate share of their communities' poorest patients, illustrates a growing divide nationwide.

In states like Illinois that have opted to accept federal money to expand Medicaid, some large, public hospitals are finding themselves on solid financial footing for the first time in decades, and formerly uninsured patients are now getting regular care.

But in states that did not expand the government medical program for the poor, primarily ones with conservative electorates opposed to Obamacare, including Georgia, the impact of the Affordable Care Act on public hospitals has been negligible.

While the public exchanges established by the federal government and 14 states have brought coverage to many previously uninsured people in all parts of the country, the effect on the poorest Americans varies drastically from state to state.

Nearly four million low-income, uninsured Americans living in states that didn't expand Medicaid would have qualified for coverage had their states chosen to expand it, according to the Kaiser Family Foundation. And public hospitals in those states, many of which rely on bond markets for funding, are likely to feel the pinch even more acutely over time, experts said.

"Providers in these states are going to be at a disadvantage," said Jim LeBuhn, senior director at Fitch Ratings. "It's going to make it that much more challenging for these providers to maintain their financial profiles."

Since the Affordable Care Act's first open enrollment in 2013, the number of Americans covered under Medicaid has risen by 21 percent, to 71.1 million.

Nonprofit hospitals in the 30 states that expanded Medicaid reported on average 13 percent less bad debt from unpaid bills last year, according to Moody's Investors Service. In contrast, according to Moody's, such "hospitals in non-expansion states saw bad debt increase through much of the year."

Hospitals in Medicaid expansion states, according to Kaiser, reported an average 32 percent decrease in uninsured patients and a 40 percent cut in unreimbursed costs of care for patients without the ability to pay, known in the industry as charity care costs. In non-expansion states, the number of uninsured patients declined by 4.4 percent and charity care costs dropped by 6.2 percent.

New recipients of Medicaid benefited, too. After one year, adults who gained the coverage were 55 percent more likely to have their own doctor than those who did not, Kaiser found. Medicaid also increased the likelihood of receiving preventive care, such as mammograms and cholesterol checks.

A TALE OF TWO HOSPITALS

Both Cook County and Grady are safety-net hospitals based in urban counties where the poverty level is slightly higher than the national average, and both have handled high numbers of uninsured clients in recent years: about half of the patients at Cook and nearly a third at Grady.

Since Obamacare took effect, the numbers at the Georgia hospital have remained about the same. But things have changed dramatically at the Illinois hospital, in large part due to the area's enrollment of about 170,000 of an estimated 330,000 eligible for the expanded Medicaid.

"This has been a sea change for us," said Dr. John Jay Shannon, Cook County Health's chief executive.

Within two years, the percent of uninsured patients at the hospital had dropped from more than a half to about a third, almost entirely driven by increased Medicaid coverage, hospital data show. And for the first time in the hospital's history, a majority of the patients it treated had coverage.

A third of the new Medicaid enrollees treated at Cook County were patients new to the system. And, hospital administrators say, those with chronic diseases such as diabetes, who used to be frequent emergency room visitors, now have personal physicians to help them manage their conditions.

In the fiscal year ending in November 2014, uncompensated charity care dropped to $342 million from $500 million the year before. Funding from Medicaid nearly doubled the health system's operating revenues, a major reason that, after ending 2013 with a net loss of $67.6 million, Cook County Health finished its most recent fiscal year in the black.

Now, the provider, like other safety-net hospitals, has a new challenge: holding onto old clients.

"For the first time in our history, we need to compete for our patients," said Shannon. "A world of improved access is also a world of choice."

At Grady Health System in Atlanta, meanwhile, the number of patients covered by insurance increased by less than 2 percent last year. Bad debt from unpaid bills has continued to climb, to $396 million from $269 million in 2013. And the percentage of patients covered by Medicaid didn't change.

"We've seen no difference from the Affordable Care Act," said John Haupert, Grady's chief executive. Many patients "are still coming to us as a safety-net provider and falling under our charity care."

Georgia is one of 20 states, disproportionately clustered in the South, that didn't expand Medicaid. About 89 percent of those left out of the new Medicaid coverage, because their states chose not to expand the program, live in the South, Kaiser Family Foundation found.

Grady has a better financial outlook than many hospitals in states that didn't expand Medicaid, thanks to a philanthropic campaign that has raised $350 million since 2008 to fund new infrastructure and expand clinical services. But, unlike Cook County, which has reduced some dependence on local government support with the help of Medicaid expansion dollars, Grady remains reliant on $57 million in tax support from two local counties. Without the local funding, Grady would be running a deficit.

"From a global perspective, it seems like the ACA is working," said Kevin Holloran, senior director at Standard & Poor's. But in non-expansion states, like Georgia, "it's really a neutral. It's just the status quo."

SAN FRANCISCO (Reuters) - A year and a half after the Affordable Care Act brought widespread reforms to the U.S. healthcare system, Chicago's Cook County Health & Hospitals System has made its first profit in 180 years.

Seven hundred miles south, the fortunes of Atlanta's primary public hospital, Grady Health System, haven't improved, and it remains as dependent as ever on philanthropy and county funding to stay afloat.

The disparity between the two "safety net" hospitals, both of which serve a disproportionate share of their communities' poorest patients, illustrates a growing divide nationwide.

In states like Illinois that have opted to accept federal money to expand Medicaid, some large, public hospitals are finding themselves on solid financial footing for the first time in decades, and formerly uninsured patients are now getting regular care.

But in states that did not expand the government medical program for the poor, primarily ones with conservative electorates opposed to Obamacare, including Georgia, the impact of the Affordable Care Act on public hospitals has been negligible.

While the public exchanges established by the federal government and 14 states have brought coverage to many previously uninsured people in all parts of the country, the effect on the poorest Americans varies drastically from state to state.

Nearly four million low-income, uninsured Americans living in states that didn't expand Medicaid would have qualified for coverage had their states chosen to expand it, according to the Kaiser Family Foundation. And public hospitals in those states, many of which rely on bond markets for funding, are likely to feel the pinch even more acutely over time, experts said.

"Providers in these states are going to be at a disadvantage," said Jim LeBuhn, senior director at Fitch Ratings. "It's going to make it that much more challenging for these providers to maintain their financial profiles."

Since the Affordable Care Act's first open enrollment in 2013, the number of Americans covered under Medicaid has risen by 21 percent, to 71.1 million.

Nonprofit hospitals in the 30 states that expanded Medicaid reported on average 13 percent less bad debt from unpaid bills last year, according to Moody's Investors Service. In contrast, according to Moody's, such "hospitals in non-expansion states saw bad debt increase through much of the year."

Hospitals in Medicaid expansion states, according to Kaiser, reported an average 32 percent decrease in uninsured patients and a 40 percent cut in unreimbursed costs of care for patients without the ability to pay, known in the industry as charity care costs. In non-expansion states, the number of uninsured patients declined by 4.4 percent and charity care costs dropped by 6.2 percent.

New recipients of Medicaid benefited, too. After one year, adults who gained the coverage were 55 percent more likely to have their own doctor than those who did not, Kaiser found. Medicaid also increased the likelihood of receiving preventive care, such as mammograms and cholesterol checks.

A TALE OF TWO HOSPITALS

Both Cook County and Grady are safety-net hospitals based in urban counties where the poverty level is slightly higher than the national average, and both have handled high numbers of uninsured clients in recent years: about half of the patients at Cook and nearly a third at Grady.

Since Obamacare took effect, the numbers at the Georgia hospital have remained about the same. But things have changed dramatically at the Illinois hospital, in large part due to the area's enrollment of about 170,000 of an estimated 330,000 eligible for the expanded Medicaid.

"This has been a sea change for us," said Dr. John Jay Shannon, Cook County Health's chief executive.

Within two years, the percent of uninsured patients at the hospital had dropped from more than a half to about a third, almost entirely driven by increased Medicaid coverage, hospital data show. And for the first time in the hospital's history, a majority of the patients it treated had coverage.

A third of the new Medicaid enrollees treated at Cook County were patients new to the system. And, hospital administrators say, those with chronic diseases such as diabetes, who used to be frequent emergency room visitors, now have personal physicians to help them manage their conditions.

In the fiscal year ending in November 2014, uncompensated charity care dropped to $342 million from $500 million the year before. Funding from Medicaid nearly doubled the health system's operating revenues, a major reason that, after ending 2013 with a net loss of $67.6 million, Cook County Health finished its most recent fiscal year in the black.

Now, the provider, like other safety-net hospitals, has a new challenge: holding onto old clients.

"For the first time in our history, we need to compete for our patients," said Shannon. "A world of improved access is also a world of choice."

At Grady Health System in Atlanta, meanwhile, the number of patients covered by insurance increased by less than 2 percent last year. Bad debt from unpaid bills has continued to climb, to $396 million from $269 million in 2013. And the percentage of patients covered by Medicaid didn't change.

"We've seen no difference from the Affordable Care Act," said John Haupert, Grady's chief executive. Many patients "are still coming to us as a safety-net provider and falling under our charity care."

Georgia is one of 20 states, disproportionately clustered in the South, that didn't expand Medicaid. About 89 percent of those left out of the new Medicaid coverage, because their states chose not to expand the program, live in the South, Kaiser Family Foundation found.

Grady has a better financial outlook than many hospitals in states that didn't expand Medicaid, thanks to a philanthropic campaign that has raised $350 million since 2008 to fund new infrastructure and expand clinical services. But, unlike Cook County, which has reduced some dependence on local government support with the help of Medicaid expansion dollars, Grady remains reliant on $57 million in tax support from two local counties. Without the local funding, Grady would be running a deficit.

"From a global perspective, it seems like the ACA is working," said Kevin Holloran, senior director at Standard & Poor's. But in non-expansion states, like Georgia, "it's really a neutral. It's just the status quo."

SAN FRANCISCO (Reuters) - A year and a half after the Affordable Care Act brought widespread reforms to the U.S. healthcare system, Chicago's Cook County Health & Hospitals System has made its first profit in 180 years.

Seven hundred miles south, the fortunes of Atlanta's primary public hospital, Grady Health System, haven't improved, and it remains as dependent as ever on philanthropy and county funding to stay afloat.

The disparity between the two "safety net" hospitals, both of which serve a disproportionate share of their communities' poorest patients, illustrates a growing divide nationwide.

In states like Illinois that have opted to accept federal money to expand Medicaid, some large, public hospitals are finding themselves on solid financial footing for the first time in decades, and formerly uninsured patients are now getting regular care.

But in states that did not expand the government medical program for the poor, primarily ones with conservative electorates opposed to Obamacare, including Georgia, the impact of the Affordable Care Act on public hospitals has been negligible.

While the public exchanges established by the federal government and 14 states have brought coverage to many previously uninsured people in all parts of the country, the effect on the poorest Americans varies drastically from state to state.

Nearly four million low-income, uninsured Americans living in states that didn't expand Medicaid would have qualified for coverage had their states chosen to expand it, according to the Kaiser Family Foundation. And public hospitals in those states, many of which rely on bond markets for funding, are likely to feel the pinch even more acutely over time, experts said.

"Providers in these states are going to be at a disadvantage," said Jim LeBuhn, senior director at Fitch Ratings. "It's going to make it that much more challenging for these providers to maintain their financial profiles."

Since the Affordable Care Act's first open enrollment in 2013, the number of Americans covered under Medicaid has risen by 21 percent, to 71.1 million.

Nonprofit hospitals in the 30 states that expanded Medicaid reported on average 13 percent less bad debt from unpaid bills last year, according to Moody's Investors Service. In contrast, according to Moody's, such "hospitals in non-expansion states saw bad debt increase through much of the year."

Hospitals in Medicaid expansion states, according to Kaiser, reported an average 32 percent decrease in uninsured patients and a 40 percent cut in unreimbursed costs of care for patients without the ability to pay, known in the industry as charity care costs. In non-expansion states, the number of uninsured patients declined by 4.4 percent and charity care costs dropped by 6.2 percent.

New recipients of Medicaid benefited, too. After one year, adults who gained the coverage were 55 percent more likely to have their own doctor than those who did not, Kaiser found. Medicaid also increased the likelihood of receiving preventive care, such as mammograms and cholesterol checks.

A TALE OF TWO HOSPITALS

Both Cook County and Grady are safety-net hospitals based in urban counties where the poverty level is slightly higher than the national average, and both have handled high numbers of uninsured clients in recent years: about half of the patients at Cook and nearly a third at Grady.

Since Obamacare took effect, the numbers at the Georgia hospital have remained about the same. But things have changed dramatically at the Illinois hospital, in large part due to the area's enrollment of about 170,000 of an estimated 330,000 eligible for the expanded Medicaid.

"This has been a sea change for us," said Dr. John Jay Shannon, Cook County Health's chief executive.

Within two years, the percent of uninsured patients at the hospital had dropped from more than a half to about a third, almost entirely driven by increased Medicaid coverage, hospital data show. And for the first time in the hospital's history, a majority of the patients it treated had coverage.

A third of the new Medicaid enrollees treated at Cook County were patients new to the system. And, hospital administrators say, those with chronic diseases such as diabetes, who used to be frequent emergency room visitors, now have personal physicians to help them manage their conditions.

In the fiscal year ending in November 2014, uncompensated charity care dropped to $342 million from $500 million the year before. Funding from Medicaid nearly doubled the health system's operating revenues, a major reason that, after ending 2013 with a net loss of $67.6 million, Cook County Health finished its most recent fiscal year in the black.

Now, the provider, like other safety-net hospitals, has a new challenge: holding onto old clients.

"For the first time in our history, we need to compete for our patients," said Shannon. "A world of improved access is also a world of choice."

At Grady Health System in Atlanta, meanwhile, the number of patients covered by insurance increased by less than 2 percent last year. Bad debt from unpaid bills has continued to climb, to $396 million from $269 million in 2013. And the percentage of patients covered by Medicaid didn't change.

"We've seen no difference from the Affordable Care Act," said John Haupert, Grady's chief executive. Many patients "are still coming to us as a safety-net provider and falling under our charity care."

Georgia is one of 20 states, disproportionately clustered in the South, that didn't expand Medicaid. About 89 percent of those left out of the new Medicaid coverage, because their states chose not to expand the program, live in the South, Kaiser Family Foundation found.

Grady has a better financial outlook than many hospitals in states that didn't expand Medicaid, thanks to a philanthropic campaign that has raised $350 million since 2008 to fund new infrastructure and expand clinical services. But, unlike Cook County, which has reduced some dependence on local government support with the help of Medicaid expansion dollars, Grady remains reliant on $57 million in tax support from two local counties. Without the local funding, Grady would be running a deficit.

"From a global perspective, it seems like the ACA is working," said Kevin Holloran, senior director at Standard & Poor's. But in non-expansion states, like Georgia, "it's really a neutral. It's just the status quo."

NEW YORK (Reuters Health) - Patients transitioning from warfarin to rivaroxaban for atrial fibrillation, who are taking both drugs before dropping warfarin, may be at risk for spontaneous vitreous hemorrhage, according to a new case report.

Judy H. Jun and Dr. John C. Hwang, of Retina Associates of Orange County in Laguna Hills, California, report three such cases of vitreous hemorrhage in an article online June 25 in JAMA Ophthalmology.

"It doesn't look like it's a huge phenomenon, but we're the first to report the association," said Dr. Hwang, also of the University of Southern California Eye Institute and Keck School of Medicine in Los Angeles.

Two men in their 70s and one in his 80s all presented with a vitreous hemorrhage of the right eye, confirmed by B-scan ultrasonography. They all were taking warfarin and rivaroxaban (Xarelto, Janssen) in transition to taking just rivaroxaban. They stopped taking warfarin and continued the rivaroxaban.

The vitreous hemorrhages in the first two cases largely resolved by a month after presentation and the men's visual acuity returned. For the third man, the vitreous hemorrhage resolved by two months and his visual acuity had largely returned.

"In all cases, an acute vitreous hemorrhage occurred shortly after rivaroxaban treatment was initiated. The vitreous hemorrhage resolved spontaneously in all cases and subsequent clinical and angiographic assessments did not reveal any ocular pathology to account for the hemorrhage," the authors wrote.

"I think it's the double-whammying of the drugs, two anticoagulants at once," Dr. Hwang told Reuters. "All three patients were transitioning in treatment. At the time when they had the bleed, all of them were taking two medications. So we definitely think that the highest risk period for developing a bleeding is during this transition period when patients are stopping one medication and starting another one."

As the trend continues for switching patients from warfarin to rivaroxaban, so may the trend for patients to develop vitreous hemorrhage, he added, and clinicians should be aware of the potential risk and advise patients accordingly.

One study in 2013 found an association between use of aspirin, clopidogrel, and warfarin and vitreous hemorrhage (http://bit.ly/1Jl76YK). And a 2007 paper reported an association between warfarin and ocular bleeding (http://bit.ly/1Lx6BeC).

Janssen Pharmaceuticals issued the following statement in response to the JAMA Ophthalmology report: "Bleeding events are a known consequence of anticoagulation, and these types of bleeding events were identified in the clinical development program for Xarelto. We carefully monitor the safety performance of our medicine and Xarelto continues to perform as expected in the real-world setting, as evidenced by the 24 month results, in 39,000 patients, from our ongoing postmarketing safety surveillance program. We will continue to advance our real world data to ensure doctors and patients are equipped with the latest information about our medicine to optimize patient care."

In May, Janssen said at the American Geriatrics Society meeting that new data from their postmarketing study show that the safety profile of the drug in routine clinical practice is consistent with phase 3 clinical trial data, "which show a correlation between increased age and bleeding."

The authors of the case report made disclosures.

NEW YORK (Reuters Health) - Patients transitioning from warfarin to rivaroxaban for atrial fibrillation, who are taking both drugs before dropping warfarin, may be at risk for spontaneous vitreous hemorrhage, according to a new case report.

Judy H. Jun and Dr. John C. Hwang, of Retina Associates of Orange County in Laguna Hills, California, report three such cases of vitreous hemorrhage in an article online June 25 in JAMA Ophthalmology.

"It doesn't look like it's a huge phenomenon, but we're the first to report the association," said Dr. Hwang, also of the University of Southern California Eye Institute and Keck School of Medicine in Los Angeles.

Two men in their 70s and one in his 80s all presented with a vitreous hemorrhage of the right eye, confirmed by B-scan ultrasonography. They all were taking warfarin and rivaroxaban (Xarelto, Janssen) in transition to taking just rivaroxaban. They stopped taking warfarin and continued the rivaroxaban.

The vitreous hemorrhages in the first two cases largely resolved by a month after presentation and the men's visual acuity returned. For the third man, the vitreous hemorrhage resolved by two months and his visual acuity had largely returned.

"In all cases, an acute vitreous hemorrhage occurred shortly after rivaroxaban treatment was initiated. The vitreous hemorrhage resolved spontaneously in all cases and subsequent clinical and angiographic assessments did not reveal any ocular pathology to account for the hemorrhage," the authors wrote.

"I think it's the double-whammying of the drugs, two anticoagulants at once," Dr. Hwang told Reuters. "All three patients were transitioning in treatment. At the time when they had the bleed, all of them were taking two medications. So we definitely think that the highest risk period for developing a bleeding is during this transition period when patients are stopping one medication and starting another one."

As the trend continues for switching patients from warfarin to rivaroxaban, so may the trend for patients to develop vitreous hemorrhage, he added, and clinicians should be aware of the potential risk and advise patients accordingly.

One study in 2013 found an association between use of aspirin, clopidogrel, and warfarin and vitreous hemorrhage (http://bit.ly/1Jl76YK). And a 2007 paper reported an association between warfarin and ocular bleeding (http://bit.ly/1Lx6BeC).

Janssen Pharmaceuticals issued the following statement in response to the JAMA Ophthalmology report: "Bleeding events are a known consequence of anticoagulation, and these types of bleeding events were identified in the clinical development program for Xarelto. We carefully monitor the safety performance of our medicine and Xarelto continues to perform as expected in the real-world setting, as evidenced by the 24 month results, in 39,000 patients, from our ongoing postmarketing safety surveillance program. We will continue to advance our real world data to ensure doctors and patients are equipped with the latest information about our medicine to optimize patient care."

In May, Janssen said at the American Geriatrics Society meeting that new data from their postmarketing study show that the safety profile of the drug in routine clinical practice is consistent with phase 3 clinical trial data, "which show a correlation between increased age and bleeding."

The authors of the case report made disclosures.

NEW YORK (Reuters Health) - Patients transitioning from warfarin to rivaroxaban for atrial fibrillation, who are taking both drugs before dropping warfarin, may be at risk for spontaneous vitreous hemorrhage, according to a new case report.

Judy H. Jun and Dr. John C. Hwang, of Retina Associates of Orange County in Laguna Hills, California, report three such cases of vitreous hemorrhage in an article online June 25 in JAMA Ophthalmology.

"It doesn't look like it's a huge phenomenon, but we're the first to report the association," said Dr. Hwang, also of the University of Southern California Eye Institute and Keck School of Medicine in Los Angeles.

Two men in their 70s and one in his 80s all presented with a vitreous hemorrhage of the right eye, confirmed by B-scan ultrasonography. They all were taking warfarin and rivaroxaban (Xarelto, Janssen) in transition to taking just rivaroxaban. They stopped taking warfarin and continued the rivaroxaban.

The vitreous hemorrhages in the first two cases largely resolved by a month after presentation and the men's visual acuity returned. For the third man, the vitreous hemorrhage resolved by two months and his visual acuity had largely returned.

"In all cases, an acute vitreous hemorrhage occurred shortly after rivaroxaban treatment was initiated. The vitreous hemorrhage resolved spontaneously in all cases and subsequent clinical and angiographic assessments did not reveal any ocular pathology to account for the hemorrhage," the authors wrote.

"I think it's the double-whammying of the drugs, two anticoagulants at once," Dr. Hwang told Reuters. "All three patients were transitioning in treatment. At the time when they had the bleed, all of them were taking two medications. So we definitely think that the highest risk period for developing a bleeding is during this transition period when patients are stopping one medication and starting another one."

As the trend continues for switching patients from warfarin to rivaroxaban, so may the trend for patients to develop vitreous hemorrhage, he added, and clinicians should be aware of the potential risk and advise patients accordingly.

One study in 2013 found an association between use of aspirin, clopidogrel, and warfarin and vitreous hemorrhage (http://bit.ly/1Jl76YK). And a 2007 paper reported an association between warfarin and ocular bleeding (http://bit.ly/1Lx6BeC).

Janssen Pharmaceuticals issued the following statement in response to the JAMA Ophthalmology report: "Bleeding events are a known consequence of anticoagulation, and these types of bleeding events were identified in the clinical development program for Xarelto. We carefully monitor the safety performance of our medicine and Xarelto continues to perform as expected in the real-world setting, as evidenced by the 24 month results, in 39,000 patients, from our ongoing postmarketing safety surveillance program. We will continue to advance our real world data to ensure doctors and patients are equipped with the latest information about our medicine to optimize patient care."

In May, Janssen said at the American Geriatrics Society meeting that new data from their postmarketing study show that the safety profile of the drug in routine clinical practice is consistent with phase 3 clinical trial data, "which show a correlation between increased age and bleeding."

The authors of the case report made disclosures.

(Reuters Health) - Overweight and obese people with type 2 diabetes may feel better after a meal if they start it off with vegetables or proteins and end with the carbs, suggests a new study of 11 people.

Finishing the broccoli and chicken before tucking into bread and fruit juice was tied to a lower rise in blood sugar levels over the next two hours, compared to eating the same foods in the opposite order, researchers report in Diabetes Care.

"When we saw the result, we were really encouraged that this is something that could potentially benefit people," said Dr.Louis Aronne, the study's senior author from Weill Cornell Medical College in New York.

Approximately 29 million Americans - about 9 percent of the U.S. population - have diabetes, according to the Centers for Disease Control and Prevention. About 30 percent of those people are undiagnosed.

Type 2 is the most common form of diabetes and is often linked to obesity. In type 2 diabetes, the body's cells are resistant to the hormone insulin, or the body doesn't make enough of it. Insulin helps the body's cells use glucose in the blood for fuel.

Drinking whey protein shakes before meals has been linked to lower blood sugar levels after eating, but little was known about the influence of foods, and the order in which they're consumed, on blood sugar levels following a meal, the researchers write.

Blood sugar normally rises after eating, but for people with diabetes it can spike dangerously. Diabetics are often told to avoid foods high on the glycemic index - a measure of how rapidly a food gets converted to glucose in the blood - like white breads and sugary drinks.

The new research suggests that people may benefit from timing their consumption of carbohydrates during a meal instead of simply avoiding certain foods.

The researchers recruited 11 people with type 2 diabetes who were all overweight or obese. They were also taking a drug called metformin, which helps to control blood sugar.

The participants all fasted for 12 hours overnight before consuming a 628 calorie meal with protein, carbohydrates and fat.

One week, they consumed the carbohydrates (ciabatta bread and orange juice) first. Then they ate skinless grilled chicken, a small salad and buttered steamed broccoli 15 minutes later.

The participants ate the same meal a week later, but the order of the foods was reversed, with the salad and broccoli first, then the chicken, then the carbs.

The researchers also took blood samples before the meals and 30, 60 and 120 minutes afterward.

When the participants ate vegetables and proteins first, their blood sugar levels were about 29 percent lower 30 minutes after starting the meal, compared to when they ate the carbs first. At 60 and 120 minutes after participants began eating, blood sugar levels were 37 percent and 17 percent lower, respectively, compared to when the carbs came first.

"It's possible what this is doing is delaying or tempering how fast the carbohydrates get absorbed," said Dr. Sethu Reddy, chief of the Adult Diabetes Section at the Joslin Diabetes Center in Boston.

"I think certainly it's an interesting study that says eating a good salad before your meal may help with glucose absorption," said Reddy, who was not involved with the new study.

The new study may not be the full story, Reddy told Reuters Health. For example, he said, it will be important to see what happens beyond two hours, and what's happening to the carbohydrates.

The researchers also say more studies with longer follow-up times are needed.

"We're doing the next study," Aronne told Reuters Health. "We're doing a longer study and we're looking at some of the other key hormones."

As of now, he said, the theory is that the absorption of the carbohydrates is somehow slowed down by eating vegetables, which are low on the glycemic index.

"This shows that the highly desired foods can be a part of a diet if we sneak them in there," Aronne said.

(Reuters Health) - Overweight and obese people with type 2 diabetes may feel better after a meal if they start it off with vegetables or proteins and end with the carbs, suggests a new study of 11 people.

Finishing the broccoli and chicken before tucking into bread and fruit juice was tied to a lower rise in blood sugar levels over the next two hours, compared to eating the same foods in the opposite order, researchers report in Diabetes Care.

"When we saw the result, we were really encouraged that this is something that could potentially benefit people," said Dr.Louis Aronne, the study's senior author from Weill Cornell Medical College in New York.

Approximately 29 million Americans - about 9 percent of the U.S. population - have diabetes, according to the Centers for Disease Control and Prevention. About 30 percent of those people are undiagnosed.

Type 2 is the most common form of diabetes and is often linked to obesity. In type 2 diabetes, the body's cells are resistant to the hormone insulin, or the body doesn't make enough of it. Insulin helps the body's cells use glucose in the blood for fuel.

Drinking whey protein shakes before meals has been linked to lower blood sugar levels after eating, but little was known about the influence of foods, and the order in which they're consumed, on blood sugar levels following a meal, the researchers write.

Blood sugar normally rises after eating, but for people with diabetes it can spike dangerously. Diabetics are often told to avoid foods high on the glycemic index - a measure of how rapidly a food gets converted to glucose in the blood - like white breads and sugary drinks.

The new research suggests that people may benefit from timing their consumption of carbohydrates during a meal instead of simply avoiding certain foods.

The researchers recruited 11 people with type 2 diabetes who were all overweight or obese. They were also taking a drug called metformin, which helps to control blood sugar.

The participants all fasted for 12 hours overnight before consuming a 628 calorie meal with protein, carbohydrates and fat.

One week, they consumed the carbohydrates (ciabatta bread and orange juice) first. Then they ate skinless grilled chicken, a small salad and buttered steamed broccoli 15 minutes later.

The participants ate the same meal a week later, but the order of the foods was reversed, with the salad and broccoli first, then the chicken, then the carbs.

The researchers also took blood samples before the meals and 30, 60 and 120 minutes afterward.

When the participants ate vegetables and proteins first, their blood sugar levels were about 29 percent lower 30 minutes after starting the meal, compared to when they ate the carbs first. At 60 and 120 minutes after participants began eating, blood sugar levels were 37 percent and 17 percent lower, respectively, compared to when the carbs came first.

"It's possible what this is doing is delaying or tempering how fast the carbohydrates get absorbed," said Dr. Sethu Reddy, chief of the Adult Diabetes Section at the Joslin Diabetes Center in Boston.

"I think certainly it's an interesting study that says eating a good salad before your meal may help with glucose absorption," said Reddy, who was not involved with the new study.

The new study may not be the full story, Reddy told Reuters Health. For example, he said, it will be important to see what happens beyond two hours, and what's happening to the carbohydrates.

The researchers also say more studies with longer follow-up times are needed.

"We're doing the next study," Aronne told Reuters Health. "We're doing a longer study and we're looking at some of the other key hormones."

As of now, he said, the theory is that the absorption of the carbohydrates is somehow slowed down by eating vegetables, which are low on the glycemic index.

"This shows that the highly desired foods can be a part of a diet if we sneak them in there," Aronne said.

(Reuters Health) - Overweight and obese people with type 2 diabetes may feel better after a meal if they start it off with vegetables or proteins and end with the carbs, suggests a new study of 11 people.

Finishing the broccoli and chicken before tucking into bread and fruit juice was tied to a lower rise in blood sugar levels over the next two hours, compared to eating the same foods in the opposite order, researchers report in Diabetes Care.

"When we saw the result, we were really encouraged that this is something that could potentially benefit people," said Dr.Louis Aronne, the study's senior author from Weill Cornell Medical College in New York.

Approximately 29 million Americans - about 9 percent of the U.S. population - have diabetes, according to the Centers for Disease Control and Prevention. About 30 percent of those people are undiagnosed.

Type 2 is the most common form of diabetes and is often linked to obesity. In type 2 diabetes, the body's cells are resistant to the hormone insulin, or the body doesn't make enough of it. Insulin helps the body's cells use glucose in the blood for fuel.

Drinking whey protein shakes before meals has been linked to lower blood sugar levels after eating, but little was known about the influence of foods, and the order in which they're consumed, on blood sugar levels following a meal, the researchers write.

Blood sugar normally rises after eating, but for people with diabetes it can spike dangerously. Diabetics are often told to avoid foods high on the glycemic index - a measure of how rapidly a food gets converted to glucose in the blood - like white breads and sugary drinks.

The new research suggests that people may benefit from timing their consumption of carbohydrates during a meal instead of simply avoiding certain foods.

The researchers recruited 11 people with type 2 diabetes who were all overweight or obese. They were also taking a drug called metformin, which helps to control blood sugar.

The participants all fasted for 12 hours overnight before consuming a 628 calorie meal with protein, carbohydrates and fat.

One week, they consumed the carbohydrates (ciabatta bread and orange juice) first. Then they ate skinless grilled chicken, a small salad and buttered steamed broccoli 15 minutes later.

The participants ate the same meal a week later, but the order of the foods was reversed, with the salad and broccoli first, then the chicken, then the carbs.

The researchers also took blood samples before the meals and 30, 60 and 120 minutes afterward.

When the participants ate vegetables and proteins first, their blood sugar levels were about 29 percent lower 30 minutes after starting the meal, compared to when they ate the carbs first. At 60 and 120 minutes after participants began eating, blood sugar levels were 37 percent and 17 percent lower, respectively, compared to when the carbs came first.

"It's possible what this is doing is delaying or tempering how fast the carbohydrates get absorbed," said Dr. Sethu Reddy, chief of the Adult Diabetes Section at the Joslin Diabetes Center in Boston.

"I think certainly it's an interesting study that says eating a good salad before your meal may help with glucose absorption," said Reddy, who was not involved with the new study.

The new study may not be the full story, Reddy told Reuters Health. For example, he said, it will be important to see what happens beyond two hours, and what's happening to the carbohydrates.

The researchers also say more studies with longer follow-up times are needed.

"We're doing the next study," Aronne told Reuters Health. "We're doing a longer study and we're looking at some of the other key hormones."

As of now, he said, the theory is that the absorption of the carbohydrates is somehow slowed down by eating vegetables, which are low on the glycemic index.

"This shows that the highly desired foods can be a part of a diet if we sneak them in there," Aronne said.

(Reuters Health) - For overweight and obese people with atrial fibrillation, improving cardiorespiratory fitness with exercise may help to reduce or eliminate symptoms, a recent Australian study found.

Participants with the greatest improvements in their cardiorespiratory fitness were less burdened by symptoms of the arrhythmia and more likely to be symptom free during the study, compared to those who had smaller or no fitness improvements.

A possible side effect of the cardio exercise regimen, weight loss, may have also contributed to the improvements, researchers say.

Atrial fibrillation (AF) is a "growing epidemic" and obesity is a risk factor, the study's lead author Prash Sanders, director of the Center for Heart Rhythm Disorders at Royal Adelaide Hospital, told Reuters Health in an email.

The researchers examined the role of cardiorespiratory fitness and the incremental benefit of cardiorespiratory fitness improvement on rhythm control in 308 overweight and obese individuals with AF.

At the start of the study and four years later, participants completed questionnaires about their AF symptoms. The researchers also had patients wear a heart monitor for seven days at a time.

Based on baseline exercise stress testing, 95 people were classified as having low cardiorespiratory fitness, 134 had adequate fitness and 79 were classified as high fitness, Sanders and colleagues report in the Journal of the American College of Cardiology online June 22.

The research team prescribed the patients an exercise program tailored to their age and physical ability, which gradually increased in intensity.

By the end of four years, those who had increased their fitness levels by two metabolic equivalents (METs) or more, and those who lost weight were more likely to have reduced or no AF symptoms than those who improved by less than two METs or not at all.

Though increasing cardiorespiratory fitness seems to be beneficial, Dr. Michael Lloyd, a cardiologist at Emory University Hospital in Atlanta, Georgia, advises caution. "Overweight people should check with their doctor prior to embarking on any exercise program," said Lloyd, who was not involved in the study.

Sanders recommends a tailored exercise program, "in which consideration for age and physical ability should be made so that targets are achieved without risking injuries."

Dr. Waqas Qureshi, a cardiology researcher at Wake Forest University in Winston-Salem, North Carolina, who also was not involved in the study, noted that weight loss from exercise may add to the protection against heart irregularities.

Lloyd, however, emphasized that cardiorespiratory fitness is beneficial even apart from weight loss. "If you are overweight, it's not just the pounds that matter, it's how fit you are. This study shows that increasing your fitness through exercise and lifestyle choices does reduce your chance of having the most common arrhythmia."

(Reuters Health) - For overweight and obese people with atrial fibrillation, improving cardiorespiratory fitness with exercise may help to reduce or eliminate symptoms, a recent Australian study found.

Participants with the greatest improvements in their cardiorespiratory fitness were less burdened by symptoms of the arrhythmia and more likely to be symptom free during the study, compared to those who had smaller or no fitness improvements.

A possible side effect of the cardio exercise regimen, weight loss, may have also contributed to the improvements, researchers say.

Atrial fibrillation (AF) is a "growing epidemic" and obesity is a risk factor, the study's lead author Prash Sanders, director of the Center for Heart Rhythm Disorders at Royal Adelaide Hospital, told Reuters Health in an email.

The researchers examined the role of cardiorespiratory fitness and the incremental benefit of cardiorespiratory fitness improvement on rhythm control in 308 overweight and obese individuals with AF.

At the start of the study and four years later, participants completed questionnaires about their AF symptoms. The researchers also had patients wear a heart monitor for seven days at a time.

Based on baseline exercise stress testing, 95 people were classified as having low cardiorespiratory fitness, 134 had adequate fitness and 79 were classified as high fitness, Sanders and colleagues report in the Journal of the American College of Cardiology online June 22.

The research team prescribed the patients an exercise program tailored to their age and physical ability, which gradually increased in intensity.

By the end of four years, those who had increased their fitness levels by two metabolic equivalents (METs) or more, and those who lost weight were more likely to have reduced or no AF symptoms than those who improved by less than two METs or not at all.

Though increasing cardiorespiratory fitness seems to be beneficial, Dr. Michael Lloyd, a cardiologist at Emory University Hospital in Atlanta, Georgia, advises caution. "Overweight people should check with their doctor prior to embarking on any exercise program," said Lloyd, who was not involved in the study.

Sanders recommends a tailored exercise program, "in which consideration for age and physical ability should be made so that targets are achieved without risking injuries."

Dr. Waqas Qureshi, a cardiology researcher at Wake Forest University in Winston-Salem, North Carolina, who also was not involved in the study, noted that weight loss from exercise may add to the protection against heart irregularities.

Lloyd, however, emphasized that cardiorespiratory fitness is beneficial even apart from weight loss. "If you are overweight, it's not just the pounds that matter, it's how fit you are. This study shows that increasing your fitness through exercise and lifestyle choices does reduce your chance of having the most common arrhythmia."

(Reuters Health) - For overweight and obese people with atrial fibrillation, improving cardiorespiratory fitness with exercise may help to reduce or eliminate symptoms, a recent Australian study found.

Participants with the greatest improvements in their cardiorespiratory fitness were less burdened by symptoms of the arrhythmia and more likely to be symptom free during the study, compared to those who had smaller or no fitness improvements.

A possible side effect of the cardio exercise regimen, weight loss, may have also contributed to the improvements, researchers say.

Atrial fibrillation (AF) is a "growing epidemic" and obesity is a risk factor, the study's lead author Prash Sanders, director of the Center for Heart Rhythm Disorders at Royal Adelaide Hospital, told Reuters Health in an email.

The researchers examined the role of cardiorespiratory fitness and the incremental benefit of cardiorespiratory fitness improvement on rhythm control in 308 overweight and obese individuals with AF.

At the start of the study and four years later, participants completed questionnaires about their AF symptoms. The researchers also had patients wear a heart monitor for seven days at a time.

Based on baseline exercise stress testing, 95 people were classified as having low cardiorespiratory fitness, 134 had adequate fitness and 79 were classified as high fitness, Sanders and colleagues report in the Journal of the American College of Cardiology online June 22.

The research team prescribed the patients an exercise program tailored to their age and physical ability, which gradually increased in intensity.

By the end of four years, those who had increased their fitness levels by two metabolic equivalents (METs) or more, and those who lost weight were more likely to have reduced or no AF symptoms than those who improved by less than two METs or not at all.

Though increasing cardiorespiratory fitness seems to be beneficial, Dr. Michael Lloyd, a cardiologist at Emory University Hospital in Atlanta, Georgia, advises caution. "Overweight people should check with their doctor prior to embarking on any exercise program," said Lloyd, who was not involved in the study.

Sanders recommends a tailored exercise program, "in which consideration for age and physical ability should be made so that targets are achieved without risking injuries."

Dr. Waqas Qureshi, a cardiology researcher at Wake Forest University in Winston-Salem, North Carolina, who also was not involved in the study, noted that weight loss from exercise may add to the protection against heart irregularities.

Lloyd, however, emphasized that cardiorespiratory fitness is beneficial even apart from weight loss. "If you are overweight, it's not just the pounds that matter, it's how fit you are. This study shows that increasing your fitness through exercise and lifestyle choices does reduce your chance of having the most common arrhythmia."

(Reuters Health) - Patients with hypertension who regularly take non-steroidal anti-inflammatory drugs (NSAIDs) may increase their risk of developing chronic kidney disease, a study from Taiwan suggests.

The researchers examined data on more than 30,000 people with hypertension and found that those who'd been taking NSAIDs for at least three months were 32% more likely to have chronic kidney disease than participants who didn't use NSAIDs.

In addition, participants who typically took NSAIDs more than once a day had a 23% greater risk of developing chronic kidney disease than people who didn't use the pills.

Even if patients used NSAIDs for less than three months, they still had an 18% higher risk of developing chronic kidney disease, the study found.

"Our results suggest that NSAID duration plays a role in chronic kidney disease among subjects with hypertension," said senior study author Hui-Ju Tsai, a scientist at the Institute of Population Health Sciences, National Health Research Institutes in Zhunan.

"Physicians should exercise caution when administering NSAIDs to people with hypertension and closely monitor renal function," Tsai said by email.

One shortcoming of the study is a lack of blood test data to confirm the severity of kidney disease, the authors noted online July 13 in Hypertension. It's also possible that some patients with kidney disease weren't identified due to a lack of clinical or laboratory data.

In addition, the study only tracked prescription NSAID use. In Taiwan, the vast majority of people taking these drugs get prescriptions because the cost is much lower than it would be for over-the-counter versions of the drugs, the authors point out.

While past research has suggested that kidney damage linked to NSAIDs might be reversed if the drugs are stopped, the current study points to the possibility that long-term use of these painkillers might lead to permanently impaired renal function, said Dr. Liffert Vogt, a nephrologist at Academic Medical Center at the University of Amsterdam in The Netherlands.

NSAIDs can cause the kidney to retain salts and water, prompting a rise in blood pressure and potentially making medications to lower hypertension ineffective, Vogt, who wasn't involved in the study, said by email.

"When a patient is already treated with a blood pressure lowering drug, NSAIDs should be avoided," Vogt said. "The negative effects of NSAIDs on the kidneys can be explained by their effects on blood pressure control."

(Reuters Health) - Patients with hypertension who regularly take non-steroidal anti-inflammatory drugs (NSAIDs) may increase their risk of developing chronic kidney disease, a study from Taiwan suggests.

The researchers examined data on more than 30,000 people with hypertension and found that those who'd been taking NSAIDs for at least three months were 32% more likely to have chronic kidney disease than participants who didn't use NSAIDs.

In addition, participants who typically took NSAIDs more than once a day had a 23% greater risk of developing chronic kidney disease than people who didn't use the pills.

Even if patients used NSAIDs for less than three months, they still had an 18% higher risk of developing chronic kidney disease, the study found.

"Our results suggest that NSAID duration plays a role in chronic kidney disease among subjects with hypertension," said senior study author Hui-Ju Tsai, a scientist at the Institute of Population Health Sciences, National Health Research Institutes in Zhunan.

"Physicians should exercise caution when administering NSAIDs to people with hypertension and closely monitor renal function," Tsai said by email.

One shortcoming of the study is a lack of blood test data to confirm the severity of kidney disease, the authors noted online July 13 in Hypertension. It's also possible that some patients with kidney disease weren't identified due to a lack of clinical or laboratory data.

In addition, the study only tracked prescription NSAID use. In Taiwan, the vast majority of people taking these drugs get prescriptions because the cost is much lower than it would be for over-the-counter versions of the drugs, the authors point out.

While past research has suggested that kidney damage linked to NSAIDs might be reversed if the drugs are stopped, the current study points to the possibility that long-term use of these painkillers might lead to permanently impaired renal function, said Dr. Liffert Vogt, a nephrologist at Academic Medical Center at the University of Amsterdam in The Netherlands.

NSAIDs can cause the kidney to retain salts and water, prompting a rise in blood pressure and potentially making medications to lower hypertension ineffective, Vogt, who wasn't involved in the study, said by email.

"When a patient is already treated with a blood pressure lowering drug, NSAIDs should be avoided," Vogt said. "The negative effects of NSAIDs on the kidneys can be explained by their effects on blood pressure control."

(Reuters Health) - Patients with hypertension who regularly take non-steroidal anti-inflammatory drugs (NSAIDs) may increase their risk of developing chronic kidney disease, a study from Taiwan suggests.

The researchers examined data on more than 30,000 people with hypertension and found that those who'd been taking NSAIDs for at least three months were 32% more likely to have chronic kidney disease than participants who didn't use NSAIDs.

In addition, participants who typically took NSAIDs more than once a day had a 23% greater risk of developing chronic kidney disease than people who didn't use the pills.

Even if patients used NSAIDs for less than three months, they still had an 18% higher risk of developing chronic kidney disease, the study found.

"Our results suggest that NSAID duration plays a role in chronic kidney disease among subjects with hypertension," said senior study author Hui-Ju Tsai, a scientist at the Institute of Population Health Sciences, National Health Research Institutes in Zhunan.

"Physicians should exercise caution when administering NSAIDs to people with hypertension and closely monitor renal function," Tsai said by email.

One shortcoming of the study is a lack of blood test data to confirm the severity of kidney disease, the authors noted online July 13 in Hypertension. It's also possible that some patients with kidney disease weren't identified due to a lack of clinical or laboratory data.

In addition, the study only tracked prescription NSAID use. In Taiwan, the vast majority of people taking these drugs get prescriptions because the cost is much lower than it would be for over-the-counter versions of the drugs, the authors point out.

While past research has suggested that kidney damage linked to NSAIDs might be reversed if the drugs are stopped, the current study points to the possibility that long-term use of these painkillers might lead to permanently impaired renal function, said Dr. Liffert Vogt, a nephrologist at Academic Medical Center at the University of Amsterdam in The Netherlands.

NSAIDs can cause the kidney to retain salts and water, prompting a rise in blood pressure and potentially making medications to lower hypertension ineffective, Vogt, who wasn't involved in the study, said by email.

"When a patient is already treated with a blood pressure lowering drug, NSAIDs should be avoided," Vogt said. "The negative effects of NSAIDs on the kidneys can be explained by their effects on blood pressure control."

NEW YORK (Reuters Health) - For patients with low-risk venous thromboembolism (VTE) who can safely be discharged from the emergency department, rivaroxaban is a less costly treatment than heparin and warfarin, according to results of a case-control study.

"The biggest surprise to me was that using the Hestia criteria in the emergency department produced a low-enough risk population that we had zero incidence of either recurrent clots or bleeding," Dr. Jeffrey A. Kline, from Indiana University School of Medicine in Indianapolis, told Reuters Health by email. "The second surprise was the strength of gratitude by the patients that they did not have to have injections and take warfarin."

Dr. Kline's team developed a protocol for home treatment of low-risk patients with VTE using a target-specific anticoagulant like rivaroxaban. They compared the costs of medical care accrued by 50 patients treated with rivaroxaban and 47 matched controls who received bridging low-molecular-weight heparin (LMWH) for five to seven days and were then transitioned to warfarin.

All 50 rivaroxaban patients were discharged home from the emergency department on the day of diagnosis, whereas only 18 control patients were treated at home, according to the June 25 Academic Emergency Medicine online report.

Over the six months of follow-up, median total charges were $4787 with rivaroxaban, compared with $11,128 with LMWH-warfarin.

When the analysis was confined to patients who were never hospitalized, rivaroxaban was still less costly (median, $5932 vs $9016), although the difference was not statistically significant.

In-patient pharmacy median charges were significantly less with rivaroxaban than with LMWH-warfarin (median, $215 vs $742), but a survey of hospital outpatient pharmacies found the median cash cost of rivaroxaban to be significantly higher than that of LMWH-warfarin ($1856 vs $724 for six months).

"In low-risk patients, target-specific anticoagulants require minimal maintenance, and patients can be managed with no coagulation testing at all, and almost no other laboratory monitoring unless other factors suggest anemia or a reason to suspect change in renal function," Dr. Kline said.

Dr. Nathan T. Connell, from Brigham and Women's Hospital in Boston, told Reuters Health by email, "Recently, there has been a lot of discussion about cost differences between various anticoagulation strategies. This paper helps put the cost in perspective and that treatment with rivaroxaban may be more cost-effective in the long term."

"This difference went away when hospitalized patients were removed from the analysis, suggesting that the cost of hospitalization was the major driver for cost difference between the two strategies," Dr. Connell said. "For well-selected low-risk patients, however, rivaroxaban is an attractive choice because it often allows direct discharge from the Emergency Department. Also, we know from other studies that the risk of certain types of serious bleeding, such as intracerebral hemorrhage, is lower with rivaroxaban as compared to warfarin."

Dr. Connell noted, "This is a retrospective study, which can have issues with selection bias. The authors took several steps to minimize this bias, such as matching on a comorbidity score, in an attempt to make sure the two comparison groups were as balanced as possible."

NEW YORK (Reuters Health) - For patients with low-risk venous thromboembolism (VTE) who can safely be discharged from the emergency department, rivaroxaban is a less costly treatment than heparin and warfarin, according to results of a case-control study.

"The biggest surprise to me was that using the Hestia criteria in the emergency department produced a low-enough risk population that we had zero incidence of either recurrent clots or bleeding," Dr. Jeffrey A. Kline, from Indiana University School of Medicine in Indianapolis, told Reuters Health by email. "The second surprise was the strength of gratitude by the patients that they did not have to have injections and take warfarin."

Dr. Kline's team developed a protocol for home treatment of low-risk patients with VTE using a target-specific anticoagulant like rivaroxaban. They compared the costs of medical care accrued by 50 patients treated with rivaroxaban and 47 matched controls who received bridging low-molecular-weight heparin (LMWH) for five to seven days and were then transitioned to warfarin.

All 50 rivaroxaban patients were discharged home from the emergency department on the day of diagnosis, whereas only 18 control patients were treated at home, according to the June 25 Academic Emergency Medicine online report.

Over the six months of follow-up, median total charges were $4787 with rivaroxaban, compared with $11,128 with LMWH-warfarin.

When the analysis was confined to patients who were never hospitalized, rivaroxaban was still less costly (median, $5932 vs $9016), although the difference was not statistically significant.

In-patient pharmacy median charges were significantly less with rivaroxaban than with LMWH-warfarin (median, $215 vs $742), but a survey of hospital outpatient pharmacies found the median cash cost of rivaroxaban to be significantly higher than that of LMWH-warfarin ($1856 vs $724 for six months).

"In low-risk patients, target-specific anticoagulants require minimal maintenance, and patients can be managed with no coagulation testing at all, and almost no other laboratory monitoring unless other factors suggest anemia or a reason to suspect change in renal function," Dr. Kline said.

Dr. Nathan T. Connell, from Brigham and Women's Hospital in Boston, told Reuters Health by email, "Recently, there has been a lot of discussion about cost differences between various anticoagulation strategies. This paper helps put the cost in perspective and that treatment with rivaroxaban may be more cost-effective in the long term."

"This difference went away when hospitalized patients were removed from the analysis, suggesting that the cost of hospitalization was the major driver for cost difference between the two strategies," Dr. Connell said. "For well-selected low-risk patients, however, rivaroxaban is an attractive choice because it often allows direct discharge from the Emergency Department. Also, we know from other studies that the risk of certain types of serious bleeding, such as intracerebral hemorrhage, is lower with rivaroxaban as compared to warfarin."

Dr. Connell noted, "This is a retrospective study, which can have issues with selection bias. The authors took several steps to minimize this bias, such as matching on a comorbidity score, in an attempt to make sure the two comparison groups were as balanced as possible."

NEW YORK (Reuters Health) - For patients with low-risk venous thromboembolism (VTE) who can safely be discharged from the emergency department, rivaroxaban is a less costly treatment than heparin and warfarin, according to results of a case-control study.

"The biggest surprise to me was that using the Hestia criteria in the emergency department produced a low-enough risk population that we had zero incidence of either recurrent clots or bleeding," Dr. Jeffrey A. Kline, from Indiana University School of Medicine in Indianapolis, told Reuters Health by email. "The second surprise was the strength of gratitude by the patients that they did not have to have injections and take warfarin."

Dr. Kline's team developed a protocol for home treatment of low-risk patients with VTE using a target-specific anticoagulant like rivaroxaban. They compared the costs of medical care accrued by 50 patients treated with rivaroxaban and 47 matched controls who received bridging low-molecular-weight heparin (LMWH) for five to seven days and were then transitioned to warfarin.

All 50 rivaroxaban patients were discharged home from the emergency department on the day of diagnosis, whereas only 18 control patients were treated at home, according to the June 25 Academic Emergency Medicine online report.

Over the six months of follow-up, median total charges were $4787 with rivaroxaban, compared with $11,128 with LMWH-warfarin.

When the analysis was confined to patients who were never hospitalized, rivaroxaban was still less costly (median, $5932 vs $9016), although the difference was not statistically significant.

In-patient pharmacy median charges were significantly less with rivaroxaban than with LMWH-warfarin (median, $215 vs $742), but a survey of hospital outpatient pharmacies found the median cash cost of rivaroxaban to be significantly higher than that of LMWH-warfarin ($1856 vs $724 for six months).

"In low-risk patients, target-specific anticoagulants require minimal maintenance, and patients can be managed with no coagulation testing at all, and almost no other laboratory monitoring unless other factors suggest anemia or a reason to suspect change in renal function," Dr. Kline said.

Dr. Nathan T. Connell, from Brigham and Women's Hospital in Boston, told Reuters Health by email, "Recently, there has been a lot of discussion about cost differences between various anticoagulation strategies. This paper helps put the cost in perspective and that treatment with rivaroxaban may be more cost-effective in the long term."

"This difference went away when hospitalized patients were removed from the analysis, suggesting that the cost of hospitalization was the major driver for cost difference between the two strategies," Dr. Connell said. "For well-selected low-risk patients, however, rivaroxaban is an attractive choice because it often allows direct discharge from the Emergency Department. Also, we know from other studies that the risk of certain types of serious bleeding, such as intracerebral hemorrhage, is lower with rivaroxaban as compared to warfarin."

Dr. Connell noted, "This is a retrospective study, which can have issues with selection bias. The authors took several steps to minimize this bias, such as matching on a comorbidity score, in an attempt to make sure the two comparison groups were as balanced as possible."