(Circulation. 2001;103:e9007.)
© 2001 American Heart Association, Inc.
Cardiovascular News
Although he called his Children’s Health Insurance Program (CHIP) a success because it has brought 3.3 million youngsters into the program since it began 3 years ago, President Clinton in the waning days of his administration announced new rules that he said he hoped would make the program accessible to at least 1.7 million more—the goal he has set for the program.
The new rules would allow states to use school lunch enrollment data to contact families who may be eligible for the program, which targets children whose parents make too much to qualify them for Medicare but still cannot afford to provide health insurance to their families. Under the new plan, parents can enroll their children in CHIP or Medicaid at the same time that they fill out applications at day care centers, in school nurse offices, or other convenient locations. Finally, the President said employers will be able to insure the children of low-wage workers and have most of the cost picked up by CHIP.
In a January 6 radio broadcast, President Clinton urged parents of children who are now uninsured to call 1-877-KIDS NOW to receive more information about the insurance program.
In that same week, the new director of the National Center for Minority Health and Health Disparities, John Ruffin, PhD, was sworn in; he is a symbol of the Clinton Administration’s attempt to attack the disparities in health status and healthcare delivery among racial and ethnic groups. "While the diversity of the American population is one of the Nation’s greatest assets, one of its greatest challenges is reducing the profound disparity in health status of America’s racial and ethnic minorities, Appalachian residents, and other similar groups, compared to the population as a whole. And although some of the causes of disparate health outcomes, such as differences in access to care, are beyond the scope of biomedical and biobehavioral research, the National Institutes of Health (NIH) can play a vital role in addressing and easing health disparities involving cancer, diabetes, infant mortality, AIDS, cardiovascular illnesses, and many other diseases. The NIH has made health disparities a budget priority and an area of emphasis," Dr Ruffin explained.
The NIH is also seeking to improve the visibility of minority health disparities research and other health disparities research, as well as to expand the role of such research in learning why some groups have proportionately high rates of disease.
Yet at the same time that the Clinton Administration was demonstrating some of its successes, the Institute of Medicine (IOM) was recommending broad changes in the way health care is delivered and monitored for quality (Informing the Future: Critical Issues in Health. Washington, DC: National Academy of Sciences; 2001). In a wide-ranging report, the unofficial conscience of the nation’s healthcare system recommended strategies for reducing medical errors, revamping Medicare to deal with an aging population, and improving the surveillance systems designed to reduce the effects of infectious disease in the developing world.
In an interview with Reuters Health, IOM president Dr Kenneth Shine said that the report calls for "a new vision" that views health care as an interdependent system of physicians, pharmacists, private insurance, and information management rather than a collection of individual doctor-patient relationships. The new report leaned heavily on findings in a prior IOM study on medical errors; this previous report shocked the nation and evoked immediate action toward improving the situation.
However, the new report takes a system approach to the problem rather than pointing the finger of blame in individual circumstances. For example, the report states "that errors can best be prevented by designing systems that make it harder for healthcare professionals and other healthcare workers to make mistakes and easier for them to do the right thing. Even well-trained, conscientious people working in poorly designed and managed systems will sometimes commit serious errors. Medical errors will be reduced and patient safety increased by focusing on the design and management of good systems."
In a section on demographics, the report calls for states and the federal government to protect the healthcare safety net. Federal programs and policies targeted to support the safety net and the populations it serves should be reviewed for effectiveness in meeting the needs of uninsured people. The nation’s capacity to monitor the changing structure and financial stability of the safety net must be improved. The report also calls for health insurance for all the nation’s children and careful assessment and research into the reasons for disparities in disease among the nation’s ethnic and racial minorities. Under the heading of healthcare delivery, the report calls for improvements in the treatment provided to dying patients, including a revision in payment systems to remove barriers to systems that provide such treatments. In addition, the report calls for better care in nursing homes, including a congressional requirement that registered nurses be present in all nursing homes 24 hours a day, 7 days a week. The authors of the report warned that such requirements might require increasing payments from Medicare and Medicaid to make such staffing levels possible.
The report further calls for closer cooperation between medicine and public health and a redefinition of the role of public health in preventing disease. Specifically, the report addresses the need for a comprehensive, effective, and efficient strategy for preventing infection with HIV, which causes AIDS. "It will be necessary to improve the way the epidemic is monitored, change how prevention resources are allocated, change how activities are prioritized and conducted, foster interactions between the public and private sectors to promote new prevention tools and technologies, and reduce or eliminate social barriers to HIV prevention," the report said, quoting an earlier publication, No Time to Lose: Getting More from HIV Prevention (National Academy of Sciences Press, 1986).
The IOM also called for "development and support" of a national system for controlling sexually transmitted diseases in the United States. The organization also called for a renewed effort to fight tuberculosis, noting that it might be possible "to virtually eliminate tuberculosis in the United States over the next decade," referring to a report issued in the year 2000, Ending Neglect: The Elimination of Tuberculosis in the United States. (National Academy of Sciences Press).
The report repeatedly refers to previous statements from the IOM; these statements created a sense of concern at the time but were quickly forgotten or only imperfectly put into practice at the legislative level. Yet in a poll released January 10, 2000 by the Robert Wood Johnson Foundation, 82% of Americans said they would pay more taxes if by doing so they could insure that families and children would have access to affordable health insurance. Of those surveyed, 91% said the new president and Congress should make the approval of laws to help the uninsured receive health coverage an issue ranking just behind protecting Medicare and Social Security.
Food and Drug Administration Issues New Rules to Insure Safety of Cellular and Tissue-Based Products
On January 5, 2000, the US Food and Drug Administration (FDA) issued new rules to insure that the donors of human cellular and tissue-based products are free of infectious or communicable diseases and that such products do not become contaminated in the manufacturing process.
Under the proposed rules, the manufacturers of such products would have to establish practices, rules, and record-keeping and monitoring procedures to insure the safety of their products. They would be required to report all adverse reactions and some product quality deviations. The labeling should be adequate and without false or misleading statements. They should also allow FDA inspections to insure that they are complying with regulations.
Another Step Toward Polio Eradication, This Time in the Western Pacific
The World Health Organization (WHO) declared the Western Pacific Region free of indigenous wild poliovirus transmission, another milestone on the way to the total eradication of the disease. According to WHO, the last known case of indigenous poliovirus transmission occurred in Cambodia in March 1997, when a 15-month-old girl contracted the disease.
The Western Pacific Region comprises 37 countries and territories with an estimated population of 1.6 billion people. It is the second such region to be declared free of wild poliovirus. The first was the Region of the Americas, which was declared free of wild poliovirus in 1995. In 1988, the Global Poliomyelitis Eradication Initiative was established by the World Health Assembly and was coordinated by WHO, the United Nations Children’s Fund (UNICEF), Rotary International, and the Centers for Disease Control (CDC); it is the largest public health effort ever established for disease eradication.
Letter Follows-Up First Coronary Angioplasty Patient
A short letter in the January 11, 2001 issue of the New England Journal of Medicine revisited a medical breakthrough: the first patient ever to receive coronary angioplasty.
The procedure took place September 16, 1977, in a 38-year-old man who had a high-grade, discrete stenosis of the proximal left anterior descending coronary artery just before the first large diagonal branch, wrote Bernhard Meier, MD, of the Swiss Cardiovascular Center in Bern, who was the first to see the patient. "I told the patient that Dr Andreas Gruentzig (credited with developing the technique) would offer him an alternative to bypass," Dr Meier wrote.
Dr Gruentzig warned the patient that procedure had only been done in patients with peripheral artery stenoses; however, the patient readily agreed to the procedure, although he knew that he might have to undergo a coronary bypass procedure if there were problems. The angioplasty was done without complications and seemed to have eliminated the patient’s symptoms, Dr Meier wrote.
The patient took measures to eliminate the problem himself, Dr Meier noted. He gave up cigarettes and, on the 20th anniversary of the procedure, agreed to take aspirin and a statin for an elevated cholesterol level. In the year 2000, the man was 61 years old and reported recurrent chest discomfort for the first time. He underwent coronary angiography on April 10, 2000. The physicians found that the area that had been dilated earlier was still open and that there were only a few minor abnormalities elsewhere. A subsequent exercise stress test showed normal results.
"Dr Gruentzig and his wife died in an airplane crash on October 27, 1985," Dr Meier wrote. "I do not believe that Dr Gruentzig would have dreamed that his first patient could remain free of recurrent symptoms of coronary artery disease for such a long time" (N Engl J Med. 2001;344:144–145).\.
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