At least seven cities or towns across the country debated it just this summer.

For example, , decided to add fluoride back into the water in July after the city council voted two years ago to remove it. Across the country in , voters will revisit a ballot question in November regarding whether to stop adding the mineral to the water supply.

“There has always been periodic discussion,” said , a dentistry professor at the University of Iowa. Levy is involved in an Iowa-based longitudinal study that tracks fluoride intake and its effects on children’s bones. “We are seeing more challenges now because of the communication explosion with the internet.”

The debate started well before 1945 when Grand Rapids, Mich., became the first U.S. city to add fluoride to its water supply. In the decades since, opposition usually stems from studies linking fluoride intake by children with lower IQs, higher rates of attention deficit/hyperactivity disorder and potential toxicity.

Still, fluoridation has become a fairly common practice, with about 74 percent of the population receiving fluoridated water from community water systems, according to the . But the intervention, which is considered by the CDC to be one of the 10 top public health achievements of the 20thÌýcentury and backed by the American Dental Association and the World Health Organization, also continues to raise grass roots concerns. These range from casting fluoride as unnecessary and ineffective to efforts to paint the mineral as “mass medication” and a “damaging environmental pollutant.”

“I watch the videos that they email me, I read the information they send me,” Gerwig said. Gerwig has no background in science, but she read studies and fact-checked the claims being made by the town’s residents. Gerwig said she decided to support fluoridation after she found scientific consensus about the benefits of fluoridation in preventing tooth decay.

The CDC, for instance, water fluoridation to be the most cost-effective method of delivering fluoride to all, reducing tooth decay by 25 percent in children and adults. is still one of the most common chronic conditions among children.

“A big thing about community water fluoridation is that it’s a passive intervention, you don’t really have to do anything other than drink tap water,” said Katherine Weno, oral health director at the CDC. “You don’t have to buy a product or access to a dental professional. It people who don’t have money to go to a dentist or don’t have any insurance.”

But some question the need for continued fluoridation, especially as products such as toothpaste and rinses containing fluoride are available, and because the chemical’s levels vary and indications of harm are not always clear.

, an adjunct professor at Harvard University School of Public Health, has authored a questioning the need for the added fluoride.

“Our dental health is clearly much less dependent on fluoride in drinking water than way back when this important public health intervention was initiated,” Grandjean said.

In a 2016 , Grandjean commented about the need for more research about populations that may be vulnerable to the mineral and the proper dose of it in drinking water. In response, the article drew multiple critical .

“The article misrepresents the current state of the science of community water fluoridation, and does not provide a fair and balanced perspective,” wrote Francis Kim and Scott L. Tomar from the American Association of Public Health Dentistry and Bruce Donoff, dean of the Harvard School of Dental Medicine in .

New studies are published almost every year that bring up concerns about fluoridation in drinking water, linking the intake with various and even , issues that Osmunson also brought up. Weno and Levy said those studies were performed in places where natural fluoride levels are higher and where residents may get fluoride through milk or salt rather than water. Excessive fluoride intake does have health implications —Ìý commonly found in places with high concentrations of natural fluoride such as China, India and Africa. receive water with low natural levels of fluoride.

Health officials also monitor and review what is appropriate. The Department of Health and Human Services in April 2015 released new recommendations for fluoride levels in drinking water, updating and replacing the level in place since 1962 in order to reflect the fact that Americans now have more sources of fluoride in toothpaste, mouthwashes and other products.

But other towns continue to wrestle with the issue. In July, the commissioners of , voted to stop adding fluoride and Ìýcity council chose to leave it in. In August, , stopped fluoridation until voters decide in November 2017.

And for some of the local officials involved in these debates, their take on the issue is part of even greater political questions.

“The individuals who benefit the most are poor children,” said , mayor pro tem of Durango, Colo. The town to continue adding fluoride to its water. “If we get national health care for every single person, we could probably eliminate fluoridation in the water because we can ensure that every child is getting dental care.”

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Eventually, the pain often lands these patients in hospital emergency rooms, which also may not have the facilities to deal with the overall dental care they need. Instead, they are with pain medications, antibiotics and referrals back to community health centers.

It’s a problem experienced around the country —Ìýbut in some areas, health centers and emergency departments are experimenting with a variety of programs that aim to divert patients with dental complaints into specialty clinics.

“Dental access has been so limited and care has been episodic for so many people or not at all,” said , chief dental officer of Neighborcare Health, a network of health centers in Seattle. In 2015, the clinic employed about 20 dentists who saw 60,545 patients. “It just created a lot of people who have end-stage disease for their teeth with no other options but to have multiple or all of their teeth removed.”

In Washington’s King County, which includes Seattle, dentists from health centers voiced their frustrations about the gap in dental care to the local dental society. To address the problem, in 2011 established a pilot project that connects Swedish Medical Center, a large nonprofit health care provider in Seattle; its dental residents, or dentists who have finished school but are in training; oral surgeons and health centers in the county in a streamlined system of referrals that will see any Medicaid and uninsured patients.

Here’s how it works: Patients with non-life-threatening dental emergencies who visit the hospital’s emergency department will be referred to a Neighborcare Health center. The health center will perform checkups, provide dental care and serve as a “home” for the patient. Those patients needing more complex dental surgery will be referred to the housed within the hospital. The clinic offers procedures that the local health centers may not be able to handle, such as difficult extractions, surgeries for pre-prosthetic preparation and medically complex patients. The clinic accepts Medicaid coverage. It will provide the service at reduced cost for Medicaid patients and free for uninsured patients under a certain income threshold who cannot afford to pay.

At the specialty clinic, an attending dentist treats patients and oversees residents working with patients. A volunteer oral surgeon comes in every week.

“The need is great. We get about 300 referrals a month in the county,” said Jennifer Freimund, executive director of the Seattle-King County Dental Society.

With this program, patients have quicker —Ìýand more affordable —Ìýaccess to dental surgeries. Before, Vander Beek said, choices for patients were severely limited because these services are so expensive and few dental surgeons accept Medicaid.

“There are various places we would try, but there wasn’t a consistent or reliable source for our patients,” she said. “An oral surgeon may take a limited number of Medicaid [patients] … maybe only on Mondays and they’re booked out for eight months.”

Demand for services has increased in Washington since it reinstated Medicaid , when it was expanding the Medicaid program under the federal health law. That brought an influx of patients who needed advanced dental care.

Medicaid dental coverage for children is required by federal rules, but it is for adults and is often the when the state has budget problems. Even when Medicaid patients do have dental coverage, it can be difficult to find a dentist who would accept them because of . By the time the oral disease becomes severe, a visit to a health center may not be sufficient.

“Connecting people with care not only addresses their issue of the moment, but it provides a foundation of understanding to them on where they can get a continual level of care,” said Jane Grover, director of the council on access, prevention and interprofessional relations at the American Dental Association.

Among the type of cases health centers would refer to the specialty clinic are patients who have complicated medical histories or who might need access to a hospital setting and operating rooms.

Vander Beek said she referred someone recently who had rampant tooth decay. He was 37 years old and he had never been to a dentist. The health center could take all his teeth out and arrange for him to get dentures, but he would still be charged a fee on a sliding scale despite being uninsured. Vander Beek referred him to the center so he could get the treatment free-of-charge, which would then allow him to afford his dentures.

“I think it’s a program that if replicated is a good model,” Vander Beek said. “There needs to be more access for the most vulnerable folks, most of which are adults. There needs to be more robust services like this.”

An in Missouri also has a similar referral process between a local hospital and health center, while the partnered with a hospital to open a dental clinic.

While programs like this that streamline the referral process are beneficial, another solution might be to hire dental surgeons in health centers to deal with the complex procedures. But center officials say they are already struggling to keep even dentists on staff, with the responsibilities in some cases.

“The most significant reason that federally qualified health centers do not have oral surgeons on staff is because they’re lean fighting machines because of budgeting and funding,” Freimund said. “A specialist costs more than a generalist.”

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Over the next months, when his symptoms progressed into a slight loss of hearing and sensitivity to noise, he became worried. Ammon, a construction worker for 32 years, eventually started wearing ear protection hoping this would address these complaints —Ìýbut it was too late.

From that point on, sounds ranging from the hum of a lawnmower to normal tones of conversation caused a piercing, jabbing pain in his inner ear. He stopped working in 2011, when the pain became unbearable. He also hears ringing in his ears and experiences dizziness, both side effects of the auditory damage.

“It’s debilitating … completely,” he said.

In an effort to reduce these numbers, the Labor Department launched a challenge earlier this summer called ” in which it is soliciting pitches for innovative ideas and technology to better alert workers of hazardous noise levels.

But critics say that while these efforts might help, technology to reduce hearing injuries already exists. They contend that the maximum level of noise exposure allowed before employers are required to provide sound-protection equipment is too low, and the regulations developed by the Occupational Safety and Health Administration are outdated. For example, those regulations use sound level limits that don’t factor in the noise exposures that occur beyond the workplace —Ìýat and for instanceÌý—Ìý that can add to workers’ cumulative risks of harm.

According to OSHA officials, the agency will issue a request for information later this year about current regulations at construction sites to figure out if more stringent protections are needed and how companies are complying. (The construction industry has often been held to noise-related rules and requirements than those in place for other industries.)ÌýThe review may lead to an update to these rules, most of whichÌý. AÌýÌýwas issued in 2002, butÌýÌýresulted from the action.

Employers may also have to shoulder the responsibility of instilling more awareness and education among their workers. For example, workers sometimes choose not to wear hearing protection at work sites because they are not aware of their risks —Ìýespecially when they are not operating loud equipment.

, a professor at Stanford University who explores workplace hazards, that the employees who suffer most from hearing loss were those who were working in jobs involving moderate noise levels instead of high-noise environments.

“At very high noise exposures, people very faithfully wear hearing protection and at low noise situations, people don’t,” he said.

For general industry workers who are exposed to noise for eight hours a day at or above a time-weighted average of 85 decibels, employers to provide notification, audiometric testing and free hearing protectors. Employers also have to offer training programs for affected workers. The limit is 90 decibels for an eight-hour exposure for construction industry workers.

Cullen said employers could build noise barriers or eliminate noisy equipment, but old factories often choose to just offer hearing protection gears.

“But the problem with hearing protections is it is way too easy, unsupervised, to take it off,” he said. “What would really make a difference is to train employers.”

He said there is also that will measure noise exposure in real time in each worker’s hearing protection gear, with lights that will flash when the level becomes hazardous. The data can be downloaded each day to monitor daily exposures.

, hearing conservation manager at Honeywell Safety Products, said many companies, including hers, already have such products. While she sees more large employers expressing interest in these technologies, the cost might be a deterrent for others.

“But when you think about it … the cost of having these electronics to protect the workers is nothing compared to the damage after that,” she said.

Meanwhile, the CDC, as part of its has an online with information about sound levels of different tools to encourage businesses to invest in quieter tools and machinery.

Ammon worked for several small construction companies building houses. He said he was never told to wear ear protection. His colleagues didn’t wear it either. No one talked about it and, even when he worked with loud equipment, he wasn’t aware of the need for it.

“It costs money. That’s my opinion on why it’s gotten as bad as it has, at least for small construction companies,” Ammon said, and the rules are “just not enforced.”

Some of the steps taken by the federal government to move toward tightening regulations and increasing awareness suggest this might be changing. But in the meantime, people like Ammon, who feel disabled by their condition, might face difficulties in getting recognition for their symptoms and financial support.

He applied for Social Security disability benefits but was rejected because his condition was not on the Social Security Administration’s considered disabling. When he first experienced his symptoms, he visited dozens of audiologists who only told him he had slight hearing loss. Research linking Ìý— unusual tolerance towards ordinary sounds —Ìýand pain was .Ìý still are not available for people with this type of hearing damage.

These days, he experiments with new medications or therapies, hoping for more awareness about the illness — and about protecting hearing at the workplace. He is waiting for the third appeal for Social Security disability benefits.

“I’m hearing a little more about it, but not nearly enough,” he said. “And it needs to start at the workplace.”

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In recognition of these possible consequences, living kidney donors who are in need of a transplant have, since 1996, been given priority status on the waiting list.

But according to a published Thursday in the Clinical Journal of the American Society of Nephrology, prior living donors do not always receive that priority status in a timely manner. Some had to wait for years and go through dialysis before moving to the front of the line —Ìýwhile some possibly never got to priority status.

“This is a big deal to donors and the transplant community,” said Jennifer Wainright, an analyst at the United Network for Organ Sharing research department and the study’s lead author. “Living kidney donors should know that they are entitled to priority … if they ever need a kidney, and also that most prior living donors receive their transplant quickly.”

Wainright stumbled upon this issue when she was examining data on donors, waitlist candidates and transplant recipients from the national for another project.

“We put the original project on hold, explored the data, and figured out a way for UNOS to help transplant programs try to prevent the problem in the future,” she said.

The researchers sought to characterize how quickly prior living donors were added to and activated on the transplant list. They studied data related to living donors and their transplant needs from January 2010 through July 2015. During that period, 210 transplant candidates who were prior living donors with priority status were added to the transplant waiting list. As of Sept. 4, 2015, 167 of them received deceased donor transplants, six received living donor transplants, two died, five were too sick for transplants and 29 were still waiting.

Because of the “priority” designation, most of these patients were able to receive transplants quickly, the study found. But a number waited a long time.

For example, among the living donors studied, only 40.7 percent were added to the transplant waiting list before they needed dialysis, which is a treatment that becomes necessary when the kidneys are no longer functioning optimally. Half of the patients in the study were on dialysis for 332 days or longer before their priority was recognized.

The process of requesting the priority status goes like this: If a prior living donor needs a kidney transplant, the transplant program at the hospital will submit information and contact the UNOS Organ Center to request priority. The center is supposed to complete the request within a day. Patients healthy enough to receive the transplant immediately will be listed in an active status.

The reasons for the delays in this process detected by the study may be, in part, due to a patient’s ill health or to paperwork and bureaucratic problems. These can include incomplete data submission and insurance issues, or a lack of awareness among patients and transplant programs about living donors’ priority.

In an effort to smooth out the process and raise awareness among living donors and transplant programs, UNOS since last year has linked their list of living donors with the current kidney waiting list. The goal is to identify transplant candidates who were living donors but have yet to receive priority status. UNOS will then contact the person’s transplant program to see that the situation is addressed.

But there are limitations to the data collection. The data tracking living donors only goes back to 1987, and have only includedÌýSocial Security numbers since 1994. If a person donated a kidney before 1994 and changed his or her name, UNOS wouldn’t be able to identify the person —Ìýthus still missing prior living donors who may have not been informed of their priority status.

Another solution Wainright identifies is ensuring use of the current OPTN policy that to inform living donors about their priority on kidney waiting lists if they need a transplant after donation.

Between Sept. 2, 1996, and July 31, 2015, a total of 422 living donors were added to the kidney transplant waiting list. According to the, being a living kidney donor is relatively common —Ìýthere were 5,538 living kidney donors in 2014 compared with 7,761 deceased donors. Living donors 25 to 35 percent permanent loss of kidney function after donation on average, but their risks of getting end stage renal disease 15 years after the donation.

, assistant professor of medicine at the University of Pennsylvania School of Medicine, said his center always makes sure the living donors know about their right to a priority status. He was not associated with the study.

“If you tell kidney donors that, they will remember,” he said. “I’m surprised by this UNOS data, I think it’s a shame that centers are not getting their donors registered in a timely way.”

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A published Monday in JAMA Internal Medicine illustrates that phenomenon. Most Americans who screen positive for depression don’t receive treatment — while most who didÌýreceive treatment don’t actually have the condition.

“Over the last several years there has been an increase in prescription of antidepressants,” said , professor of psychiatry at the Columbia University Medical Center and lead author of the study. “In that context, many people assumed that under-treatment of depression is no longer a common problem.”

But Olfson found the opposite to be true after analyzing data from in 2012 and 2013 that includes questionnaires screening for depression. Of the 46,417 adults surveyed, 8.4 percent answered in ways that suggested they had depression, but only 28.7 percent of them received any treatment for it.

“The findings highlight that there are continuing challenges in aligning depression care with patient needs,” he said.

Adults in the lowest income group were five times more likely to be depressed compared with those in the highest income group. But they, along with uninsured adults, racial and ethnic minorities, and men, were also less likely to receive treatment.

On the other hand, among the 8.1 percent of adults who received treatment for depression, only 29.9 percent of them had depression and 21.8 percent of them had serious psychological distress. And those with either less serious or no depression were more likely to receive antidepressants. It’s a problem of overprescription, Olfson said, because that antidepressants are not any more effective for patients with mild depression than a placebo.

“Being a little less aggressive in medication in mild depression would be beneficial,” he said. “There are simpler forms of psychological interventions that can be adapted for primary care.”

Rather than relying on these drugs, the patients can be given other treatments ranging from counseling and exercise to yoga.

In addition, researchers concluded that those with serious psychological distress are more likely to be treated by psychiatrists instead of general medical professionals, but this trend does not translate to older patients, African Americans, the uninsured or those with less education.

“Some when they have depression don’t believe they require treatment or that they could benefit from treatment,” Olfson said. “People are visiting doctors but the attention is to current, pressing medical problems.”

But these doctor visits can be used as an opportunity for increasing access to treatment for depression to disadvantaged populations. Olfson found that most people with untreated depression make at least one visit to a primary care doctor annually. If depression screening and mental health services can be integrated into primary care, Olfson said, there will be better access and awareness about the illness.

“If you give them a referral to a mental health clinic, they simply won’t go if they don’t think they have a mental health disorder,” he said. “By embedding the services within primary care, it becomes more accessible and less stigmatized.”

It’s an idea , director of the Health Equity Research Lab and assistant professor at Harvard Medical School, agrees on, but he said increasing access for minorities would require professionals who speak their languages and Ìýunderstand what type of treatment they are open to. Cook was not involved in the study.

“(For example) African Americans and Latinos prefer antidepressants less than whites,” Cook said.ÌýThat might be an underlying reasonÌý“not to go for mental health treatment, why they might not stay at treatment for as long.”

This integration of services would also benefit patients who are over treated —Ìýthose who receive antidepressants when they don’t need to. Olfson said many primary care doctors expressed frustrations in finding mental health professionals particularly in small and rural areas, so prescribing antidepressants might become their go-to when they don’t have resources. If there is a mental health professional right in the clinic, patients might get access to more services that a general doctor cannot offer such as counseling and psychotherapy.

“Depression really is a serious condition and we’re finding that so many Americans aren’t receiving care,” he said. “I hope that it (this study) brings attention to this situation.”

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But the opposite seems to be true regarding the causal link with obesity, according to a scientific review by the International Agency for Research on Cancer.

Fourteen years ago when the , based in Lyon, France, first reviewed relevant studies, its expert panel issued a report finding sufficient evidence that excess body fat increases the risk of certain cancers. Now, the, published Wednesday in the New England Journal of Medicine, reaffirms those findings —Ìýand adds eight more cancers to the list.

“Since 2002 there have been a lot of new studies conducted. We felt like it was the right time to review the literature and maybe confirm the science that has been established,” said , lead author of the article and an IARC scientist responsible for the agency’s Handbooks of Cancer Prevention Series. The IARC is part of the World Health Organization.

A working group of 21 independent international cancer experts reviewed more than 1,000 studies on cancer risk and excess body fat published since the IARC’s 2002 report. That evaluation identified that preventing weight gain can reduce the risk of colon and rectum cancer; a stomach cancer called esophagus adenocarcinoma; kidney or renal cell carcinoma; postmenopausal breast cancer and cancer in the endometrium of the uterus. This year’s Ìýreassessment added to this list gastric cancer, liver, gallbladder, pancreas, ovary and thyroid cancers as well as the blood cancer and Ìý— cancer that affects the tissue surrounding the brain and spine.

The risks are highest for , a cancer in the uterus, and .

“The number of cancers that are linked to obesity has increased a lot, which means a much higher proportion of cancer that occurs today is due to obesity,” Lauby-Secretan said. Public health messages should be tailored to raising awareness about this fact, she added.

Results also were consistent for children, adolescents and adults younger than 25.

Overweight adults are defined in the study as those with Ìý(BMI) of 25.0 to 29.9, while obese adults have BMIs above 30. According to the study, an estimated 640 million adults worldwide were obese in 2014, which is six times more than in 1975. Around 110 million children and adolescents were obese in 2013, two times more than in 1980.

Meanwhile, the report also found that an estimated 4.5 million deaths in 2013 were related to overweight and obesity, a number that may increase as more cancers are found to be related to the condition.

“The epidemic of obesity has become a global concern,” Lauby-Secretan said.

Not all cancers have positive correlations with obesity, though. For example, there is only limited evidence of this link for fatal cancer of the prostate, breast cancer in men and , the most common blood cancer. Evidence is inadequate for cancers of the lung, testis, urinary bladder, brain or spinal cord. While excess fat does lead to higher risks of postmenopausal breast cancer, it does not have the same effect for premenopausal breast cancer.

The reason obesity may increase cancer risks, Lauby-Secretan said, is because excess body fat has been known to trigger . It also disturbs the regulation of sex hormones. Both are common pathways for the development of cancer cells in the body.

But the awareness about the link can be low especially when Americans are inundated with news about how many substances —Ìýcoffee or sugar, for instance — may or may not cause cancer. According to the released in February 2015, a little more than half of Americans realize that being overweight can increase cancer risk, a slight increase over prior surveys.

, head of nutrition programs for AICR, said there will always be studies that disprove or prove links —Ìýbut when you look at the whole body of research, there is a scientific consensus on this particular point. And people can actively reduce cancer risks from excess body fat, Bender said, by eating healthier meals and exercising more.

“Oftentimes people are concerned about exposures in the environment or genetics or things you can’t control,” she said. “Rather than increase fear about this, we can see this as an empowering message: Here is something I can do to help myself lower the risk for many of these cancers … here are some lifestyle changes that I can make.”

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Should she apologize? How much detail should she share about the mistake? Would a frank discussion put the hospital at risk of a lawsuit?

“I had never really been in that situation before,” said O’Brien, recalling the 2004 incident. She decided to tell the patient’s family about the error, bracing herself to face their anger. While the family was stricken by grief, they appreciated her honesty.

“I spent a lot of time with the patient’s family supporting them and explaining what had happened, and yet I felt so unsupported in that experience,” said O’Brien, a physician at MedStar Georgetown University Hospital.

Hospitals have traditionally been reticent to disclose to patients or their family members the specifics of how a medical procedure didn’t go as planned for fear of malpractice lawsuits. In recent years, though, many are beginning to consider a change. Instead of the usual “deny-and-defend” approach, they are revamping their policies to be more open.

Hospitals’ interest in this approach has been fueled by studies showing that when an adverse event has occurred and doctors when there are restrictions and concerns about what they are allowed to discuss. have found that patients are more likely to sue when they perceive that there is a lack of honesty.

MedStar Health, which is among the largest health providers in Maryland and the Washington, D.C. region, has been one of the pioneers in setting up such programs at all of its 10 hospitals. In 2012, it launched standardized program based on AHRQ’s guidelines across the system that drew on similar initiatives that were already in place at its various facilities. O’Brien was one of the first to sign up as a volunteer at Georgetown University Hospital.

The initiative established a standardized approach for physicians when they have to communicate with patients and family members about adverse events. A team of physicians —Ìýcalled the “Go Team” —Ìýcomplete a four-hour initial training program and then annual booster courses every six to eight months to prepare them for these conversations and also to help other staff physicians who confront the problem. After that, Go Team members are on call 24/7 to provide guidance. Another program, “Care for the Caregiver,” provides psychological support to other physicians as needed.

One of central elements of the training program for the Go Team involves role-playing exercises with professional actors who simulated patient scenarios. O’Brien remembers clearly one session when she had to confront actors portraying patient’s family almost hysterical with anger. The patient had suffered from severe burns due to a fire in the operating room.

“It’s scary to be in that room even though I knew it was a simulation,” she said. It was helpful, “in terms of preparing for the family’s emotions … and making sure they get the information that is needed while acknowledging that they needed to express their emotions.”

The exercises are uncomfortable and incredibly personal, O’ Brien said. Through the training sessions, she learned about the importance of being honest upfront, expressing empathy and apologizing.

MedStar is not the only hospital system implementing the system. Since 2012, second-year medical students at Johns Hopkins University are required to learn how to disclose adverse events in their patient safety classes by participating role-playing exercises. Several Harvard teaching hospitals also have coaching models similar to MedStar’s.

Part of the motivation for , vice president of quality and safety for MedStar Health, to establish open communication programs came from his personal experience about a decade ago when he was the co-executive director at the University of Illinois Institute for Patient Safety Excellence. Back then, he and his colleagues were frustrated with the tension between doctors, patients and the amount of lawsuits the hospital had to field from patients who wanted to know more.

“We felt horrible that we couldn’t openly talk to patients and families … our attorneys would tell us we can’t do that because we’re going to give them all the information that will cause us to lose a lawsuit,” he said. “There were no winners.”

After a colleague brought the issue to the attention of that hospital’s board, they began working on a better system, said Mayer, who participated in the development of AHRQ’s guidelines. And when Mayer arrived at MedStar he continued working on this mission. The results he has seen reflect a hospital culture shift.

“Instead of shutting down conversations with patients, we want to respond to them immediately, we want to share everything we can with them,” Mayer said. “Many times when they get their questions answered in an open and honest way, they realize a lawsuit wasn’t really necessary.”

Mayer said by emphasizing transparency and creating an open environment, the doctors have been able to learn from past events and improve their performance. At MedStar Health, he has seen a 60 percent reduction in serious safety events in the past four years.

But the openness also has a cost. The hospital might have to pay for remedies, such as waiving medical bills, if a patient believes the hospital was at fault.

Mayer recognizes that there are still many hospitals who go by the “deny and defend” approach.

“There are programs that say they’re doing it when they’re not really doing it, they’re not waiving bills, they’re still charging the Centers for Medicare & Medicaid Services and third party payers for the mistakes,” he said. “There are a lot of people making money off denying what is technically right for the patient.”

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Take, for instance, , one of the most common hereditary heart diseases. It is also a silent disorder that has caused countless to suffer sudden collapse or cardiac arrest during team practices or sporting events.

African Americans have at higher risk for the disorder. But a study out Wednesday in the concluded that common ways to determine that level of risk may be skewed because studies have traditionally had low numbers of black participants. It turns out that genetic characteristics based on ethnic differences caused some people to be diagnosed with a predilection for the disease —Ìýeven though those markers were actually benign.

The researchers suggest these findings indicate a need for diversity in genomic research in interpreting these differences.

“Historically we’ve had less African American representation in these studies,” said , lead author of the study and research fellow at the Harvard Medical School. “Our paper highlights ethnicity as a key way to get a handle on classification of genetic variants.” are differences in DNA structure that determine human features and are unique to every person.

Manrai first looked at the data from the , which includes genomic data from 4,300 white Americans and 2,204 African Americans. He expected to find that would have the genetic variants that cause the disease —Ìýthat’s the rate at which the disorder occurs in the general population. But instead, he found that 1 out of 4 individuals had those mutations and those individuals were disproportionately African Americans.

“This was the initial shocking revelation,” he said.

His team decided to figure out if those mutations were misclassified as harmful. They first looked at the initial studies that identified these genetic variants as disease-causing, focusing on five specific abnormalities that appear most frequently in the NHLBI population. They found that these studies had small sample sizes and none had representative samples of African Americans in their control groups.

They then compared genetic sequences of African Americans and whites through the , which has genome data from 14 populations worldwide, confirming the five variants they identified occurred most commonly among African Americans.

At the same time, they examined data from the Laboratory for Molecular Medicine operated by , a clinical lab that diagnoses and performs genetic testing for patients. By using the lab’s classification system that includes data regarding the frequency of genetic variants in control populations, they determined that these five variants were actually benign. Four had been classified by the in the most pathogenic category.

In the Partners’ clinic records for the past decade, the authors found seven patients of African or unspecified ancestry between 2005 and 2007 who were told they had the disease-causing genes based on these misclassified variants. According to their calculations, inclusion of even a small number of African Americans in study control groups could have prevented the misclassifications.

In regard to hypertrophic cardiomyopathy, the misdiagnoses of risk may have resulted in unnecessary hardships for the patients and the families. But the lack of diversity in scientific studies and control groups can have other significant implications. , a professor at the University of California San Francisco, how genetic differences can lead to higher rates of asthma among African Americans, but the drugs designed to treat diseases, he wrote, often in people of European origins.

Burchard published a study last year that showed of lung disease studies funded by the National Institutes of Health in the last two decades have statistically meaningful number of participants from ethnic minorities.

“It’s like basing your whole world … on one opinion or one biologic resource,” Burchard said. “And that’s a problem because we miss the variation in genetics that is present worldwide.”

Genomic data from diverse populations is needed to find mutations specific to different ethnicities that indicate disease or in some cases, demonstrate responsiveness to treatments, he said.

Manrai points toward relatively new projects, such as the NHLBI Exome Sequencing Project and the 1,000 Genomes that now have genomic sequences from diverse populations, although there is still a need for data from Native Americans and Asian Americans.

“There is now an opportunity to use those resources to study hypertrophic cardiomyopathy and other diseases as well as reassess a lot of studies that support the genetic studies that might be decades old,” Manrai said. “Since studies in the past do not have perfect mixes and they shape the current literature, it’s important to evaluate those studies with current data.”

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Stowe, who lives about five miles from the hospital, comes into the medical center twice every three months to get checkups for chronic kidney failure. She doesn’t own a car and relies on buses. During rush hour, buses are more frequent, and she can keep the commute to about 30 minutes. But when she has to come in the middle of the day, it takes her at least an hour to get in and another hour to get home.

“It’s pretty good except for waiting during non-rush hours,” she said. “When that happens I don’t plan anything else for the day.”

For people without access to private transportation, getting to medical appointments can be a challenge, especially if they have that require frequent appointments.

Some hospitals and medical providers think that the hot-new technology in town —Ìýride-hailing services such as Uber and Lyft —Ìýcan address this problem by making the trips easier and, in some cases, it is even covered by Medicaid and other insurance plans. Partnerships between ride-hailing companies and hospitals are emerging around the country. While the efforts are still small, some hospitals and medical transportation providers think the potential for growth is large.

, a nonprofit health care system with hospitals in Maryland and the districtÌýbegan a partnership with Uber in January that allows its patients who use Uber to access the ride service while on the hospital’s website and for appointments. Medicaid patients who may not have access to the Uber app can also arrange the ride by calling the hospital’s patient advocates.

, a transportation system that provides non-emergency medical rides for patients and medical providers in a number of states, expanded its services through a partnership with Lyft last year in New York, California and Nevada.

, a hospital in New Jersey, the Sarasota Memorial Hospital in Florida, and , a health care communication company have also announced partnerships with Uber in the past year. , a San Diego startup, says it is offering a ride-hail-like technology for health care appointments in Idaho, Arizona, Texas, Colorado and California.

“We probably had 50 different systems across the country reach out to us and ask us ‘How did you do it?’” said Michael Ruiz, chief digital officer for MedStar. “I would say that it has been a seismic shift for the people who have used the service and the places we’ve provided it.”

Patients’ costs for the services vary. For , transportation for non-emergency medical visits are covered, although the extent of reimbursement . Traditional Medicare does not cover non-emergency medical transportation, although some private Medicare Advantage plans may offer some benefits.Ìý

Getting To Your Doctor

When going to a medical appointment becomes a hassle, patients are , and that can help lead to untreated symptoms or worsening health.

“Transportation can make it difficult for people to see health care providers on a regular basis,” said , an associate professor of medicine at the University of Illinois at Chicago who has studied patient transportation issues. “It is important to see health care professionals regularly, especially for patients with diabetes or asthma.”

In a of 25 studies, Gerber and colleagues found that 10 to 51 percent of patients reported that lack of transportation is a barrier to health care access. showed that 82 percent of those who kept their appointments had access to cars, while 58 percent of those who did not keep appointments had that access.Ìý reported bus users were twice as likely to skip on appointments compared to car users.

In addition to concerns about patients’ health, those absences can also be expensive for medical institutions, which from the missed appointment.

Hospitals and managed care organizations do offer a variety of options to assist with transportation for non-emergency medical appointments. Health centers often work with volunteer drivers to pick up and drop off patients.

Patients can call them ahead of time to arrange a ride, but these services generally require advance planning, which becomes a problem when the patient needs to go in for an unscheduled appointment or if the patient forgets to book ahead.

Some patients also end up calling 911 for non-emergency situations, potentially diverting resources that could be used for others with more pressing needs.

Timely ServicesÌý

The National Medtrans Network partnership with Lyft began after an incident in February 2015. One of its clients, an elderly woman, was left waiting for a ride to a hospital in New York in freezing weather for 30 minutes. The contracted provider failed to show up.

“It was almost a dangerous situation,” said CEO Andrew Winakor. When his company was notified of the situation, officials immediately called a ride-hail service. The ride arrived within six minutes. Winakor said Medtrans officials realized they had to find a transportation option that could respond immediately to canceled rides.

But ride-hailing services do have some disadvantages. Wheel-chair friendly rides are still limited to a few cities. They also depend on the availability of drivers, which might be scarce in rural areas and low-income communities.

MedStar in Washington, dealt with the problem in one of its hospitals in rural Maryland, where there was a lack of Uber drivers, when a patient there had to travel to the flagship hospital in D.C. for an outpatient surgery at 6 a.m.

“Our social workers worked with the folks at Uber to be able to coordinate the ride to pick this patient up at 4:30 am, and coordinate the ride back,” Ruiz said.

Buses, vans and local public transportation for people in wheelchairs come and go frequently in MedStar Washington Hospital Center’s bus center. Stowe is satisfied with the transport options available. While she hasn’t used Uber before, she said it is something she wouldn’t mind trying especially when it gets cold outside.

“There are times when you come out and you really don’t feel that well. If Uber is here, it’d be really nice to have it,” said Stowe.

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The donor registration drive is the culmination of the partnership between Tinder and a nonprofit group called , which aims to end the organ donor shortage. between Tinder and the National Health Service was carried out in Britain last year. Organize is also partnering with the comedy video website Funny or Die, Facebook, various universities and hospitals to launch apps and social media campaigns to boost registrations for organ donations.

These partnerships were mentioned as part of a last month to increase organ donations. That effort called for a more streamlined process for organ donations and an increase in research on fields such as tissue preservation and cell-replacement – that may eventually lead to organ replacement.

The wait for an organ transplant can be daunting. Half of all kidney transplant patients spend more than 3.6 years waiting for an organ. On average, while on a transplant list.

Traditionally, the registry for organ donation has been run through state motor vehicle departments, and people can register when getting their driver’s license. But that doesn’t capture everyone. According to the White House, 95 percent of Americans support organ donation but only half are registered as donors.

Dr. , a transplant surgeon and the executive director of the MedStar Georgetown Transplant Institute, is optimistic about the Tinder and Organize partnership in attracting potential donors, especially younger ones.

His institute is trying a somewhat similar strategy by developing a free app that allows people to indicate their desire to be organ donors. The information would then be sent to the relevant donor registry and to friends or family members designated by the person who is signing up to be a donor. He said the app is slated to go live at the end of this year.

Fishbein spoke with Kaiser Health News’ Zhai Yun Tan recently about organ shortages and technology-centered solutions to attract donor. The interview has been edited for length and clarity.

Q: Why is there a discrepancy between the number of Americans who support organ donation and those who are actually registered as donors?

A: There is not an automated, standardized mechanism through which people — who might generally support organ donation — [can] in a very simple action become registered to be an organ donor. When you turn 16 or 17 and you get your driver’s license, you are asked in many states, because the donor registry collaborates with the motor vehicle administration, if you want to be an organ donor and they print it right on your driver’s license. Right there with a simple “yes” or “no,” a check on the box, you’re registered.

[Otherwise] you’ve got to figure out on your own how to become an organ donor. It’s not that easy because you don’t have an automatic interaction. Imagine if every year you fill out your income tax you have to check the box “yes” or “no” — “I will become a donor” or “I won’t become a donor.” You don’t have to opt in, you can opt out, but at least you have an automatic interface and then you turn the form in and you are automatically registered.

Q: How did the idea for the app come about?

A: We have within MedStar an institute called MI2 which stands for the . This app is Pete Celano’s brainchild. He is a super technologically savvy innovator who comes up with things that bring health care to patients through technology. He happened to have a family friend who needed a transplant and was asked the question “Why the heck don’t we have a super easy simple way that people can just register to be a donor?” That grew out of a simple personal, human interaction. So that’s what transplants are all about — it all comes down to the human interactions that people have.

Q: Other initiatives focus very much on sharing personal stories on social media to attract potential donors. What do you think of this approach?

A: It’s very individualized what people are comfortable with and not comfortable with. Some feel like their health care needs are very private and don’t feel like sharing them. We’ve had patients who, for instance, did not want us to promote them in local or national news stories and other people are very extroverted and feel very comfortable with that. More and more, people are telling their stories and looking for specific donors who will help them.

We have over 1,000 patients right now sitting, waiting on our organ transplant list so we couldn’t possibly get the attention of the news media for a 1,000 patients. The patient and the families may do that themselves.

We try to educate the community at large, I think, get [people] invested and active about the problem. Ultimately through actions like these — very easy interactions between a person and turning the idea of supporting organ donation into a concrete action — we’re going to possibly in the future eliminate the shortage that we have now.

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