By Paula Span, for The New York Times.

When Janet Halloran last saw her primary care physician, the doctor asked whether she had undergone her annual mammogram. Yes, she replied, she had.

At 76, Ms. Halloran, a real estate broker in Cambridge, Mass., is past the age that most medical guidelines recommend breast cancer screening for someone with no history of the disease. Even for younger women, the guidelines call for a mammogram every other year, not annually.

So Ms. Halloran could consider stopping mammograms, or at least having them less often. But her doctor has never discussed that prospect. “She says, ‘These are the things you need to do,’” Ms. Halloran said. Besides, she added, it’s an easy test: “Go once a year, hold your breath and you’re done for another year. It’s just routine.”

But for older women, should it be?

“There’s been a lot of uncertainty,” said Dr. Xabier Garcia-Albéniz, an oncologist and epidemiologist at RTI Health Solutions and lead author of a new observational study that tries to answer that question. “This is an area with a complete lack of randomized clinical trials.”

Breast cancer studies, like medical research in general, have often excluded older subjects. So the data on whether mammography improves survival is very limited in women ages 70 to 74, and nonexistent for those 75 and older.

That’s why the independent U.S. Preventive Services Task Force has concluded that while having mammograms every other year improves survival for women ages 50 to 74, there’s “insufficient” evidence to assess their use for those over 75.

The American Geriatrics Society includes screening for breast and other cancers on its Choosing Wisely list of tests that should be questioned. It urges doctors not to recommend it “without considering life expectancy and the risks of testing, overdiagnosis and overtreatment.”

Yet more than half of women over 75 have had a screening mammogram (a test for individuals with no history or symptoms of breast cancer) within the past two years, the Centers for Disease Control and Prevention reported in 2018.

“Whether this investment in breast cancer screening alters survival is a critical question,” said Dr. John Hsu, a health services researcher at Harvard Medical School and senior author of the new study, published in the Annals of Internal Medicine.

3 Medical Routines That Older People May Not Need

The research team used Medicare claims from 2000 to 2008 to follow more than one million women, ages 70 to 84, who had undergone a mammogram.

They had never had breast cancer and had a “high probability,” based on their medical histories, of living at least 10 more years. “That’s the population who will reap the benefit of screening,” Dr. Garcia-Albéniz said, because it takes 10 years for mammography to show reduced mortality.

The researchers divided the subjects into two groups: one that stopped screening, and another that continued having mammograms at least every 15 months. They found that mammograms provided a survival benefit, if a modest one, for women ages 70 to 74. In line with previous research, the study found that annually screening 1,000 women in that age group would result, after 10 years, in one less death from breast cancer.

But among the women who were 75 to 84, annual mammograms did not reduce deaths, although they did, predictably, detect more cancer than in the group that discontinued screening.

“You’re diagnosing more cancer, but that’s not translating to a mortality benefit,” Dr. Garcia-Albéniz said.

Why not? “The cancers themselves might be different at different ages,” Dr. Hsu said. “They might grow faster or slower, or be more likely to spread.”

Treatments may also be less effective at older ages, said Dr. Otis Brawley, an oncologist and epidemiologist at the Johns Hopkins University School of Medicine, who wrote an editorial accompanying the study.

But older people typically are also subject to what researchers call “competing mortality.” Many of the cancers detected by mammography — tiny tumors that earlier technology wouldn’t have spotted — are unlikely to cause any harm if left untreated. But most older people have other diseases that will progress.

“It’s very difficult to tell someone in her 70s or 80s that we’re going to modify your treatment, or not treat you, because of the likelihood that something else will kill you before this cancer will,” Dr. Brawley said.

That reluctance to discuss life expectancy and the limitations of screening also means that many women don’t recognize that, in addition to being inconvenient, expensive and a cause of discomfort or anxiety, mammograms can actually do harm. The tests often prompt unneeded surgery, radiation or drug regimens for cancers that would never have caused symptoms or shortened lives.

Still, because life expectancy varies widely, some very healthy older women may live long enough to benefit and may indeed want screening. Mammograms could lead to treating an aggressive cancer earlier, and with less extensive surgery, for instance.

“I would be very happy if doctors started using our paper to inform the discussion they have with their patients,” Dr. Garcia-Albéniz said.

Yet women remain so committed to regular mammograms that experts doubt they could recruit enough people for a large randomized trial in which half the subjects forgo the tests.

Dr. Mara Schonberg, an internist at Beth Israel Deaconess Hospital in Boston, has worked for years to help women make decisions about breast cancer screening, and has found it tough going.

“These women were told for 40 years to get screened,” Dr. Schonberg said. “They get reassurance from a negative mammogram. And it’s very hard to understand that finding breast cancer early may not help you live longer or better.”

To help explain, Dr. Schonberg developed a decision aid: a brochure, written at a sixth-grade reading level, that uses research findings to explain the pros and cons.

A pilot study showed that, after reading it, women from 75 to 89 were more knowledgeable about mammography, more apt to discuss it with their doctors and less enthusiastic about continuing it.

But they did continue. More than 60 percent, including those with lower life expectancies, had another mammogram within 15 months. A larger study with 546 participants, being readied for publication, will report similar results, Dr. Schonberg said.

Perhaps, as Dr. Brawley said, “the most important thing we can do is get people to understand what the questions are, and to understand that nobody has the exact answers.”

But Dr. Schonberg’s grandmother, who followed her doctor’s recommendation and had a mammogram at age 78, came to a more definitive conclusion.

Ann Schonberg was a Detroit homemaker and a lifelong smoker with mild emphysema. When her mammogram found a small Stage 1 cancer, she underwent a lumpectomy and began endocrine therapy, taking drugs that might lower the risk of recurrence. “She didn’t like how she felt, so she stopped everything after three years,” Dr. Schonberg said.

When Ann Schonberg reached her mid 80s, a mammogram picked up another small cancer, prompting another lumpectomy. At the same time, although she had stopped smoking at 80, her emphysema worsened steadily. That is what caused her death at 88, not breast cancer.

“All the doctors’ appointments, the surgeries, the worry — for her, it was all for naught,” Dr. Schonberg said. Shortly before Ann Schonberg’s death, she told her granddaughter, “I wish I’d never had that mammogram.”

By Wendy Ruderman, The Philidelphia Inquirer, Nov. 15, 2023.

Six years ago, a nurse at a Tennessee hospital accidentally gave a patient a powerful muscle-paralyzing drug. The patient stopped breathing and later died.

The nurse, RaDonda Vaught, was convicted of negligent homicide and sentenced last year to three years’ probation. Criminal charges over medical errors are rare, and the prosecution evoked fear in nurses nationwide. Patient safety advocates argued it sent the wrong message and would deter hospitals from admitting mistakes, which would not protect patients from medication errors.

Four years after Vaught’s deadly error, a similar mistake at Mercy Fitzgerald Hospital in Darby, nearly killed patient Didier Epopa and left him with irreversible brain injuries.

Epopa, 55, recently filed a medical malpractice lawsuit against the hospital. His lawyer, Eric Zajac, said the suit is among a growing number of Pennsylvania cases related to serious medication errors that he’s filed in recent years.

Zajac noted the drug errors in his caseload share a common denominator: They’re preventable.

“The health-care provider, whether it’s a pharmacist, hospital or doctor, either doesn’t have safeguards in place — or, they have them in place, but they aren’t following them,” said Zajac, whose practice, Zajac & Padilla, is based in Ardmore.

Life-and-death drug errors

In both the Tennessee case and Epopa’s, the errors were made in the use of neuromuscular-blocking drugs, which hospitals classify as “high-alert medications” because mistakes in their use can cause catastrophic harm or death.

Vaught, then a nurse at Vanderbilt University Medical Center in Nashville, mistakenly withdrew a vial of the paralytic vecuronium from a computerized medication cabinet. She typed “VE” into the search function, intending to take out Versed, a sedative to calm the 75-year-old patient who was about to be scanned in an MRI-like machine.

In the Philadelphia-area case, a lawyer for Mercy Fitzgerald revealed in a court filing that a pharmacy intern had mislabeled an IV bag. It was supposed to contain an antiviral but instead consisted of cisatracurium, a muscle-paralyzer similar to vecuronium.

Hospitals use these paralytics to keep patients still during surgery or to relax the throat when inserting a tube through the windpipe, known as endotracheal intubation. Even then, the drug is typically administered under the supervision of an anesthesiologist.

Cruel ‘air hunger’

Cisatracurium has also been at the center of controversy over lethal injections.

In 2018, Nevada prison officials intended to use it as part of a three-drug execution protocol, in conjunction with the sedative midazolam and the synthetic opioid fentanyl, to put a prisoner to death.

The pharmaceutical companies that make the medications sued Nevada because they didn’t want their products used in lethal injections.

A state judge ruled against the use of cisatracurium after hearing medical testimony that it could cause agonizing “air hunger” in fully alert prisoners — a violation of the U.S. Constitution, which prohibits “cruel and unusual punishments.”

Nevada’s cisatracurium supply expired in 2019. About a year later, as part of a legal settlement with the drug manufacturers, the state relinquished its unused cisatracurium and the other two medications.

Flawed systems fail patients

High-alert medications should come preformulated whenever possible, not in a powder or small vial that a hospital pharmacist needs to dilute and mix with saline in an IV bag. This is the recommendation of ECRI, a Plymouth Meeting-based national nonprofit that focuses on patient safety.

Additionally, hospitals should update computerized medication cabinets so practitioners must type in five letters instead of two or three to avoid retrieving medications that look and sound alike.

Vaught, who lost her nurse’s license and job in Tennessee, admitted her mistake. She told state authorities that she got “distracted” by a trainee while operating the automated drug dispenser and had become “complacent” in her job.

But she said the fault was not hers alone. The system failed, too.

During an interview with an investigator, Vaught said, “Ultimately, I can’t change what happened. … The best I can hope for is that something will come of this, so a mistake like that can’t be made again.”

ECRI president and CEO Marcus Schabacker agrees that system failures, not individuals, are at the root of medication errors.

“This is not about catching someone doing something wrong,” Schabacker said. “This is about understanding why a miss or near miss happens and then putting things in place to avoid a similar mistake.”

Schabacker noted that there hasn’t been a deadly accident in commercial air-safety traffic in the United States since 2009. Yet, each year, about 100,000 patients die of preventable medical errors in America. Like commercial aviation, health-care institutions should not only scrutinize errors, but near errors as well, so safety gaps can be closed tight, he said.

An anesthesiologist and intensive care specialist, Schabacker said hospitals must employ additional safeguards for cisatracurium and other high-alert medications, including limiting access and double verification by two qualified practitioners prior to dispensing and administering.

Hospital administrators who want to prevent errors must set the tone and atmosphere for staffers to come forward and report incidents in which a mistake occurred or nearly did, without fear of blame or discipline.

Until that happens, medical errors, particularly those related to medications, will continue, Schabacker said.

“We, as a medical profession, have just become too complacent,” he said.

By Amanda Holpuch, Dec. 29, 2022, The New York Times.

In the next few weeks, tens of thousands of people in Cook County, Ill., will open their mailboxes to find a letter from the county government explaining that their medical debt has been paid off.
Officials in New Orleans and Toledo, Ohio, are finalizing contracts so that tens of thousands of residents can receive a similar letter in the coming year. In Pittsburgh on Dec. 19, the City Council approved a budget that would include $1 million for medical debt relief.

More local governments are likely to follow as county executives and city councils embrace a new strategy to address the high cost of health care. They are partnering with RIP Medical Debt, a nonprofit that aims to abolish medical debt by buying it from hospitals, health systems and collections agencies at a steep discount.

“What we need in this country is universal health care, clearly,” Toni Preckwinkle, the president of the Board of Commissioners in Cook County, said. “But we’re not there as a nation yet, and so those of us who are responsible for local units of government have to do everything we can to make health care available, accessible to people.”

About 18 percent of Americans have medical debt that has been turned over to a third party for collection, according to a report published in July 2021 in the medical journal JAMA. That figure does not account for medical debt that is carried on credit cards or all medical bills owed to providers. Research shows that people with medical debt are less likely to seek needed care and that medical debt can damage people’s credit and make it more difficult for them to secure employment.

Cook County plans to spend $12 million on medical debt relief and expects to erase debt for the first batch of beneficiaries by early January. In Lucas County, Ohio, and its largest city, Toledo, up to $240 million in medical debt could be paid off at a cost of $1.6 million. New Orleans is looking to spend $1.3 million to clear $130 million in medical debt. The $1 million in Pittsburgh’s budget could wipe out $115 million in debt, officials said.

ProMedica Toledo Hospital is one of the largest hospitals in Toledo, where the city, Lucas County and RIP Medical Debt are working out a $1.6 million plan to relieve eligible residents of medical debt.

These initiatives are all being funded by President Biden’s trillion-dollar American Rescue Plan, which infused local governments with cash to spend on infrastructure, public services and economic relief programs. Health policy experts say that while medical debt relief provides an immediate benefit to people, it does not address the root causes of medical debt, which is almost nonexistent outside the United States.

To be eligible for debt relief through RIP Medical Debt, people must have a household income up to 400 percent of the federal poverty level, or about $111,000 for a family of four, or have medical debts that exceed 5 percent of their annual income. People cannot apply to be considered for debt relief, and they do not pay taxes on the purchase of their debt. RIP Medical Debt analyzes debt portfolios to determine who qualifies.

Wendy Pestrue, the chief executive of the United Way of Greater Toledo, said debt relief could remove a source of economic stress for the 43 percent of families who either were living in poverty or were unable to afford housing, child care, food, transportation or health care in Toledo, which has a population of nearly 269,000.

“It puts some of this economic strength back in the hands of those who are having debt exonerated and really helps them plan for their stability,” she said.

Michele Grim, who joined Toledo’s City Council in January 2022, pushed for some of the city’s $180 million in American Rescue Plan funds to be used for medical debt relief after she read about the Cook County initiative.

Michele Grim is one of the leading voices behind Toledo’s use of the American Rescue Plan for medical debt relief.

“Here’s something so simple that local governments can do, maybe even state governments can do, to really help ease that burden on people, because we really need an overhaul in our system, and that’s going to take years,” said Ms. Grim, who is leaving the council at the end of the year because she was elected in November to be a Democratic state representative.

Toledo’s City Council voted 7-5 on Nov. 9 to provide $800,000 to pay off the debts. Its contribution was matched by Lucas County, resulting in $1.6 million for medical debt relief. The city, the county and RIP Medical Debt are now working out a contract.

One council member who opposed the plan was George Sarantou, who said that he voted against it because his top funding priority was public safety, including upgrading city fire stations and police vehicles. While Mr. Sarantou said he was not opposed to medical debt relief, he was concerned about state funding for cities and villages, which is expected to be 1.66 percent of Ohio’s 2022-23 budget. “Ohio has the money,” he said. “Toledo does not.”

Medical debt relief appears to be popular. A poll by Tulchin Research found that 71 percent of respondents supported it. Fifty percent supported relieving student loan debt, 65 percent supported “Medicare for all” and 68 percent supported expanding Medicaid. The national poll of 1,500 people was conducted online from Nov. 14 to 20, after the Toledo vote, and had a margin of sampling error of plus or minus three percentage points. (Ms. Grim’s husband works for the polling company.) This debt relief comes as states change how medical debt is treated.

In November, Gov. Kathy Hochul of New York signed legislation that blocked health care providers from using property liens or garnishing wages to collect medical debt. The day before the Toledo City Council vote, 72 percent of Arizona voters chose to lower interest rates for medical debt and to increase protections for people who owe debt, though a judge has since halted part of the measure.

Officials in Toledo and other cities are partnering with a nonprofit organization that aims to abolish medical debt by buying it from hospitals, health systems and collections agencies at a steep discount.

Wesley Yin, an associate professor of economics at the University of California, Los Angeles, said medical debt relief could be a “game changer” for some people, but governments should also be addressing the causes of medical debt, including high costs and limited access to good health insurance.

In partnership with RIP Medical Debt, Professor Yin is studying how the group’s work affects people’s livelihoods. “I believe there are some positive effects economically, but it might be more muted compared to the face value of the debt that is being forgiven,” he said.

Daniel Skinner, a health policy professor at Ohio University in Athens, said that debt relief was “low-hanging fruit,” considering that the mean amount of medical debt people carry is in the hundreds, not tens of thousands, of dollars.

“We need to get the cost of medicine under control, ultimately,” Professor Skinner said. “I’m all for what Toledo is doing, I’m all for what Cook County and now New Orleans are doing, but, ultimately, we can’t come back every couple of years and do this. It’s not good policy, it’s not efficient.”

Supporters of debt relief measures agree that there is more to be done.

RIP Medical Debt’s chief executive, Allison Sesso, said that a key part of the group’s work was to further discussions about changing the health care system.

In the past two years, RIP Medical Debt has placed more of an emphasis on buying debt directly from hospitals and health systems, before it reaches collectors. Ms. Sesso said that this gave the group a direct channel to talk with hospitals about how their own health repayment plans for low-income patients work. Some of the people whose debt RIP Medical Debt buys should have qualified for these programs in the first place, but they were not enrolled, she said.

“I do this job every day, and I appreciate that what we’re doing is really important and helpful for the individuals that we are helping and it’s resolving this problem for them,” Ms. Sesso said. “At the same time, I can’t help but wonder and question why my existence as an institution is needed in the first place.”

Link to article.