According to the council, the manufacturing of COVID-19 vaccines in Africa could be achieved through sharing of the intellectual property right, technology transfers and open non-exclusive licensing.
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One year into the pandemic, the World Health Assembly is holding its annual meeting. The continued financial challenges loomed over delegates as they discussed the possibility of a Pandemic Treaty, local production of medicines, and WHO’s COVID-19 response
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As most of us sat at home during the past year, seeking safety from the pandemic and isolated from each other, we had little to protect us from the onslaught of historic national traumas and anxieties. We watched in horror as over half a million Americans died, millions lost their livelihoods while others had to face the virus at work, an unarmed Black man was slowly murdered by a policeman on camera, and our President encouraged a white rightwing insurrection. All of this is superimposed on the global existential crisis of climate change and the economic abandonment of many places across the country. If years can be ranked by their impact on the mental health and well- being of people, 2020-2021 would easily be near the top of the list.
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The World Health Organization (WHO) has made an urgent call for another 20 million doses of AstraZeneca’s COVID-19 vaccine to be distributed in African nations in the next six weeks, or many who have received their first dose will not get the boosted protection of a second shot.
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Left Voice interviewed Mohammad Samara, a nurse from the West Bank, during the increased assault on Palestinian people and their land. We spoke about his experience seeing the disparities in healthcare and the recent strike on May 18.
Thanks a lot for being willing to do this interview with us, it means a lot. Could you start by telling us your name, where you live and what you do for work?
My name is Mohammed Samara, and I live in Nablus in Palestine. I work at Refugee Surgical Hospital Perfidia, which is in one of the big neighborhoods in Nablus City. The hospital I work in is for surgical cases only. I have two daughters and we live very close to the hospital. When [anything happens], sometimes I’m the closest one, so I have to go to the hospital for an emergency. I finished my nursing degree in 2005 and I have worked in the medical hospital since 2008. There are two public hospitals — one is a medical hospital and the other a surgical hospital. Throughout these years, I knew there were clashes and anger, but because we are a medical hospital, we haven’t had these cases in our hospitals. Since I transferred to the surgical hospital [in 2013], I started to be more aware of such things. When there are clashes, demonstrations, or attacks from settlers or Israeli soldiers, we are the first hospital to receive the injured. I have witnessed many cases and heard many stories. Working in this hospital opened my eyes more to the cause and what the Israelis can do. Besides that, in my free time, I volunteer in some associations as a translator in English and Arabic. I teach English to kids, and I teach Arabic to international volunteers. I also do tours of the old city of Nablus. On the tours, I talk about Palestinian history and politics, which are often distorted. We can’t just separate [history and politics] from culture. So this is all included in my tours. It’s all voluntary. I just do what I do because I want them to see how we live and what the Palestinians are facing, even if they are in their home.
What type of responses do you get when you include that type of political history for people who go on your tours?
And as I mentioned, we’ve been occupied since 1948. It’s been 72 years. I can’t just, you know, put this aside and say, “I’m just not talking about it.” When you go to the Old City — and I hope one day you both come and visit us — you will see a lot of things that I can’t just avoid and not mention — memorials, pictures, so many writings of the world, some demolished houses. I can’t just deny it. Most of the people who come to see, they kind of have an idea. On the tours, they open their eyes more; they see the real story, they see where it actually happened. They see it without changing the facts. They witness it. They really talk to the people who have faced these events. I have never had anyone who didn’t like what I said or what they saw. Of course, they were very sad. They were very angry. They were surprised or shocked. But it is a bit of a shock, the realities they see, even in Hebron or Bethlehem. These are, of course, the cities that as a Palestinian who lives in the West Bank, I have access to. I can’t go to Jerusalem or any other city, Jaffa or Haifa.
Over the past several days, Israel has been conducting this attack on Palestine as part of its genocidal campaign against the Palestinian people. Could you tell us about your experience over this past week and how your work in the hospital has changed since the bombings began?
At a surgical hospital, we have to be not 100 percent prepared, we have to be more than 100 percent prepared for such events. I’m going to say something first about the Covid-19 situation we’ve had since last year. Here in Nablus, we had a massive increase in the numbers of people infected with Covid-19. Here in Nablus, we have five or six private hospitals and two public hospitals. But after the huge number of critical Covid-19 patients, the Ministry of Health opened two centers for Covid-19 and turned Al-Watani hospital, which is a public hospital for medical cases, into a Covid-19 center. So they transferred all the medical patients to our hospital, which made our hospital fully occupied — no beds. That lasted for several months. And at the time that these events [the bombings] started, we weren’t really well prepared for it. It was very sudden. So luckily, the numbers of Covid patients decreased and Al-Watani hospital was able to take back their patients. If it wasn’t for that, it would have been a huge mess. And really, we couldn’t have done anything for the injured because the hospital was full. So luckily, like on the day that the injured started to come to the hospital, they took back the medical patients to the other hospital, and in a few hours the hospital was full. We have more than 200 beds, and it was full. This includes the beds that we have, the ICU, the neonatal ICU, the pediatric ward, and the burn unit. It was really busy — the nurses, the doctors who were off duty, even they were called to come and help save the injured or help in the E.R. and in the wards.
Did you have enough supplies at the hospitals?
Supply shortages are really common in Palestine. As nurses and doctors, we have to be creative and to work with what we have. It’s all because of the long years of restriction of movement and restrictions on the import of medical supplies. The electricity is intermittent and the water is not reliable. We usually face a lack of supplies, but somehow we make it work and we manage.
How do you see the occupation affecting overall patient health and your ability to care for patients as a health care worker?
It’s not only about the occupation, it’s also that we really have a lack of nurses and doctors. Where I work, I work on the orthopedic, and it’s the section that has very busy days during such events with the clashes and like the gunshots. We only have two nurses each shift and we take care of 20 patients. So that and our lack of supplies leads to low quality of medical care. When I work with patients, my priority is to give them medication and to make sure they are OK. But to be honest, I just don’t have the time to really support them or make a proper nursing care plan. I need to prioritize keeping them alive, and basically just giving as much medical care as I can.
We wanted to ask you about the disparities in health care under the umbrella of Covid-19 between Palestinians and Israelis. What are the differences in care that a Palestinian might get in, for example, Gaza versus somebody in another part of the country?
In Gaza especially, it is more unfortunate. They have more restrictions — from Egypt, from Israel. It is a really small area with a huge population. In the beginning, I think it was easier for the West Bank to get tests, and then later they started getting them for Gaza. The restrictions make it really hard to get medical supplies for them. For their population, they didn’t have enough beds and enough ventilators, they didn’t have good access to electricity because it’s intermittent, very on and off. They also lack doctors and nurses compared to the population and they don’t have enough beds.
Israel has been in the global news about its high vaccination rate. Could you talk about disparities you see regarding the vaccine response and access in Palestine going forward?
The Palestinian authorites stated that there has been a delay in getting the vaccinations because of Israel’s restrictions and because of the factories that are making the vaccines. In the beginning, people didn’t want to take these vaccines. Most of the people didn’t want to take it, but later they started to be convinced about it. It was difficult in the beginning because medical teams are supposed to be the first ones who get it, but it didn’t happen here. The politicians and other people got it first. They really made it difficult for the medical workers. I had Covid-19 in September. I am thankful I survived. That really almost killed me. I stayed locked up for one month. It was like intensive care for me. When it was time for me to take it, they said, “No, we’re not going to give it to you because you already had it.” But it had already been seven months. So they weren’t giving it to all medical workers, which we didn’t like. So we didn’t exactly protest but we started talking to everyone about it and then later because of that we got it. They set up days where people who were certain ages could get it — sixty and seventy years old. They made a schedule. But many people still didn’t believe that Covid-19 even exists. But still, there are a lot who took the vaccine.
For those who do want to take the vaccine, can anyone get the vaccine in Palestine?
At the beginning, it was not available and we didn’t have enough vaccines. As I see now, I don’t have any numbers, but as I hear from people, they say “we go to a clinic, and they give us the vaccine.” So, I’m not really sure if it’s available. There was a lot of chaos and it was really messed up. I don’t think it was very well organized because in my hometown, they started to say “Yeah, we have the vaccine, so let’s let certain people get the vaccine who meet criteria.” But I was talking to my mom and dad [who meet that criteria] and they didn’t mention anything about getting the vaccine. People all seem to have different information. I’m not sure if it’s the management and lack of organization or if it’s because it’s not available. I hear some people saying that they went to this or that clinic and they got the vaccine. It’s a bit unclear. There is something really taboo about Covid-19 here.
There was a recent strike called among the Palestinian people on May 18. Did you participate in that strike? What was the impact of the strike that you noticed?
Unfortunately, no. I was in the hospital just in case something happened. My duty was to be there if something happened, which, of course, it did. It’s been a really long time since I saw such a strike. During the second Intifada I was studying nursing, so I lived through that whole Intifada. I saw so many things during that time. And with all that was happening in the last year and in those years and what’s happening now… I was a little bit desperate. I thought maybe we just have to give up. What I saw [with the strike] was — I don’t know if it’s the right word, but it was really refreshing. I know that there is still hope for this generation. What really makes me really optimistic is that there was unity that I haven’t seen in a long time. There was unity between the Palestinians who live in the occupied land in what everybody calls “Israel” and Gaza. So after all this time, there was this [connection].
Do you know of any future plans for labor actions?
I am not sure if there will be. But what I saw is that maybe this is a seed for the future. The ceasefire in Gaza doesn’t mean that everything is done. There are still acts like what happened in Jerusalem today. After the prayer, Israelis attacked the people who were praying in Al-Aqsa. We know that this is not going to end now. This is the start for a good future, and I hope there will be more united movements for this one goal.
You mentioned the cease fire and the international media attention it has received, and Biden is being praised for it. People are thinking that this means an end to the immediate bombardment. But as you mentioned, there’s been ongoing violence during an occupation of 73 years. What would you say is important to continue sharing with people so that this movement isn’t forgotten?
About the ceasefire, yeah they say it’s “done” but that doesn’t mean that everything is actually done. There is still the situation in Sheikh Jarrah, which started everything. The ethnic cleansing that they carry out is not nearly completely finished. Not only this, but we’ve been occupied for 73 years. A ceasefire is not enough. Personally, I have lost so many friends. Two of my best friends were in prison for a long time. I work in the hospital and I see what they do with people. I was in the hospital a couple of years ago, there was a little boy who came who was burned because a settler set fire to their house. His mother, father, and one-and-a-half year [old] brother died. He survived, but he was severely burned, like third degree on more than eighty percent of his body. Of course the ceasefire made me happy, but no, it’s really not enough.
People around the world are likely thinking that the call for the ceasefire means an end to the violence. But as you mentioned, there has been a decades long occupation and you see the daily violence enacted on Palestinians. What is important to continue to share with people so that this movement and effort isn’t forgotten?
I was studying nursing in Nablus during the second intifada. At that time, there were only a few reporters, there was no Internet or social media really in 2002 and 2003. Back then, there were only reporters from CNN or Al-Jazeera or whatever, and they said what they wanted to say. If I were in the United States, let’s say, I would just be in my living room, watching the TV, getting angry, and that’s all I could do. But now everybody becomes a reporter — social media has made a huge, huge change and impact, and opened people’s eyes to what is happening here. Everyone can make their own reports. They can show the world what’s actually happening without any censoring, without manipulating words. I’m really happy with what happened with the push forward for Palestine, and social media has made a huge impact with the Palestinians and really supported us this time. That was really different.
Social media was huge in publicizing the Palestinian struggle. Is there anything else you think that made this fight so important and internationally supported in this current moment?
We have this saying in Arabic “one hand cannot clap,” I don’t know if you have anything like that in English. So, Palestine was one hand, and I think the whole international community really joined hands together and that really affected us. I can’t describe how amazing it is to see the demonstrations and people taking a stand with Palestinians. I don’t know, I don’t know what else to say. It really makes me more hopeful. I’d never seen a movement so big for Palestine.
What is your message for what people in the United States or other parts of the world can do to continue to stand in solidarity with the Palestinian people in their struggle?
I was thinking about it all day. There are so many things.
The history is clear. It’s obvious who is occupied and who is the occupier. This is not a war. Israel has the most powerful army in the world and the Palestinians have nothing, only their hands. I think the encouragement and support from people all over the world can give them power. And it’s better than any weapon that any country can provide to anyone and better than any funding. This is something that will last forever.
Thank you. The struggle of the Palestinian people against an occupying power backed by one of the largest empires in world history is something that inspires people all over the world to continue to stand against imperialism and occupation. We stand in solidarity and will continue to support in any way that we can. Thank you.
This interview has been edited for clarity and length.
This post was originally published on Latest – Truthout.
The data, provided by the Centers for Disease Control and Prevention in response to a public records request, gives a sweeping national look at the race and ethnicity of vaccinated people on a state-by-state basis. Yet nearly half of those vaccination records are missing race or ethnicity information.
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A new report NRDC published with partner groups today spotlights the enormous, often overlooked, and inequitable health and economic costs of climate change and air pollution from burning fossil fuels on the United States. This report, produced by the Medical Society Consortium on Climate & Health, Wisconsin Health Professionals for Climate Action, and NRDC focuses on the frequently ignored but profound public health problems and costs linked to the climate crisis.
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Dozens of the dead or wounded have arrived at my hospital for treatment. We are witnessing entire families being wiped off the face of the earth.
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National Nurses United (NNU), the largest union of registered nurses in the United States, today condemned new Centers for Disease Control and Prevention (CDC) guidance stating that fully vaccinated people no longer needed to wear masks, avoid crowds or large gatherings, and no longer needed to isolate after exposure or get tested unless they develop symptoms. Nurses say that given the threat to their patients across the country, they are especially disappointed that the CDC would ease up its Covid guidance on the heels of International Nurses Day.
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Ann Garrison: Mumia has finally had the open-heart surgery that his team and his wife had such a hard time getting any information about beforehand.
Johanna Fernandez: That’s correct. But Mumia’s chosen doctor, Dr. Ricardo Alvarez, has not been given access to the surgeons. Mumia was finally able to call his wife Wadiya Abu-Jamal several days before the surgery, but at that point he was very weak and was only able to whisper to her that he would be undergoing surgery two days later. He was allowed to call her after the surgery, and she said he sounded strong.
AG: Was there any response to the campaign to remove the shackles – the four-point restraints – ahead of Mumia’s surgery.
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Pfizer, which along with Moderna developed successful mRNA vaccines against COVID-19 late last year, announced on Tuesday that it could have ready by the end of the year an experimental oral drug which would treat COVID-19 as soon as patients display symptoms. The announcement was made by CEO Albert Bourla on the CNBC program “Squawk Box,” who said that for the drug to be released to the public it will first need to perform well at clinical trials and receive approval by the Food and Drug Administration (FDA).
“This is an inhibitor of the protease enzyme in the SARS-CoV-2 which is promising in pre-clinical studies to block the ability of the virus to replicate,” Dr. Monica Gandhi, infectious disease doctor and professor of medicine at the University of California — San Francisco, told Salon by email.
Pfizer had announced that Phase I trials, the first stage in testing a new drug, were to start soon to see if the virus was safe in adults.
Gandhi said that it was a “promising” oral antiviral drug, one that “could be used easily in the outpatient setting to treat COVID-19.” Remdesivir is the only other existing antiviral drug used to fight COVID-19; famously, it was administered to President Trump when he contracted the virus.
Dr. Russell Medford, Chairman of the Center for Global Health Innovation and Global Health Crisis Coordination Center, said the drug held “significant promise as a potential treatment to be used at the first sign of infection or exposure to the SARS-CoV2 virus,” with the caveat that the clinical trial process had barely begun.
“To have this drug available for broad use by the end of the year is very ambitious but not without precedent as exemplified by the extraordinary rapidity in which multiple COVID-19 vaccines were developed, tested and deployed,” Medford added.
Because such a drug would be administered to those who contracted COVID-19, and thus were either unvaccinated or breakthrough cases, its utility may be slightly more limited than the vaccine. Dr. Alfred Sommer, dean emeritus and professor of epidemiology at Johns Hopkins University, noted that preventing a disease through a vaccination is more cost effective than treating it after a person has been infected and diagnosed.
Pfizer, like Moderna, currently distributes a vaccine using a revolutionary new technology called mRNA vaccines. While conventional vaccine platforms take a weak or dead version of a pathogen (disease-causing organism) and inject it into the body, mRNA vaccines simply use a bespoke RNA strand that trains the body’s cells to recognize proteins associated with the microscopic invaders. In the case of their COVID-19 vaccine, the immune system is trained to recognize proteins associated with the spikes that poke out of the virus’ central sphere like spines from a sea urchin.
This post was originally published on Latest – Truthout.
“I couldn’t have survived if I was in America.”
That’s what one woman concluded in a video published Wednesday by the New York Times’ opinion section, after recounting the weeks she spent in the hospital as a child being treated for a brain virus.
She was just one of several people from around the world who participated in the Times project. Throughout the video, residents of Canada, Finland, Germany, Japan, Singapore, Sweden, Taiwan, and the United Kingdom respond to the high costs of healthcare in the for-profit U.S. system.
The United States is the only industrialized country in the world without universal health coverage. While the stars of the Times video were shocked and outraged upon learning how much care costs in the so-called “land of the free,” progressives in the U.S. responded with calls for Medicare for All.
We need Medicare for All. https://t.co/BtTN9cdGuw
— Ayanna Pressley (@AyannaPressley) April 28, 2021
“No one in America should vote for politicians who choose to subject us to this,” Briahna Joy Gray tweeted in response to the video. The Bad Faith podcast co-host and Current Affairs contributing editor served as press secretary to the 2020 presidential campaign of Sen. Bernie Sanders (I-Vt.), a longtime champion of Medicare for All.
In the video, residents of various countries reviewed some private health insurance options for U.S. residents and tried to make sense of terms like copay, deductible, and OOP max, which stands for out-of-pocket maximum, or the highest amount of money enrollees have to pay annually for healthcare services covered by their plan.
People for Bernie, which grew out of Sanders’ 2016 run for president, also shared the video and asserted that the “acceptable OOP max is $0.”
The acceptable OOP Max is $0 #MedicareForAll https://t.co/T83V87tk90 pic.twitter.com/tWBpziY5Bn
— People for Bernie (@People4Bernie) April 28, 2021
Some people in the U.S. praised the video as “so, so good” and “very well done.” Waleed Shahid of Justice Democrats called it an “excellent video about the cruelty and inefficiency of our healthcare system.”
Others echoed the outrage of video participants. As NARAL Pro-Choice America president Ilyse Hogue put it: “The definition of insanity is this.”
In the video, a man in Sweden contrasts the healthcare system in his country with that of the United States. “To know that I can get sick, I can get injured, but I will still be taken care of, that is freedom,” he says. “This is not freedom.”
Despite conclusions from policymakers and medical experts — including a Lancet panel in February — that “single-payer, Medicare for All reform is the only way forward,” President Joe Biden has made clear he opposes that path to universal coverage.
Biden unveiled his American Families Plan early Wednesday. Despite pressure from progressives in the House and Senate as well as dozens of advocacy groups, he declined to include an expansion of Medicare and drug pricing reforms in the plan.
Ahead of Biden’s Wednesday night address to Congress, Sanders declared in a video from his Senate office that “we’ve got to deal with healthcare.”
“We remain the only major country on Earth not to guarantee healthcare to all people as a human right,” he said. “We pay the highest prices in the world for prescription drugs. We have got to summon up the courage to take on the healthcare industry, the pharmaceutical industry.”
“My own view, as you know, is that we need a Medicare for All, single-payer system,” the Senate Budget Committee chair added, expressing hope that lawmakers can begin that process by expanding the program — by both lowering the eligibility age from 65 and including dental, hearing, and vision benefits.
“We pay for that by demanding that Medicare start negotiating prescription drug prices with the pharmaceutical industry,” Sanders explained, citing estimates that the reform would raise $450 billion over a decade.
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Last year, on the campaign trail, President Joe Biden released a $750 billion, 10-year plan designed to massively expand the reach of the Affordable Care Act (ACA). It would create a public option, allow undocumented immigrants to buy into that public option, lower the age at which Americans become eligible for Medicare, take Medicaid expansion into the 12 Republican heartland states that chose not to expand it themselves, and permit Americans to buy prescription drugs from overseas at a cheaper cost.
Since assuming office, such sweeping health care ambitions have taken a back-burner to getting COVID relief passed, to developing a large-scale infrastructure plan, and to initiating a reset on environmental policy. But that doesn’t mean there is less urgency to lock into place big-picture health insurance changes. After all, the Biden administration inherited a barn-on-fire situation from the previous president, and we are still in the middle of a pandemic.
There are, in 2021, more than 2 million low-income American adults who live in states that didn’t expand Medicaid, and who can’t access private insurance on the exchanges because their income is deemed too low to qualify for tax credits. Of these 2 million, more than a third live in Texas. All told, by the middle of 2020, at the height of the pandemic, about 30 million non-elderly Americans remained without insurance. That’s down from 48 million in 2010, but it’s up from 28 million at the end of Barack Obama’s presidency. The increased numbers of uninsured in the years from 2017 to now are the clear result of former President Donald Trump’s effort to eviscerate his predecessor’s central legislative accomplishment and make it ever-harder for Americans to enroll in the subsidized insurance plans.
From 2017 through to January 20, 2021, health care advocates had to play defense pretty much all the time. From day one of his administration, Trump, with the full backing of most of the GOP, had the ACA, known more popularly as Obamacare, in his sights. In his first months in office, the Senate came within one vote of rolling back the legislation that had created the ACA. It was that one vote, cast by an ailing Sen. John McCain against dismantling the ACA, that fueled Trump’s loathing for, and mockery of, the dying Arizonan.
After Republicans failed in Congress to repeal the ACA, Trump sought to kill it by a thousand cuts: to make it harder for patients to enroll on health care exchanges, to limit Medicaid expansion, to cut funding for outreach campaigns to educate people on how to enroll. Finally, having failed to destroy the program this way, Trump’s administration decided to side with Texas and other GOP states in their Hail-Mary lawsuit attempting to have the entire thing declared unconstitutional.
That case was heard by the Supreme Court last year, and a decision on it should come down in the next few months. Given the extraordinarily conservative composition of today’s Supreme Court, it’s at least possible — though perhaps not likely, given previous rulings on the issue — that they’ll end up taking a judicial axe to the entire project.
Which is why it’s all the more vital that, in the interim, state and federal officials work to expand the ACA as rapidly as possible. After all, the more people are covered, and the more the ACA is seen to be an indispensable, life-saving pillar of the country’s health care delivery edifice, the harder it will be to pull the rug out from under it. Given that neither party seems likely to push for a more rational, more equitable universal health care system anytime soon, ironing out the kinks in the ACA and expanding its reach seem to represent the best short-term path toward near-universal coverage.
An ACA expansion would inevitably still fall short of a truly universal, single-payer system, and it would do little to address systemic problems such as over-billing and the profiteering of middle-men institutions, which go hand in hand with for-profit insurance systems as a primary delivery system for medical services. But it would, nevertheless, bring additional millions of uninsured Americans under health care umbrellas.
Earlier this year, the Biden administration extended the special enrollment period for the ACA insurance exchange through August 15 of this year, arguing that, because of the extraordinary circumstances of the pandemic, it was imperative to make it as easy as possible for Americans to find affordable health insurance coverage. California and other states with their own exchanges also followed suit in keeping enrollment open.
The result of this has been encouraging: In the first weeks of the special enrollment period, well over 200,000 people signed up for coverage, eclipsing, by orders of magnitude, the numbers from the first weeks of earlier special enrollments. Hundreds of thousands more have begun the application process to get insurance via these exchanges; and additional tens of thousands have been declared eligible for Medicaid and the Children’s Health Insurance Program.
Moreover, the latest COVID relief package in Congress freed up billions of dollars to increase subsidies to lower-income people buying coverage on the state exchanges. In many cases, premiums for people around the country will be cut in half. And in some states, funds will be used to essentially eliminate premiums for poorer residents. In California’s case, for example, this means an additional $3 billion for subsidies. As a result, come May, some low-income Californians will be paying only $1 per month for their health insurance. Hoping to get more Californians to take up insurance through the exchange, the state will spend $20 million on an outreach and advertising campaign promoting the new lower rates.
For a state that has already managed to cut its uninsured population from about 17 percent down to roughly 7 percent, all of this is a huge deal. Combine it with the ongoing efforts to expand Medi-Cal to cover all low-income undocumented adults, and one sees a road-map being drawn in California that would, over the coming years, get the state as close to having universal coverage as possible given the nature of the current U.S. health insurance system.
Where California goes on health care coverage, the nation might one day follow – especially with California’s former Attorney General Xavier Becerra now in charge of the Department of Health and Human Services, and pushing an emphasis on health equity and public health readiness. Already, California has self-funded Medicaid expansion to include young undocumented adults up to the age of 26. Quite possibly, later this year the state may expand the expansion to include a much larger proportion of the undocumented population. This jibes well with the proposals then-candidate Biden put out on the campaign trail. Hopefully, once California paves the way, Biden and the Democratically controlled Congress will follow through on their health care commitments at a federal level too.
This post was originally published on Latest – Truthout.
President Joe Biden’s top challenger in last year’s Democratic primary, Sen. Bernie Sanders of Vermont, spearheaded a letter sent to the White House on Sunday urging the president embrace an “historic opportunity” and include key expansions to the U.S. Medicare program when he announces a detailed vision for a major federal investment and tax reform plan later this week.
The two-page letter (pdf) from Sanders and 17 Democratic senators — including other 2020 presidential candidates Cory Booker of New Jersey and Elizabeth Warren of Massachusetts — asks Biden to “propose reducing the Medicare eligibility age, expanding Medicare benefits to include hearing, dental, and vision care, implementing a cap on out-of-pocket expenses under traditional Medicare, and negotiating lower drug prices” as part of the president’s “American Families Plan” that he is expected to showcase during his first address to Congress Wednesday night.
Calling Medicare, signed into law by President Lyndon Johnson in 1965, “one of the most successful and popular federal programs in our nation’s history,” the letter argues “the time is long overdue for us to expand and improve this program so that millions of older Americans can receive the health care they need, including eyeglasses, hearing aids, and dental care.”
The lawmakers argue that lowering the Medicare eligibility age — currently set at 65 — down to 60, 55, or even 50 would be a way to expand coverage, save lives, and enact a broadly popular reform to a program that is already wildly popular by a majority of the American people across the political spectrum. The letter states:
Lowering the eligibility age for Medicare would help [millions of uninsured or under-insured older Americans] significantly. Twenty-seven percent of adults age 50 to 64 are not confident that they can afford health insurance over the next year, and more than a quarter report issues with navigating health insurance options, coverage decisions, and how their choices will affect their out-of-pocket costs. Researchers have found that there is a massive spike in the diagnosis of cancer among Americans who reach the age of 65 that could have been diagnosed much earlier if the Medicare eligibility age had been lower. Lowering the Medicare eligibility age to 60 could expand Medicare coverage to 23 million people, including nearly 2 million uninsured people, while lowering it to 55 could give over 42million people access to the program, and lowering it to 50 could cover 63 million Americans. Lowering the Medicare eligibility age is not only the right thing to do from a public policy perspective, it is also what the overwhelming majority of Americans support. According to a recent Gallup poll, 65 percent of Americans support lowering the Medicare eligibility age.
In addition to Sanders, Booker, and Warren, the letter sent to Biden on Sunday was signed by Sens. Ben Cardin (D-Md.), Debbie Stabenow (D-Mich.), Tammy Baldwin (D-Wisc.), Richard Blumenthal (D-Conn.), Sherrod Brown (D-Ohio), Tammy Duckworth (D-Ill.), Dick Durbin (D-Ill.), Kirsten Gillibrand (D-N.Y.), Edward Markey (D-Mass.), Jeff Merkley (D-Ore.), Alex Padilla (D-Calif.), Tina Smith (D-Minn.), Chris Van Hollen (D-Md.), and Sheldon Whitehouse (D-R.I.).
Biden’s proposal for an approximately $1.8 trillion spending plan, the Washington Post reported Saturday, is expected to devote “hundreds of billions of dollars to national child care, prekindergarten, paid family leave and tuition-free community college, among other domestic priorities.” On healthcare reforms specifically, however, the White House has not finalized how far it is willing to go.
According to the Post:
In a potential last-minute change, White House officials as of Friday were planning to include about $200 billion to extend an increase in health insurance subsidies through the Affordable Care Act exchanges, according to three people who spoke on the condition of anonymity to reveal internal discussions.
House Speaker Nancy Pelosi has been the key driver in Congress pushing for increased federal subsidies to private insurers under the Affordable Care Act in order to make the program created under the Obama administration more affordable and widely available, but Sanders has been leading the charge on the call to expand Medicare.
“We cannot continue to deal with millions and millions of seniors — primarily low-income seniors — who cannot afford to go to a dentist, so cannot ingest the food they eat, or the millions of seniors who live in isolation because they can’t hear,” Sanders told the Post earlier this month.
On Friday, the Congressional Progressive Caucus backed a both/and, as opposed to an either/or, approach when it comes to healthcare expansion under the Biden plan.
“Voters delivered us governing majorities and now we must deliver for them on health care policies that are not only urgent but wildly popular,” Rep. Pramila Jayapal (D-Wash.), chair of the CPC, said in a statement.
“We must immediately lower the cost of prescription drugs and use the massive savings from this to lower Medicare’s eligibility age and improve benefits while at the same time ensuring the permanent affordability of health plans obtained through the Affordable Care Act,” Jayapal said. “These necessary policies that are supported by large bipartisan majorities of the American people enjoy the strong support of our Democratic Caucus, and can be accomplished simultaneously.”
Citing the American Rescue Plan signed into law as Biden’s first major piece of legislation earlier this year, Jayapal argued passage of that Covid-19 recovery and stimulus legislation should be a lesson to Democrats “that American people of all parties support us when we enact bold, populist policies that deliver for them.”
Alex Lawson, executive director of the advocacy group Social Security Works, struck a similar message when speaking to the Post earlier this month about the competing plans in Congress and what Democrats should understand about what’s at stake in terms of healthcare policy and reforms.
“Before the next election, we need the American people — and particularly seniors, who have suffered so much during this pandemic — to see that this government is working for them,” Lawson advised. “People would get hearing aids, get their teeth checked, before the next election. That will show them Biden is on their side. Democrats have to deliver for seniors if they are going to win.”
And as Sunday’s letter to Biden concluded, “We have an historic opportunity to make the most significant expansion of Medicare since it was signed into law. We look forward to working with you to make this a reality and, in the process, substantially improve the lives of millions of older Americans and persons with disabilities.”
This post was originally published on Latest – Truthout.
We look at pandemic profiteering in the medical system as a new report by Kaiser Health News reveals some of the nation’s richest hospitals recorded hundreds of millions of dollars in surplus over the past year after accepting federal healthcare bailout grants. This comes as hospitals in New York have sued thousands of patients during the pandemic, and Northwell — which is run by a close ally of New York Governor Andrew Cuomo — has faced intense criticism for practices like billing patients at its Lenox Hill Hospital over $3,000 for COVID tests — more than 30 times the typical cost. “There’s a lot of talk in our healthcare system about putting patients first, … but this is not doing that,” says Elisabeth Benjamin, vice president of health initiatives at the Community Service Society of New York and co-founder of the Health Care for All New York campaign. “Suing patients ruins their lives.” We also discuss how Biden’s CARES Act made 3.7 million more people eligible for the Affordable Care Act’s premium subsidies.
This is a rush transcript. Copy may not be in its final form.
AMY GOODMAN: This is Democracy Now! I’m Amy Goodman, with Juan González.
As the United States reports over 79,000 new coronavirus infections Monday and cases continue to rise nationwide even with the vaccines, we turn now to look at pandemic profiteering in the medical system.
A new report by Kaiser Health News reveals some of the nation’s richest hospitals recorded hundreds of millions of dollars in surplus over the past year after accepting federal healthcare bailout grants.
In Texas, the state’s largest nonprofit hospital system, Baylor Scott & White Health, received over $450 million in relief funds, despite laying off 1,200 workers. Baylor is now sitting on a surplus of [$815 million] — appropriate I should cough during a healthcare segment.
The report cited the Mayo Clinic, the University of Pittsburgh Medical Center and NYU Langone Health as other big beneficiaries.
Here in New York, the state’s largest nonprofit health system, Northwell, received $1.2 billion in federal funds from the CARES Act. But Northwell, which is run by a close ally of New York Governor Andrew Cuomo, has faced intense criticism for suing over 2,500 patients last year for failing to pay their medical bills. It only stopped suing for medical debt after a report by the Community Service Society exposed the practice. Meanwhile, The New York Times recently revealed one of Northwell’s facilities, the Lenox Hill Hospital, billed over $3,000 for COVID tests — more than 30 times the typical cost.
We’re joined now by Elisabeth Benjamin, vice president of health initiatives at the Community Service Society of New York, co-founder of Health Care for All New York campaign.
Elisabeth, can you start off by talking about these pandemic profiteers? Why don’t you start off by talking about Northwell and what happened? As patients were in such dire circumstances this year, the hospital sued thousands of them.
ELISABETH BENJAMIN: Yes. So, I think it’s really important to note that two-thirds of all hospitals in America are nonprofit hospitals. In New York state, every single hospital, by law, is a nonprofit 501(c)(3) charity. And we have to remember that the first tenet of medicine is to do no harm.
There’s a lot of talk in our healthcare system about putting patients first and social determinants of health, but this is not doing that. This is not taking care of patients first. Suing patients ruins their lives. It means you have to make decisions between paying your rent or paying a medical bill, putting food on your table or paying a medical bill.
I think what our work has shown — and we’ve looked now at every single hospital in New York state and found that they have collectively sued over 50,000 patients, despite all being charities, and over 5,000 patients during the pandemic — is that there’s a deep problem here with our so-called not-for-profit hospitals. And I think we really need to take stock as a country and say, “Look, either you get to be a charity and you get to raise money and not pay taxes and pull down billions of dollars — for example, $178 billion in CARES Act funding went to hospitals during the pandemic — you can get all that, but you must not sue your patients. Suing your patients hurts them.”
JUAN GONZÁLEZ: Elisabeth, I’m wondering if you could talk a little bit more about this whole issue of the enormous money that the hospitals have made. I did a deep dive into the finances here in New Jersey of the largest hospital chain, RWJBarnabas, and I discovered that they received about $1.2 billion in grants and loans from the federal government, far more than they lost in patient revenues, and during last year as a result of CARES Act funding. At the same time, they were making huge gains in their investment portfolios as a result of the tremendous drive-up in the market. So, they are sitting in far more — it’s almost like the coronavirus became a financial windfall for the hospital, supposed, as you say, nonprofit corporations. The federal government even gave them advanced Medicare reimbursements, which was basically a loan, a zero-interest loan, for these hospitals. And so, how are they able to get away with this?
ELISABETH BENJAMIN: So, I think the issue is, look, we want hospitals, right? We are so grateful to the staff and everybody that works at hospitals for helping us to survive this horrible pandemic. In New York, our nonprofit hospitals got well over $13 billion in CARES Act funding. And, you know, most of the hospitals in New York, I don’t believe, ended up — with the exception of NYU and a few others — with huge surpluses by the end of the year. And perhaps that’s because New York was hit so hard by the pandemic.
My concern is: If we’re going to invest our public dollars and our public good into hospitals, what business do they have in suing patients? And let’s just talk about what happens with these lawsuits. Most patients, you know, are sued, and what happens is there’s a default judgment. If you look at Lenox Hill, for example, the hospital with the $3,000 CARES — corona test, they sue patients — they sue patients for about 1,900 bucks. That’s the median amount that they’re suing for. So, they’re suing patients for not very much in terms of their huge surpluses. They have a nearly $100 million surplus. And they’re suing patients for about $1,900. Altogether, they’re suing patients — they get 34 times more in their annual surplus than they get in what they’re suing for patients over five years. So, what’s going on here? They’re ruining patients’ lives while reaping surpluses in revenue. This is not the way to pay for healthcare, by suing your patients. That’s the problem here.
And so, you know, I think we, as a country, need to really look at how we’re supporting nonprofit hospitals. If we’re going to be investing billions of dollars in them through CARES Act funding, through Medicare, through Medicaid, then I think we have the right to demand certain practices just be dropped. And the first practice that should be dropped is suing low-income patients of color. And I think what’s really important is to understand that LendingTree said that 72% of the people that they surveyed said that medical debt prevents them from achieving their major milestones in life. Forty percent of people of color have medical debt. A hundred and thirty-seven million Americans had medical debt in 2019, before the pandemic.
We really need to have some political action here that says, if you’re a nonprofit hospital, your first tenet is to do no harm. And I think that’s a reasonable expectation. I mean, after all, it was the public outcry that stopped the Humane Society from killing the animals. Hospitals should not be suing their patients. That should be a never event. It should be approved by the CFO and the board of directors if they must sue at all.
JUAN GONZÁLEZ: And, Elisabeth, aren’t most hospitals, because they are nonprofits and charities, required to do indigent care, to a certain degree, and get reimbursed by the state governments for their charity care? How do you reconcile this issue of their having to have some public good as a result of being a charity, and yet they’re continuing to sue as would any for-profit company?
ELISABETH BENJAMIN: I can’t reconcile it. In New York state, we give our hospitals a billion dollars in what’s called indigent care pool funding, or charity care pool funding, and yet, altogether, they’re suing people for, you know, a couple $10 million in each year. It makes no sense.
And when we review the pleadings, because we go to court and we pull all the court case files — for example, Lenox Hill — we found not one offer of financial assistance was actually made or attested to in their court documents. And the documents that they use when they sue people, they use sort of creepy law firms. For example, with Lenox Hill, they’re using a law firm that’s alleged to use process servers that falsify their service of processing. In a federal court action, they’re alleged to basically use a process server that pretends to serve patients, but they really don’t. And then they wonder why all the hospital lawsuits are won based on default. That means that the patient never shows up in court. And if the very, very few that do get their pleadings and are served, when they do show up, you know, they never have lawyers, because they can’t afford it.
What are we doing here as a society? We need to make demands. And, you know, our political leaders need to step up and make demands and say these lawsuits should be never events. We need to have fair and transparent billing. Most patients don’t understand their bills. Consumer Reports did a survey and found that a third of patients pay bills they don’t even think they owe, because they’re so afraid of having an adverse event on their credit report. It’s out of control. And we need to demand more from our nonprofit hospitals.
AMY GOODMAN: Elisabeth, I —
JUAN GONZÁLEZ: Well, you mentioned Lenox Hill Hospital, which is part of the Northwell chain, headed by Michael Dowling, a very close friend and ally of Governor Cuomo. Where is the governor on these issues these days?
ELISABETH BENJAMIN: We have met with the administration several times. And we worked — I co-chaired a committee on indigent care that the governor empaneled a couple years ago. And there were some reforms made on that charity care pool, that indigent care pool. And so that was a great thing that the governor did.
In his State of the State, he said and promised that he would have one unified financial aid form that every single hospital must use in New York state. That has yet to be materialized. And so, we’ve gone to the Legislature and said, “Hey, we need one simple, uniform financial aid form.”
So, every hospital in New York state — there’s over 200 — gets to design their own financial aid form. And if you see one financial aid form, you’ve seen one. In Lenox Hill’s case, you can’t even find the financial aid form on their website. You have to know exactly what to be looking for. And after like four clicks, maybe you’ll make it to the Northwell — the mothership — website, where you might be able to find their financial aid policies. They make it as hard as possible to apply for financial aid. And in all — we’ve never seen a lawsuit where they actually said that they offered financial aid and found that the patient was not eligible. So we need massive reform here.
AMY GOODMAN: Elisabeth, I wanted to ask you about the distinction in hospitals, because people might lump them all together. You’ve got the so-called not-for-profit hospitals, the private hospitals. Then I’m looking at a piece by Politico, “New York’s safety-net hospitals were the front lines of the coronavirus. Now they’re facing ruin.” So, compare them, like Lenox Hill, Northwell, etc., to New York City hospitals that serve the city’s poorest patients facing financial ruin after being on the frontlines.
ELISABETH BENJAMIN: Well, that’s one of the things that we did a big report in the middle of the summer, because the original allocation of the CARES Act funding was based on commercial interest — sorry, commercial insurance practices, your past performance, in terms of getting receipts from commercial carriers. So, you know, NewYork-Presbyterian, originally, and Northwell were getting hundreds and hundreds of millions, and Health + Hospitals, which has a much smaller commercial insured base of business, was getting tiny amounts. That was eventually corrected towards the end of the year, where the big safety-net institutions, they ended up sort of rejiggering the pool. But the idea that the federal government thought it was OK to allocate hospital relief packages based on commercial insurance performance, and not based on Medicaid performance, for example, is crazy making, especially given the fact that the pandemic had such a disparate impact on low-income communities of color, where our beloved essential workers live and work.
AMY GOODMAN: Elisabeth —
ELISABETH BENJAMIN: That was — sorry.
AMY GOODMAN: Keep going.
ELISABETH BENJAMIN: So, that was sorted out, eventually. And I think the allocation, by the time we re-reviewed it in the end of December, early January, it looked like it was sort of right-sized.
But it’s interesting, going back to our indigent care pool that New York state gives out, the billion dollars to support the provision of charity care, that was never allocated as it should have been to the top 25% a safety-net hospitals, of which our public hospitals are all part of, and, in fact, had been spread around like peanut butter to these hospitals, that are so-called charities, that are suing the pants off of patients. So, there’s something deeply wrong. I don’t believe that one charitable hospital who’s suing a patient should be getting any indigent care pool funding, because clearly they aren’t actually following the letter of the law and really getting the financial aid out to the patients that need it.
AMY GOODMAN: Elisabeth, before you go, there’s two critical issues, and we only have a few minutes. One is, we did that first segment on especially undocumented essential workers getting aid. What’s the situation in New York and in California for undocumented people getting healthcare? And then, if you could briefly address the expansion of the Affordable Care Act? I don’t think most people know this.
ELISABETH BENJAMIN: Sure.
AMY GOODMAN: Who has access to Obamacare, depending on their wealth or not wealth?
ELISABETH BENJAMIN: Sure. So, two things. The first thing, on immigrant health, like the essential workers, New York state really fumbled in its budget this year, our leaders. We had put together a package of $20 million — just $20 million — to provide coverage to undocumented immigrants who have COVID. That was unacceptable to our state lawmakers, and that did not pass in our state budget, where they’re raising billions in revenue. So, that’s just a total abdication of leadership by all our lawmakers, and we’re completely upset about that.
In terms of the Affordable Care Act, this is quite extraordinary, what the Biden administration did. They did four things that really help people right now.
Number one, if you’re going — if you’re getting coverage through the marketplace, you are eligible for more financial assistance. So you should immediately go back onto the marketplace and reestimate your tax credits.
Number two, you should — higher-income people are now eligible for financial aid, so if you ever applied for financial assistance through the marketplace and were turned down because of your income, go back. You might be eligible now.
Number three, if you get even one unemployment check in 2021, you can get a zero-premium plan right now that’s super good, a platinum-level plan.
And, number four, they were totally paying for COBRA subsidies between April and September. You get free — the government will pay for your COBRA payments, insurance premium payments. That’s when you get terminated from your job or you lose your job, and you can get the offer of insurance, your job-based insurance. You can get the government to pay for your premiums between April and September 2021.
So, the Biden package, American Rescue Plan, has really done a lot on health coverage for Americans, and we’re super grateful to the administration for that.
AMY GOODMAN: And where can people go to get this information?
ELISABETH BENJAMIN: You can go to, if you’re in a federal, you can go to HealthCare.gov. Or, if you’re state, many states run their own marketplace, and you should go to your own state marketplace and call the call centers. They’re standing by. They can help you. You can also go to a local navigator. That’s a real person. They can — you know, is your champion and can help you sort through all of this.
AMY GOODMAN: Elisabeth Benjamin, we want to thank you for being with us, vice president of health initiatives at the Community Service Society of New York, co-founder of Health Care for All New York campaign.
This is Democracy Now! When we come back, we’ll look at President Biden’s infrastructure plan. Stay with us.
This post was originally published on Latest – Truthout.
While the White House in recent weeks has taken steps to overturn a Trump-era initiative enabling states to restrict Medicaid eligibility by imposing punitive work requirements, healthcare advocates on Monday urged President Joe Biden to rescind all Medicaid work requirement policies approved by his predecessor.
In 2018, Seema Verma, then-director of the Centers for Medicare and Medicaid Services under former President Donald Trump, issued guidance allowing states to apply for a waiver to significantly alter eligibility requirements for Medicaid, a Great Society-era program on which more than 72 million low-income adults, people with disabilities, and children rely for health insurance.
Several Republican-led states quickly jumped at the offer to strip healthcare away from poor and vulnerable Americans, and the Trump administration ultimately approved policies to “take Medicaid coverage away from people who don’t comply with stringent work requirements” in 13 states, as Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities (CBPP), noted Monday in a blog post.
While litigation and the coronavirus pandemic have put the implementation of work requirement policies “on hold,” Wagner stressed that “taking coverage away from enrollees or otherwise conditioning coverage on meeting a work requirement doesn’t further Medicaid’s purposes,” which exists to provide healthcare to the impoverished. “Accordingly,” she added, “the Biden administration should now withdraw all of the previous approvals.”
The Trump admin approved policies in 13 state demo projects that take #Medicaid coverage away from people who don’t comply with stringent work requirements.
The Biden admin should now withdraw all of the previous approvals.https://t.co/rIHI3ndkPr
— Center on Budget (@CenterOnBudget) April 5, 2021
The White House in February invalidated the previous administration’s guidance allowing states to apply for Medicaid eligibility restriction waivers and notified states that had already been given permission to impose work requirements that the policies would soon be reversed due to the detrimental impact of coverage loss on Medicaid recipients, particularly during the pandemic, as Common Dreams reported at the time.
Last month, the Biden administration told Medicaid officials in New Hampshire and Arkansas — which was the first and only state to fully implement Medicaid work requirements, taking healthcare away from at least 18,000 people over a period of several months in 2018 — that approval for their work requirement policies had been rescinded.
While “Georgia, Indiana, Nebraska, Ohio, South Carolina, and Utah have objected” to Biden’s efforts to dismantle Medicaid work requirements, Wagner reiterated that “the administration should nevertheless continue with its plan.”
Wagner continued: “The Trump administration claimed that requiring work or other activities as a condition of coverage would ‘improve beneficiaries’ health,’ ignoring evidence from other programs suggesting these restrictions would significantly harm Medicaid enrollees. After states began implementing these policies, their experiences confirmed the harmful effects of work requirements.”
Citing a new analysis from the Department of Health and Human Services, Wagner wrote that “these policies are deeply harmful to Medicaid enrollees and confirms that they don’t promote Medicaid’s objectives.”
Referring to the 18,000 Arkansas residents who lost Medicaid coverage in 2018, Wagner said that “uninsurance rates among people subject to the work requirement rose, but their employment rates didn’t.”
Arkansans “who lost coverage were more likely to have chronic conditions, and many had difficulty paying their medical bills and accessing healthcare and medications,” she continued. “Data from New Hampshire and Michigan also show a significant loss of coverage would have occurred if the states’ work requirement policies had been implemented, largely due to enrollees’ limited awareness of the policies and challenges in reporting compliance.”
“The evidence of the detrimental impact of work requirements from Arkansas, New Hampshire, and Michigan demonstrates that other state policies would face the same challenges and harmful consequences,” she added. “All policies that take away coverage from people not meeting work requirements are marred by complex rules about who is exempt and what activities count, challenges communicating with enrollees, and burdensome paperwork and reporting requirements. These policies inevitably lead to eligible enrollees losing coverage — work requirements can’t be fixed.”
According to Wagner, “There’s nothing left to demonstrate by letting more states take risks with Medicaid enrollees’ health. The Centers for Medicare and Medicaid Services should withdraw all waiver authority for policies that take coverage away from people not meeting work requirements or otherwise condition coverage or benefits on meeting them and make clear that these policies won’t be allowed in Medicaid.”
This post was originally published on Latest – Truthout.
One year ago, as both the Trump administration in the US and the Johnson government in the UK responded fitfully to the growing pandemic, the international media were looking for whipping boys: other countries whose response to the virus was even worse.
There were some cases of obvious neglect—Brazil was and is a prime example (FAIR.org, 4/12/20). But the press also turned on Nicaragua, repeating allegations from local opposition groups that the Sandinista government was in denial about the dangers, and that the country was poised on the edge of disaster.
When, as the death toll in other countries grew alarmingly, Nicaragua “flattened the curve” of virus cases more quickly than its neighbors, its apparent success was ignored.
The post Nicaragua: Scary Covid Projections Are More Newsworthy Than Hopeful Results appeared first on PopularResistance.Org.
This post was originally published on PopularResistance.Org.
En una investigación que llevaron a cabo New Mexico In Depth y ProPublica durante un año, se descubrió que los bebés más pequeños y prematuros nacidos en el Hospital de Mujeres Lovelace de Albuquerque, morían en proporciones dobles que los de otro hospital situado a pocos kilómetros de distancia, el Hospital Presbiteriano (Presbyterian Hospital).
El hospital Lovelace, institución con fines de lucro, y el Presbyterian, organización sin fines de lucro, son los mayores centros de maternidad de Nuevo México.
Los datos más completos sobre los resultados hospitalarios de bebés recién nacidos quedan recopilados en la Red Oxford Vermont (Vermont Oxford Network, VON), una colaboración internacional de investigación de unidades de cuidados intensivos neonatales. Dicha Red mantiene las estadísticas de admisión y atención de pacientes de las unidades de cuidados intensivos neonatales de sus miembros, incluidos los hospitales Lovelace y Presbyterian y el de la Universidad de Nuevo México. Los datos se pueden utilizar para calcular las tasas de mortalidad de los distintos hospitales. En las estadísticas también se captan los datos demográficos de las madres y los recién nacidos, así como información sobre la atención prenatal, los procedimientos médicos y las complicaciones, el historial de traslados a un hospital neonatal y los resultados de los bebés.
No obstante, la información de la Red Oxford Vermont no es pública y la organización únicamente revela los resultados a los hospitales miembros. El grupo rechazó la petición de las organizaciones de noticias para conocer las tasas de mortalidad de los bebés extremadamente prematuros de los hospitales Lovelace y Presbyterian. En respuesta a una solicitud de archivos públicos, la Universidad de Nuevo México, que opera la unidad de cuidados intensivos neonatales (UCIN) de mayor nivel en el estado, compartió su base de datos de la Red Oxford Vermont (sin información de identificación), así como sus informes anuales; en cambio, ni Lovelace ni Presbyterian estuvieron dispuestos a hacer lo mismo. Tanto los hospitales y como la Red Oxford Vermont también se negaron a compartir la tasa nacional promedio de mortalidad de bebés extremadamente prematuros que obra en la red.
Debido a que la Red Oxford Vermont no dio acceso a sus datos de Lovelace y Presbyterian, las organizaciones de noticias acudieron a la Oficina de Registros Vitales y Estadísticas de Salud del Departamento de Salud del estado para obtener datos globales de los certificados de nacimiento y defunción de bebés extremadamente prematuros. Los hospitales presentan datos de cada nacimiento vivo, así como de las muertes de recién nacidos en las instalaciones del hospital, para todos los bebés que nacen de residentes legales de Nuevo México. Al principio analizamos las estadísticas de los últimos cinco años disponibles (2015-2019), desglosadas por edad gestacional y peso al nacer. Utilizamos esos datos para calcular las tasas de mortalidad de los hospitales. Para hacer un análisis secundario más detallado, las organizaciones de noticias obtuvieron los datos de los bebés que nacieron durante 2010-2019, los 10 años más recientes disponibles, bajo la categoría de la edad gestacional. Dado que el periodo de tiempo más largo incluía más nacimientos, también fue posible comparar subgrupos y variables adicionales de los pacientes.
Los hospitales también comunican los datos de los códigos de diagnóstico y facturación a la base de datos de altas de pacientes hospitalizados del Departamento de Salud del estado (Hospital Inpatient Discharge Database, HIDD), en la cual se recopila la información relacionada con el diagnóstico y el tratamiento de los pacientes ingresados en todos los hospitales del estado (sin contar los que administra el gobierno federal). Obtuvimos los datos globales de la base de datos HIDD por parte del Departamento de Salud.
Al diseñar nuestro análisis, trabajamos con expertos nacionales en cuidados intensivos neonatales como el Dr. Scott A. Lorch, profesor de pediatría y presidente adjunto de la División de Neonatología del Hospital Infantil de Philadelphia y una de las principales autoridades en materia de resultados de las UCIN, así como el Dr. David C. Goodman, profesor del Instituto para Políticas de Salud y Práctica Clínica de Dartmouth College. Goodman ayudó a analizar los datos, y el análisis luego fue revisado por Lorch.
Los bebés que pesan menos de un kilo al nacer (dos libras, aproximadamente), se denominan bebés de peso extremadamente bajo, mientras que los que nacen antes de las 28 semanas de embarazo se denominan extremadamente prematuros. (Un embarazo a término tiene entre 39 y 40 semanas). Aunque la mayoría de los bebés que nacen antes de las 28 semanas son también bebés de muy bajo peso al nacer, ese no siempre es el caso. Para tomar ese factor en cuenta, las organizaciones de noticias inicialmente evaluaron las tasas de mortalidad utilizando tanto el peso al nacer como la edad gestacional para 2015-2019, los cinco años más recientes de los que se disponía de datos del Departamento de Salud.
Utilizando información de los certificados de nacimiento y defunción del Departamento de Salud, calculamos una tasa de mortalidad neonatal para cada hospital con la que se midió el porcentaje de bebés nacidos vivos que morían en su hospital de nacimiento dentro de los 28 días siguientes al parto. Encontramos lo siguiente:
Se calcularon las tasas de mortalidad de todo el hospital, tomando en cuenta las muertes independientemente de si los bebés habían sido internados en las unidades de cuidados intensivos neonatales de los hospitales. Goodman, que fue el autor principal del Atlas de Dartmouth sobre Cuidados Intensivos Neonatales (Dartmouth Atlas of Neonatal Intensive Care), recomendó a New Mexico in Depth y ProPublica que las comparaciones más precisas incluyeran las muertes de todos los bebés extremadamente prematuros, sin importar si estos estuvieron internados o no en una unidad de cuidados intensivos neonatales.
Únicamente se contabilizaron los bebés nacidos en cada hospital en el número de nacimientos. Solo se contaron los que murieron en su hospital de nacimiento durante los 28 días siguientes. (Cuando se toma en cuenta a los bebés que murieron después de ser trasladados a la UCIN de la Universidad de Nuevo México, la tasa de mortalidad los neonatos extremadamente prematuros de Lovelace se eleva a un 39 %). Debido a que Presbyterian trasladó un solo bebé extremadamente prematuro a la Universidad de Nuevo México (en 2013) y ese recién nacido sobrevivió, la tasa de mortalidad de ese hospital no se vio afectada).
Los análisis omitieron los bebés considerados “pre-viables” (que nacen antes de las 21 semanas de embarazo o pesan menos de 350 gramos), porque probablemente morirían independientemente de la intervención médica, indicó el Departamento de Salud estatal.
Como se mencionó anteriormente, algunos bebés extremadamente prematuros que nacieron en Lovelace y Presbyterian fueron trasladados a la Universidad de Nuevo México para recibir atención. Asimismo, los archivos del equipo de transporte neonatal sugieren que cada uno de los hospitales envió a unos cuantos bebés a hospitales de fuera del estado. Esos registros no eran lo suficientemente detallados como para permitir que elimináramos de nuestros cálculos de la tasa de mortalidad, a todos los bebés extremadamente prematuros que fueron trasladados fuera del estado. Por lo tanto, nuestra tasa de mortalidad trató a todos los bebés que se enviaron fuera de Lovelace y Presbyterian como si hubieran recibido atención en su hospital de nacimiento y hubieran vivido, lo que hace, casi con seguridad, que nuestras tasas de mortalidad sean subestimadas.
Además de las muertes intrahospitalarias, también examinamos la frecuencia con la que Lovelace y Presbyterian trasladaban a los recién nacidos al Hospital de la UNM, el único hospital con una UCIN de nivel 4 del estado.
Al disponer de los datos de la UCIN de la Universidad de Nuevo México pudimos analizar la frecuencia de los traslados a esa institución, así como el estado y los resultados de esos bebés trasladados. Encontramos que:
También encontramos una discrepancia en la cantidad de bebés de Lovelace diagnosticados con ECN cuando comparamos la información de la base de datos HIDD y los registros de entrada de la Universidad de Nuevo México en la Red Oxford Vermont. En el periodo 2015-2019, el hospital únicamente informó acerca de cuatro casos de ECN neonatal al Departamento de Salud, pero los registros de admisión de la UCIN de la Red Oxford Vermont documentaron la llegada de 11 bebés con ECN procedentes de Lovelace durante esos años. Lovelace se rehusó a explicar la discrepancia.
Además de comparar los hospitales Lovelace y Presbyterian, las organizaciones de noticias buscaron una tasa de comparación nacional de muertes de bebés extremadamente prematuros en hospitales neonatales de nivel 3, pero encontraron una escasez de datos disponibles al público. La mayoría de los estudios publicados se basan en estadísticas de hace más de una década.
Sin embargo, como respuesta a las indagaciones de las organizaciones de noticias, los Centros para el Control y la Prevención de Enfermedades proporcionaron una tasa de mortalidad nacional de bebés extremadamente prematuros. Dicha tasa incluyó a todos los hospitales sin importar el nivel de atención de las instalaciones y se utilizaron los mismos parámetros de edad gestacional y peso al nacer del análisis de New Mexico In Depth y ProPublica. Los CDC determinaron una tasa del 28 % para la mortalidad de neonatos extremadamente prematuros a nivel nacional para el período 2010-2018, cerca del punto medio entre el 36 % de Lovelace y el 22 % de Presbyterian para el período de 2010-2019.
La tasa de mortalidad nacional de los CDC podría ser más alta que una posible tasa única de los hospitales de nivel 3, debido a que incluye hospitales con designaciones neonatales de nivel 1 y 2, que están menos equipados para atender a estos bebés.
Los expertos desaconsejaron comparar los centros de nivel 3, como el Lovelace y el Presbyterian, con los hospitales neonatales de nivel 4, como la UNM, ya que los hospitales de nivel 4 tratan a los recién nacidos más enfermos y cuentan con más médicos especializados y cirujanos expertos en su plantilla de personal, lo cual hace más difícil interpretar las diferencias. Sin embargo, para completar la información, calculamos las tasas de mortalidad de la UNM utilizando los datos del Departamento de Salud y los mismos métodos descritos anteriormente para Lovelace y Presbyterian. Según el análisis de las organizaciones de noticias, las tasas de mortalidad de 2015 a 2019 para los bebés de peso extremadamente bajo al nacer y los bebés extremadamente prematuros que nacieron en el hospital de la Universidad de Nuevo México fueron del 29 % y el 33 %.
La causa de la disparidad en las tasas de mortalidad de neonatos extremadamente prematuros de Lovelace y Presbyterian no queda realmente clara. Las posibilidades incluyen que uno de los hospitales tenga un grupo de pacientes más enfermos, una atención menos eficaz, o ambos factores.
El Departamento de Salud proporcionó desgloses adicionales de los resultados basados en datos demográficos de los pacientes y detalles del tratamiento, ninguno de los cuales explicaba por sí solo la diferencia en las tasas de mortalidad. Los datos a nivel de resumen no nos permitieron examinar distintas variables en combinación.
Los bebés que nacen entre las 21 y 23 semanas de gestación se consideran “peri-viables” y las prácticas de reanimación para estos bebés varían entre los hospitales. Los expertos y médicos de Albuquerque mencionaron que eso podría dar lugar a resultados diferentes.
Al no incluir en el análisis a los bebés nacidos entre las 21 y 23 semanas de gestación que murieron sin que se les haya resucitado después del parto, la tasa de mortalidad de neonatos extremadamente prematuros de Lovelace fue de un 29 % comparada con el 19 % de Presbyterian. Si se excluye a todos los bebés que murieron en la hora siguiente al parto, independientemente de la edad gestacional o de los informes de reanimación, la tasa de mortalidad de Lovelace fue del 26 %, en comparación con el 18 % del Presbyterian y la tasa nacional del 22 % indicada por los CDC.
(Goodman advirtió que las cifras de reanimación no son fiables porque los hospitales a menudo no las comunican).
Los expertos y los médicos indicaron que la reanimación siempre se intenta cuando se trata de un parto de 24 semanas de gestación. Al incluir en el análisis solo a los bebés nacidos entre las 24 y 27 semanas de gestación, la tasa de mortalidad de Lovelace fue de un 23 % comparada con el 9 % de Presbyterian (para los años 2010-2019). La tasa nacional proporcionada por los CDC para este grupo fue del 15 %.
Otra explicación de la disparidad en las tasas de mortalidad podría ser que Lovelace tuviera un número desproporcionado de bebés de 21 o 22 semanas de gestación, los cuales tienen peores resultados que los bebés nacidos entre las 24 y 27 semanas. Sin embargo, encontramos que la distribución de nacimientos por semana de gestación de los dos hospitales era muy similar.
El Departamento de Salud del estado proporcionó detalles demográficos y de tratamiento médico de los bebés extremadamente prematuros nacidos entre las 24 y 27 semanas de gestación. La tasa de mortalidad más elevada de Lovelace persiste en los análisis de tales datos. Por ejemplo, los gemelos y trillizos extremadamente prematuros a menudo les va peor que los bebés individuales, aunque eso no explicó la disparidad en la tasa de mortalidad del hospital. Tampoco lo hicieron las diferencias de raza o etnia, la proporción de nacimientos de niños (los varones tienden a tener peores resultados que las niñas), o las diferencias en las terapias prenatales. Los partos médicamente inducidos y otros factores de riesgo de los bebés extremadamente prematuros, como la proporción de madres adolescentes, madres que se sometieron a tratamiento de infertilidad o madres que tuvieron partos por cesárea, tampoco contribuyeron a la disparidad.
Las discrepancias en las cifras de ingresos en la UCIN, y de defectos de nacimiento, impidieron el análisis de esos datos. Los expertos y médicos acordaron que los bebés extremadamente prematuros que sobreviven el parto deberían ingresar a la UCIN, pero hubo bebés de los que no había registro de ingreso en la UCIN ni certificado de defunción. Ni Lovelace ni Presbyterian informaron acerca de los defectos de nacimiento con información en los certificados de nacimiento de bebés extremadamente prematuros, pero unos cuantos informes para certificados de defunción incluyeron los defectos de nacimiento como causa de muerte. Hubo un solo expediente de un bebé extremadamente prematuro de Lovelace que fue trasladado a la UNM durante las primeras 24 horas después del parto; eso indica que los traslados no deberían explicar la información faltante sobre los ingresos a la UCIN. Cuando se les solicitaron comentarios, los hospitales no reconocieron ni explicaron las discrepancias.
Según los expertos, para identificar las causas de las disparidades en la tasa de mortalidad de los hospitales para neonatos extremadamente prematuros, sería necesario acceder a los archivos de los pacientes o a los registros completos que se hayan informado acerca de los pacientes.
El hospital Lovelace presentó varias objeciones de nuestros análisis. Objetaron a la comparación de sus tasas de mortalidad de neonatos extremadamente prematuros con las de Presbyterian o de cualquier otro hospital individual, alegando que dicha comparación se debería realizar con los referentes de nivel nacional.
Goodman defendió la comparación de los resultados de los hospitales neonatales de nivel 3 de la cercanía: “Tiene mucho más valor realizar una comparación dentro de la misma comunidad, donde se atienden poblaciones similares y se opera bajo políticas y regulaciones estatales similares”.
Adicionalmente, las organizaciones de noticias obtuvieron la tasa nacional de los CDC (arriba descrita), que se mostró inferior a la tasa de mortalidad de Lovelace.
El hospital también disputó la decisión de tomar en cuenta los resultados de los bebés de todo el hospital, independientemente de si los bebés habían sido internados en las unidades de cuidados intensivos neonatales. Lovelace afirmó que sólo deberían medirse las muertes de la UCIN, ya que las tasas de todo el hospital incluyen las muertes en la sala de partos y podrían incluir a los bebés no viables. Los funcionarios de Presbyterian no objetaron a que se compararan las tasas de todo el hospital.
Lovelace señaló que, para el periodo 2015-2019, la tasa de mortalidad exclusiva de su UCIN para recién nacidos de peso extremadamente bajo fue del 22 %. No quisieron indicar en qué forma la tasa del 22 % de muertes exclusivas de la UCIN se comparaba con las tasas nacionales de la Red Oxford Vermont. Presbyterian se rehusó a divulgar la tasa de mortalidad exclusiva de su UCIN.
Goodman rechazó la objeción de Lovelace en cuanto a la comparación de las tasas totales de los hospitales, señalando que el personal de la UCIN debería estar presente en el parto de los bebés extremadamente prematuros y que su equipo de investigación incluye “en nuestro estudio… a todos los bebés extremadamente prematuros que mueren. Los atiende el equipo de la UCIN y son responsabilidad del equipo de la UCIN, estén o no ingresados administrativamente en la UCIN de un hospital”.
Otra objeción de Lovelace fue la decisión de calcular las tasas de mortalidad de los recién nacidos de peso extremadamente bajo, señalando que los bebés que nacen pesando menos de 1 kilo representan sólo el 2 % de los bebés que entran a la UCIN del hospital. “El tamaño de la muestra es demasiado pequeño para extraer conclusiones sobre la calidad general de la atención que se presta”, escribió en un correo electrónico Serena Pettes, vicepresidenta de marketing de Lovelace.
No obstante, los bebés extremadamente prematuros son una población de pacientes reconocida formalmente y que se estudia de manera amplia en los hospitales neonatales. El Colegio Americano de Obstetras y Ginecólogos define a los bebés extremadamente prematuros como los que nacen antes de las 28 semanas de gestación. Esta es la definición que utilizamos. Aunque los bebés extremadamente prematuros constituyen una pequeña parte de todos los ingresos en la unidad de cuidados intensivos neonatales, más de 500 de estos bebés nacieron en los hospitales Lovelace y Presbyterian durante el periodo de 2010-2019.
El análisis fue revisado por Hannah Fresques, editora adjunta de datos de ProPublica, junto con uno de los miembros de la junta de asesores de información científica de ProPublica.
Traducción: Mati Vargas-Gibson
Corrección de estilo: Deya Jordá Nolan
This post was originally published on Articles and Investigations – ProPublica.
Nota: Este reportaje contiene la descripción de la muerte de un recién nacido.
Era el cambio de turno de la mañana en el Hospital de Mujeres Lovelace de Albuquerque, Nuevo México. En la unidad de cuidados intensivos neonatales (UCIN), las luces eran tenues, como de costumbre. La gente hablaba en la voz baja típica de la UCIN. Pero un médico que llegó supo inmediatamente que algo había salido mal.
Un “carro de parada” con equipos de reanimación estaba situado junto a una incubadora de recién nacidos, las cunas cerradas que mantienen calientes a los bebés prematuros. Las enfermeras estaban cerca con expresiones sombrías.
La luz de la incubadora iluminaba el vientre hinchado y descolorido de un recién nacido.
“Nunca olvidaré el aspecto de ese bebé”, recordó el médico de Lovelace, que pidió no ser identificado por miedo a las represalias. “Su abdomen estaba negro y tenso y casi del tamaño de una toronja”.
El día anterior, el bebé había tenido frío y había escupido, lo cual no era particularmente inusual. “Era algo que vigilar, pero nada terriblemente mal”, dijo el clínico.
El estado del bebé había empeorado de la noche a la mañana. Ahora, estaba conectado a un respirador artificial y las contracciones de su pequeño corazón se ralentizaban. Su abdomen hinchado impidió al personal administrarle compresiones torácicas.
“No había nada que pudiéramos hacer”, añadió el clínico. “Falleció”.
El intestino del bebé había dejado de funcionar, y su sonda de alimentación quedó obstruida con alimentos no digeridos. A veces, eso es señal de una enfermedad inflamatoria de los intestinos, denominada enterocolitis necrotizante o ECN, que es una de las principales causas de muerte en los hospitales entre los bebés extremadamente prematuros.
Los problemas de estos bebés pueden convertirse en una espiral que pone en peligro su vida en cuestión de horas. No hay indicios de que en Lovelace se haya manejado indebidamente el tratamiento del bebé. Pero los bebés extremadamente prematuros murieron en el hospital con una frecuencia sorprendente, según un análisis de las estadísticas médicas del estado realizado por New Mexico In Depth y ProPublica.
Una investigación llevada a cabo durante un año por estas organizaciones de noticias descubrió que, en Lovelace, los bebés más pequeños y prematuros morían hasta el doble de lo que lo hacían a unos pocos kilómetros de distancia, en el Hospital Presbiteriano (Presbyterian Hospital), otro importante centro de maternidad y neonatología.
New Mexico In Depth y ProPublica también descubrieron que Lovelace trasladó a más del triple de recién nacidos que el Presbyterian al Hospital de la Universidad de Nuevo México, la única UCIN regional de nivel 4 a la que se refieren y envían los recién nacidos más enfermos del estado para su atención.
En total, entre 2015 y 2019, cerca de la mitad, el 46 %, de los 84 bebés extremadamente prematuros nacidos en Lovelace, murieron en el hospital o fueron trasladados a la UNM, según los datos del Departamento de Salud y los archivos de la Unidad de Cuidados Intensivos Neonatales de la UNM. El 21 % de los 170 bebés extremadamente prematuros nacidos en el Presbyterian murieron, y ninguno fue trasladado a la UNM durante esos años.
Los expertos señalaron que los hallazgos deben ser investigados.
La disparidad “debería preocupar a las familias, a la comunidad y al estado de Nuevo México”, dijo el Dr. David C. Goodman, profesor del Instituto para Políticas de Salud y Práctica Clínica de Dartmouth College. Goodman, que fue el autor principal del Atlas de Dartmouth sobre Cuidados Intensivos Neonatales (Dartmouth Atlas of Neonatal Intensive Care), publicado en septiembre de 2019, ha estudiado el historial de decenas de hospitales estadounidenses que atienden a bebés extremadamente prematuros.
Este tema también es una preocupación para los profesionales médicos de Albuquerque que atienden a estos bebés. Tres médicos del Hospital Lovelace y de la UNM que se pusieron en contacto con New Mexico In Depth y ProPublica en relación con Lovelace, expresaron su preocupación por los resultados de los bebés extremadamente prematuros y señalaron cuestiones más amplias relacionadas con su atención. Esos problemas incluían la falta de un cirujano y de otros especialistas en las mismas instalaciones, el momento de los traslados a la UNM cuando los bebés necesitaban cuidados de mayor nivel y el desacuerdo sobre la mejor manera de atender a estos frágiles recién nacidos.
Inicialmente, Lovelace y Presbyterian aceptaron compartir información detallada acerca de sus resultados neonatales con New Mexico In Depth y ProPublica, pero, al final de cuentas se negaron a proporcionar la mayor parte de lo prometido. Para investigar las preocupaciones de los médicos, las organizaciones de noticias obtuvieron datos del Departamento de Salud del estado sobre las muertes de estos recién nacidos.
Para comprender mejor la disparidad de los resultados entre los hospitales Lovelace y Presbyterian, New Mexico In Depth y ProPublica también obtuvieron los registros de ingreso y traslado del hospital de la Universidad de Nuevo México, junto con correos electrónicos y otros documentos; asimismo, entrevistaron a más de dos docenas de personas, entre ellas médicos actuales y previos de Albuquerque, miembros del equipo de transporte neonatal, funcionarios del hospital y expertos de unidades de cuidados intensivos neonatales reconocidos a nivel nacional. Los administradores de la UCIN de Lovelace y Presbyterian hablaron con las organizaciones de noticias a principios de 2020. Desde ese entonces, Lovelace no ha puesto a los administradores a disposición para que hagan comentarios.
Lovelace rechazó cualquier comparación que se centrara sólo en los bebés extremadamente prematuros o que contrastara sus tasas de mortalidad con las del Presbyterian.
“Compararnos con un solo hospital, en contraposición a los referentes nacionales, es erróneo y no constituye una base adecuada para sacar conclusiones generales”, escribió en un correo electrónico la vicepresidenta de marketing de Lovelace, Serena Pettes.
Pettes dijo que las organizaciones de noticias estaban “buscando socavar la calidad de nuestra atención” a través de una “mala interpretación de las estadísticas”. Cuando se le preguntó cómo se habían malinterpretado los datos del hospital, no respondió.
Tres expertos comentaron a New Mexico In Depth y a ProPublica que es motivo de preocupación cuando los hospitales neonatales de nivel 3, una designación que abarca tanto a Lovelace como a Presbyterian, tienen tasas de muerte y de traslado más altas que las de instalaciones vecinas. Añadieron que, sin acceso a los historiales de los pacientes, las cifras de los hospitales vecinos eran el mejor indicador para medir los resultados.
“Siempre que un hospital atiende un gran número de bebés pequeños que tiene que enviar fuera, o que mueren antes de poder enviarlos, hay que preguntarse si las madres dan a luz en el lugar adecuado”, afirma el Dr. Jeffrey B. Gould, profesor de pediatría de la Universidad de Stanford. Pionero en la mejora de la calidad de las UCIN, Gould es cofundador y director ejecutivo de la California Perinatal Quality Care Collaborative.
Además, la escasa supervisión estatal y la falta de transparencia de los hospitales en cuanto a los resultados limitan gravemente la capacidad del público para conocer la calidad del servicio que prestan los hospitales a esta población vulnerable. La laxitud de la normativa estatal contrasta con la de otros estados, como Texas y California, los cuales obligan a llevar a cabo inspecciones periódicas de los hospitales de cuidados intensivos neonatales y a analizar los resultados de los recién nacidos.
El clínico de Lovelace que presenció la muerte del bebé dijo que la falta de supervisión en Nuevo México es una de las razones por las que las familias desconocen los resultados de los bebés extremadamente prematuros en el hospital. Otro factor es la cultura de silencio que obra en el hospital cuando algo sale mal: “Ni siquiera hablamos de ello dentro de la UCIN, pero, sobre todo, tampoco con los padres”.
(Ilustración fotográfica de Shoshana Gordon/ProPublica; Fuentes de las imágenes: FrankGuido vía Flickr y Marjorie Childress/New Mexico In Depth)
En Lovelace nacieron unos 2,700 bebés en 2019; en el cercano Presbyterian nacieron unos 3 mil lo que convierte a esos dos hospitales en los mayores centros de maternidad del estado. También son los únicos hospitales de cuidados intensivos neonatales de nivel 3 del estado, según el Departamento de Salud de Nuevo México. Juntos, dieron a luz al 28 % de los bebés nacidos en todo el estado entre 2010 y 2019, y al 37 % de los bebés extremadamente prematuros a nivel estatal.
“Si su embarazo entra en la categoría de alto riesgo, puede estar segura de que recibirá la mejor atención médica disponible en cualquier lugar de la región”, afirma un anuncio de Lovelace.
Las organizaciones de noticias encontraron que, en general, el Lovelace y el Presbyterian tenían tasas de mortalidad neonatal similares, excepto cuando se trataba de los recién nacidos más pequeños y prematuros.
Los bebés que pesan menos de un kilo al nacer se denominan de peso extremadamente bajo, mientras que los que nacen antes de las 28 semanas de embarazo se denominan extremadamente prematuros. Aunque la mayoría de los bebés extremadamente prematuros son también bebés de muy bajo peso al nacer, no siempre es así. Para tener en cuenta a todos estos bebés vulnerables, las organizaciones de noticias evaluaron las tasas de mortalidad utilizando tanto el peso al nacer como la edad gestacional.
Entre 2015 y 2019, el 34 % de los 88 bebés de Lovelace con peso extremadamente bajo al nacer murieron, en comparación con el 17 % de los 197 de Presbyterian, según el análisis de New Mexico in Depth y ProPublica que comparó los datos de las actas de nacimiento y defunción de ambos hospitales. Los cálculos excluyeron a los bebés que nacieron en otro lugar y fueron trasladados a Lovelace o Presbyterian, y a los bebés que nacieron con un peso de menos de 350 gramos, que no se consideran viables.
El análisis también encontró una disparidad en la tasa de mortalidad cuando se calcula por edad gestacional, en lugar de por peso al nacer. La tasa de mortalidad de los bebés extremadamente prematuros del hospital Lovelace fue del 36 %, frente al 21 % del Presbyterian.
“Las diferencias son significativas”, dijo Goodman sobre las tasas de mortalidad de los hospitales. “No son diferencias leves. Se trata de grandes disparidades”.
“La tasa del 36 % es mucho más de lo que se espera para este grupo de edad gestacional”, indicó Goodman. “Plantea la cuestión de si la atención prestada satisface las necesidades de los pacientes recién nacidos”.
En los archivos de la Universidad de Nuevo México, las organizaciones de noticias también descubrieron que, entre 2015 y 2019, Lovelace transfirió a 66 bebés, tanto a término como prematuros, a la UCIN de nivel 4, mientras que Presbyterian envió 17 bebés, ninguno de ellos prematuro.
“Tiemblo cada vez que tenemos a un bebé pequeñito. Tenemos un historial terrible con ellos”, dijo el médico de Lovelace que estaba presente cuando murió el bebé.
Otro médico de la UCIN de Lovelace expresó una preocupación similar sobre los resultados de los bebés extremadamente prematuros, tanto en la sala de partos como en la UCIN.
“Sólo tienen políticas rudimentarias para los microprematuros, y no tan completas como las que he visto en otros hospitales”, dijo el segundo clínico del Lovelace. (Una copia de las directrices de atención a bebés de la UCIN de Lovelace, revisada por las organizaciones de noticias y fechada el 1 de febrero de 2017, menciona brevemente el cuidado de los bebés extremadamente prematuros y de muy bajo peso al nacer en las secciones relacionadas con la proporción de enfermeras por paciente, la termorregulación y la pérdida de agua, el cuidado de la piel y la posición del cuerpo).
Los médicos fueron dos de los ocho proveedores de atención de Lovelace, actuales y anteriores, que hablaron con New Mexico In Depth y ProPublica acerca de la atención de los recién nacidos en el centro, con la condición de permanecer en el anonimato porque hablar públicamente podría perjudicar su empleo dentro de la pequeña comunidad médica de Nuevo México. No todos ellos criticaron al hospital.
“Es una unidad bien administrada”, dijo un antiguo médico de Lovelace acerca de la UCIN. “Yo no dudaría en tener a mi propio hijo en esa unidad”.
Pettes se negó a responder a las preocupaciones de los médicos y criticó la decisión de las organizaciones de noticias de concederles el anonimato. “No podemos responder a fuentes anónimas”, escribió en un correo electrónico, y calificó los comentarios de los médicos como “opiniones y no hechos”.
La Academia Americana de Pediatría define los hospitales con UCIN de nivel 3 como instalaciones equipadas para atender a bebés de alto riesgo. A diferencia de las salas de recién nacidos de menor nivel, cuentan con especialistas con experiencia en el tratamiento de recién nacidos con mayores riesgos y complejidad médica.
Sin embargo, en Nuevo México no existe una definición legal de lo que constituye una UCIN de nivel 3. El estado no tiene una autoridad de supervisión legal o reguladora específica para las UCIN. Tampoco juega un papel en certificar las UCIN ni monitorear los resultados de los recién nacidos. El estado no ha realizado inspecciones de las instalaciones de ninguno de los tres hospitales de Albuquerque con unidades de cuidados intensivos neonatales y tampoco ha analizado las tasas de mortalidad neonatal de las mismas, según reconoció James Walton, portavoz del Departamento de Salud del estado.
El Departamento de Salud de Nuevo México recopila algunos detalles de los hospitales relativos a las madres y los recién nacidos, entre ellos, qué madres recibieron tratamientos de infertilidad para quedar embarazadas, si el parto fue inducido y si el parto fue por cesárea. Sin embargo, el Estado no puede imponer sanciones a los hospitales que no comuniquen esos datos, según confirmaron los funcionarios del Departamento de Salud.
Por ejemplo, New Mexico In Depth y ProPublica identificaron una discrepancia en los informes de Lovelace sobre los casos de ECN, la peligrosa condición intestinal. Lovelace únicamente informó acerca de cuatro casos de ECN neonatal al Departamento de Salud entre 2015 y 2019, pero en los registros de admisión de la UCIN de la Universidad de Nuevo México aparecen 11 bebés que fueron transferidos desde Lovelace con ECN durante esos años, incluidos cuatro tan solo en 2019.
Goodman ayudó a Nuevo México a Fondo y a ProPublica a analizar las estadísticas de nacimientos y muertes del Departamento de Salud.
A nivel nacional, las disparidades en los resultados entre las instituciones no siempre son claras. Las posibilidades incluyen un grupo de pacientes más enfermos y una atención menos eficaz, dijo Goodman.
Lovelace declinó repetidamente identificar los factores demográficos o de los pacientes que podrían explicar la disparidad en las tasas de mortalidad de bebés extremadamente prematuros de los hospitales.
Según los expertos, para identificar estos factores es necesario revisar cuidadosamente los historiales médicos de los pacientes. New Mexico in Depth y ProPublica no tuvieron acceso a dichos expedientes. No obstante, estas organizaciones de noticias intentaron identificar posibles explicaciones utilizando los datos que Lovelace y Presbyterian reportaron al Departamento de Salud del estado desde 2010 hasta 2019.
Los bebés que nacen entre las 21 y 23 semanas de gestación suelen morir poco después del parto, y las prácticas de reanimación para este grupo de edad varían, lo que podría dar lugar a resultados diferentes. Pero la disparidad de la tasa de mortalidad, de 2 a 1, persistió cuando el análisis incluyó sólo a los bebés nacidos entre las 24 y 27 semanas de gestación, que tienen menos probabilidades de morir poco después del parto. El número de gemelos y trillizos extremadamente prematuros, a los que a menudo les va mal, tampoco explica la disparidad de la tasa de mortalidad. Tampoco lo hicieron las diferencias de raza o etnia de las madres, las terapias prenatales u otros factores de riesgo potenciales para bebés extremadamente prematuros, las cuales incluyen la proporción de nacimientos de niños, madres adolescentes, madres que se sometieron a tratamiento de infertilidad o parto inducido, o madres que tuvieron partos por cesárea.
Pettes afirmó que para todos los recién nacidos internados en la UCIN, incluidos los bebés de bajo riesgo a término y los prematuros, la tasa de mortalidad neonatal de Lovelace es “significativamente inferior a la media nacional” y ha disminuido con el tiempo. “En conjunto, nuestra tasa de mortalidad es menos de la mitad del promedio nacional de las UCIN”.
Sin embargo, de acuerdo con los datos del Departamento de Salud, los bebés nacidos a término representan una proporción mucho mayor de la población de la UCIN del hospital comparada con los recién nacidos extremadamente prematuros, lo que oculta la tasa de mortalidad de los bebés de mayor riesgo del hospital.
Pettes no quiso compartir la referencia nacional que citó de la Red Oxford de Vermont, una unidad de investigación de cuidados intensivos neonatales. La red sólo revela los resultados de los hospitales miembros y rechazó la petición de las organizaciones de noticias de conocer las tasas de mortalidad de los bebés extremadamente prematuros de Lovelace y Presbyterian.
Pettes también objetó a la comparación que hicieron las organizaciones de noticias relativas a las tasas de mortalidad de todo el hospital.
Pettes reveló que, durante 2015-2019, el 22 % de los bebés de Lovelace con un peso extremadamente bajo al nacer murieron tras su ingreso en la UCIN.
Sin embargo, Goodman dijo que los índices de la UCIN no son un reflejo real de los resultados de un hospital.
“En nuestra investigación… incluimos a todos los bebés extremadamente prematuros que mueren”, añadió. “Son atendidos por el equipo de la UCIN y son responsabilidad del equipo de la UCIN, estén o no ingresados administrativamente en la unidad de cuidados intensivos neonatales de un hospital”.
Lovelace no proporcionó una tasa de mortalidad de todo el hospital para estos bebés frágiles.
Las tasas de mortalidad de todo el hospital son indicadores importantes porque las prácticas de la unidad de partos también pueden afectar a la supervivencia, y los bebés que mueren en la UCIN no siempre se registran como muertes de esa unidad, señaló un clínico del Lovelace.
A las organizaciones de noticias les resultó imposible comparar los datos de la UCIN entre los hospitales. Presbyterian no quiso facilitar la tasa de mortalidad de su UCIN. Asimismo, la información de las actas de nacimiento y defunción mostraron discrepancias en las estadísticas del Departamento de Salud relacionadas con los ingresos a la UCIN. Los expertos afirman que los bebés extremadamente prematuros que sobreviven el parto siempre deberían ingresar a las UCIN, pero las organizaciones de noticias encontraron bebés de los que no había registro de ingreso en la UCIN, ni certificado de defunción.
Los hospitales no reconocieron ni explicaron las discrepancias.
(Ilustración fotográfica de Shoshana Gordon/ProPublica; Fuentes de las imágenes: Shaun Griswold y Marjorie Childress/New Mexico in Depth y efigie sobrepuesta de Flickr)
El hospital Lovelace trasladó a la UCIN de nivel 4 de la Universidad de Nuevo México más del triple de recién nacidos que el Presbyterian, según muestran los registros de admisión de esa institución. Diez de los traslados de Lovelace eran bebés de muy bajo peso al nacer y tres de ellos murieron en la UNM. Ninguno de los bebés trasladados por el Presbyterian era extremadamente prematuro o de muy bajo peso al nacer.
La información relativa a los traslados de neonatos puede ayudar a los reguladores a identificar los centros que no satisfacen las necesidades de los bebés, o a encontrar problemas que los hospitales deben resolver, dicen los expertos.
La comparación de los registros de entrada de la unidad de cuidados intensivos neonatales de la Universidad de Nuevo México con los datos estatales mostró que cerca del 90 % de los traslados de Lovelace y Presbyterian a la UNM no se capturaron en las estadísticas del Departamento de Salud, debido a que el estado sólo exige que los hospitales informen de los traslados que se producen en las primeras 24 horas después del parto.
“Si no tienes los datos, no puedes hacer cambios”, dijo el Dr. Scott A. Lorch, profesor de pediatría y presidente asociado de la División de Neonatología del Hospital Infantil de Philadelphia, y una de las principales autoridades en materia de resultados de las UCIN.
En el Hospital de la Universidad de Nuevo México, a los bebés que llegaban en estado grave se les llamaba a veces “especiales de Lovelace”, según dos antiguos médicos de la UCIN de esa institución que pidieron que no se les nombrara por miedo a las represalias.
Algunos de los bebés de Lovelace que tenían ECN llegaron a la UNM sin informes de rayos X necesarios, o con radiografías tomadas desde ángulos que pueden pasar por alto los signos de un empeoramiento de la condición, dijo un radiólogo pediátrico de la UNM.
“Eso es lo que yo he visto basándome en las imágenes: los pacientes solían llegar a la UNM en estados más avanzados de ECN”, dijo el radiólogo. A diferencia de la UNM y el Presbyterian, Lovelace no cuenta con un radiólogo pediátrico en su plantilla de personal, señaló el radiólogo. Lovelace se negó a comentar al respecto.
Uno de los dos antiguos médicos de la UNM comentó que cuando los bebés llegaban de Lovelace, “no teníamos ni idea de lo que nos esperaba”.
Los médicos cuestionaron no sólo el número de traslados de recién nacidos, sino también la sincronización.
A veces, Lovelace es demasiado lento para enviar a los bebés en crisis al Hospital de la UNM, donde se les puede operar si es necesario, dijeron cuatro médicos tanto de Lovelace como de la UNM. Lovelace no quiso comentar acerca de esa alegación.
El ritmo del traslado es importante porque la ECN puede evolucionar en cuestión de horas desde síntomas sutiles hasta una afección potencialmente mortal que requiera una intervención quirúrgica de urgencia. No es raro que las UCIN de nivel 3 tengan cirujanos de guardia o cuenten con un acuerdo de traslado con otros hospitales. Sin embargo, si un cirujano no puede realizar procedimientos de emergencia en el mismo lugar, los traslados oportunos a hospitales quirúrgicos pueden ser una cuestión de vida o muerte.
De los 18 bebés con ECN que fueron trasladados a la Universidad de Nuevo México desde 2012, 15 procedían de Lovelace. No existe una norma estricta para cuándo se debe trasladar a un bebé enfermo a un centro de mayor nivel, pero los registros de los traslados muestran que de los 15 bebés de Lovelace enviados a la UNM, 12 estaban en un estado que requerían cirugía cuando llegaron allí, y dos, una niña de 5 días y un niño de 12 días, murieron a las pocas horas de su llegada. Sólo un bebé de Lovelace con ECN fue trasladado y sobrevivió sin cirugía.
Cuando la ECN se detecta a tiempo, puede tratarse con antibióticos, dijo un antiguo médico de la UNM. “Pero no hay que esperar a que estén tan, tan, tan enfermos y luego intentar enviarlos”, dijo el clínico.
“Simplemente esperan demasiado”, dijo el clínico de Lovelace que presenció la muerte del niño, refiriéndose a los casos que este médico manejaba. “Bebés que de otro modo podrían haber sobrevivido no lo hicieron porque no los llevaron a un lugar donde pudieran tener un cirujano si lo necesitaban”.
El ex clínico de la UNM añadió una explicación clave: “Realmente es de ahí de donde provienen muchos de los niños, especialmente los de Lovelace, es por no tener esos cirujanos pediátricos disponibles”.
La cuestión de si Lovelace tiene, de hecho, un cirujano pediátrico de planta, como en el caso del Presbyterian, es objeto de debate.
En marzo de 2019, el Departamento de Salud de Nuevo México y los Centros para el Control y la Prevención de Enfermedades informaron a Lovelace que una encuesta de los hospitales de maternidad y neonatología del estado había concluido que Lovelace no estaba operando una UCIN de nivel 3, sino una sala de recién nacidos especial de nivel 2. Los funcionarios estatales basaron su conclusión en la falta de un cirujano pediátrico y de un anestesista pediátrico en ese hospital.
Los administradores del Lovelace apelaron con éxito esa determinación, alegando en un correo electrónico que obtuvieron las organizaciones de noticias que entre los “proveedores disponibles” en Lovelace había un cirujano pediátrico y otros expertos “en las instalaciones las 24 horas todos los días”.
Sin embargo, los médicos del Lovelace comentaron a New Mexico in Depth a ProPublica, que esa declaración era engañosa.
“Llevan casi una década diciendo que tendrán a un cirujano pediátrico”, dijo un clínico de Lovelace.
En algunos estados se exige que los hospitales respalden ese tipo de declaraciones con documentación. Pero los correos electrónicos indican que el Dr. Thomas Massaro, director médico del Departamento de Salud del estado, impidió que otros miembros del personal de esa entidad pidieran a Lovelace que proporcionara los nombres y las certificaciones de sus médicos especialistas. Massaro informó a New Mexico In Depth y a ProPublica que, “Ni nosotros ni los CDC exigimos documentación de ninguna de las declaraciones o presentaciones de los hospitales”.
Existe una razón por la cual los hospitales luchan para tener la categoría de 3er. nivel.
El Hospital de Mujeres Lovelace abrió su UCIN de $11 millones de dólares en septiembre de 2007, posicionándose para competir con los hospitales Presbyterian y de la Universidad de Nuevo México en el lucrativo mercado de la atención médica aguda para recién nacidos a nivel estatal. Lovelace se comercializa como un hospital materno y neonatal de vanguardia. A los futuros padres se les informa que, en caso de que algo vaya mal, hay especialistas médicos en maternidad y neonatología para proporcionarles una atención experta. Al frente de esa promesa está la “Unidad de Cuidados Intensivos Neonatales de Nivel 3”.
A los bebés extremadamente prematuros que se atienden en la UCIN se les conoce como “bebés de un millón de dólares”, dijeron varios médicos. Esa no es una exageración: las hojas de precios del hospital sugieren que la atención de estos bebés puede brindarle a Lovelace más de $1.2 millones de dólares por bebé de parte de las aseguradoras.
Los cuidados intensivos neonatales han aportado mucho dinero a Lovelace y a su empresa matriz privada, Ardent Health Services, con sede en Nashville. Según datos del estado, entre 2015 y 2019, las instalaciones de Lovelace que cuentan con 53 camas recibieron más de $99 millones de dólares en pagos de Medicaid para la atención de pacientes de la UCIN, mientras que la UCIN de 58 camas de Presbyterian recibió $75 millones de dólares durante el mismo período.
“No es secreto que la UCIN es la gallina de los huevos de oro del Hospital de Mujeres Lovelace”, afirma Wendy Walter, antigua enfermera en jefe de la UCI de adultos de Lovelace, que “echaba una mano” cuando la UCIN tenía poco personal. (Walter fue despedida por el hospital en enero por trabajar más horas de las autorizadas. Ella sostiene que trabajaba horas adicionales al final de sus turnos para documentar adecuadamente los tratamientos de los pacientes).
Meses después de que defendiera con éxito su estatus de nivel 3, Lovelace fue más allá, informando al Departamento de Salud del estado el año pasado de que el centro merecía ser reconocido como una UCIN de nivel 4. Eso podría ponerla en competencia con la Universidad de Nuevo México, donde los bebés extremadamente prematuros pueden aportar más de $2 millones de dólares por bebé.
En un correo electrónico del 10 de enero de 2020 a Massaro, el Dr. Abraham Lichtmacher, director de servicios para la mujer de Lovelace, escribió que el hospital ahora contaba con “cirugía pediátrica, que está representada por los cirujanos pediátricos de la UNM, ya que estos han finalizado y obtenido sus privilegios en el Hospital de Mujeres Lovelace, lo cual les permite realizar sus procedimientos en las instalaciones”.
Tres médicos actuales y antiguos de Lovelace expresaron su consternación por el hecho de que un administrador del hospital hiciera tal afirmación.
“No tienen personal de apoyo quirúrgico ni enfermeras de cirugía pediátrica, ni siquiera un lugar para realizar cirugías de bebés”, dijo uno de ellos.
Unas semanas después de que Lichtmacher enviara un correo electrónico al estado, el Dr. Jason McKee, cirujano pediátrico de la UNM, contradijo la afirmación de Lichtmacher en una entrevista con New Mexico In Depth y ProPublica. Cuando se le preguntó si tenía privilegios quirúrgicos en Lovelace, McKee comentó lo siguiente a las organizaciones de noticias a principios de 2020: “Tengo privilegios de consulta en el Lovelace, así que puedo ir a ver a un niño, pero por ahora no operamos allí”.
McKee no se comprometió cuando se le preguntó si eso cambiaría en un futuro próximo, pero señaló que requeriría que Lovelace contratara personal de apoyo quirúrgico.
Recientemente, Lovelace se negó a decir si se han realizado cirugías pediátricas en el hospital o si cuenta con personal de apoyo quirúrgico para llevar a cabo dichas operaciones.
“Tenemos, y seguimos manteniendo, la disponibilidad de cirujanos pediátricos para nuestros pacientes, pero nos remitimos al juicio clínico del cirujano en cuanto al mejor lugar para que esas cirugías se lleven a cabo para lograr los mejores resultados para el paciente”, escribió en un correo electrónico Pettes, la vicepresidenta de marketing de Lovelace. No quiso decir si Lovelace empleaba a un cirujano pediátrico o a personal de apoyo para cirugía pediátrica, ni tampoco si se han realizado cirugías neonatales en Lovelace en los últimos años.
Los listados de empleo de Hospital de Mujeres Lovelace publicados tan recientemente como el 27 de febrero, afirmaban que el hospital “espera establecer la Cirugía Pediátrica en el futuro”.
La última vez que Lovelace solicitó que el Departamento de Salud reconociera a su UCIN como centro de nivel 4 fue en agosto, según Walton, el portavoz del departamento.
Lovelace se negó a comentar acerca de sus esfuerzos por ser reconocido como hospital neonatal de nivel 4.
Un documento del Departamento de Salud de noviembre de 2020 seguía catalogando a Lovelace como centro neonatal de nivel 3.
(Ilustración fotográfica de Shoshana Gordon/ProPublica; Fuentes de las imágenes: Shaun Griswold y Marjorie Childress/New Mexico In Depth y Jennifer Pack via Flickr)
Una situación que, según los expertos, puede causar disparidades en los resultados de los centros neonatales es la cantidad de pacientes que se atienden, o lo que los investigadores denominan “volumen de pacientes”.
Los hospitales que atienden a un mayor número de bebés de alto riesgo obtienen mejores resultados, probablemente producto de su experiencia, dijo Lorch, la autoridad en resultados de unidades de cuidados intensivos neonatales. Los expertos también indican que los equipos deben practicar el trabajo en conjunto para satisfacer las necesidades de los bebés de alto riesgo.
Aunque no está claro si el volumen de pacientes fue un factor en las mayores tasas de mortalidad entre los bebés más pequeños en Lovelace, el hospital tenía menos de la mitad del volumen de pacientes de bebés extremadamente prematuros comparado con Presbyterian. Cada año entre 2010 y 2019, nació un promedio de 16 bebés extremadamente prematuros en Lovelace, mientras que en Presbyterian fueron 38.
Las investigaciones de Lorch y otros demuestran que el volumen de pacientes puede predecir las tasas de supervivencia de los bebés “muy” prematuros más desarrollados, aquellos que nacen entre las 28 y las 32 semanas de gestación.
“Hay que tener experiencia en el cuidado de esos bebés”, afirma la Dra. Ann Stark, profesora de la Facultad de Medicina de Harvard y pionera de las directrices de la Academia Americana de Pediatría sobre los niveles de atención neonatal.
Aún no se ha estudiado el papel que desempeña el volumen de pacientes de los hospitales en la supervivencia de los bebés extremadamente prematuros, es decir, los que nacen antes de las 28 semanas de embarazo. Pero las investigaciones han demostrado que dedicar un equipo clínico experto a la atención de los bebés extremadamente prematuros puede mejorar los resultados. Al respecto, podría no tener sentido que en Albuquerque haya tres hospitales a pocos kilómetros de distancia que atienden a un número relativamente pequeño de bebés extremadamente prematuros, dicen varios expertos.
“Tal vez contar con un centro de gran volumen sea mejor que tener dos o tres centros que atiendan a esos mismos bebés”, dijo el Dr. José Antonio Pérez, profesor clínico de pediatría de la Universidad de Washington en Seattle y director médico de la UCIN del Centro Médico Swedish Issaquah.
Una de las formas en que los hospitales neonatales mejoran la calidad de la atención después de que las cosas vayan mal es al convocar revisiones formales de casos de morbilidad y mortalidad del personal. Los organismos reguladores de Nuevo México no exigen revisiones de casos de ese tipo, pero el personal de la UCIN tanto del Presbyterian como de la UNM las elabora de todos modos.
Los funcionarios de Lovelace se rehusaron repetidamente a informar si ellos las hacen.
New Mexico In Depth y ProPublica preguntaron a ocho médicos actuales y antiguos que trabajaron en la UCIN de Lovelace durante la última década si habían participado en las revisiones formales de casos de morbilidad y mortalidad del personal de Lovelace. Ninguno lo había hecho. Estas personas hablaron con las organizaciones de noticias sin autorización del hospital.
Sería “atroz” que un centro no llevara a cabo revisiones formales de casos de morbilidad y mortalidad del personal, dijo Goodman.
“Cada recién nacido con un evento significativo, ya sea la muerte o una morbilidad significativa que podría incluso estar relacionada con la atención administrada, creo que todos ellos requieren una discusión cuidadosa para ver si existe alguna causa en el sistema”, dijo Goodman.
Hannah Fresques, editora adjunta de datos de ProPublica revisó el análisis.
Traducción: Mati Vargas-Gibson
Corrección de estilo: Deya Jordá Nolan
This post was originally published on Articles and Investigations – ProPublica.
New Mexico parents worrying over the health of an extremely preterm baby have another reason to be concerned: Their state government provides almost no oversight of the care provided by neonatal intensive care units.
Thirty-one states, including neighboring Arizona, Oklahoma, Texas and Utah, have laws or rules requiring oversight of neonatal intensive care hospitals, according to a 2020 Centers for Disease Control and Prevention study. Some of these states make sure that hospitals provide care at the levels they claim to, and some periodically review data on patient admissions, transfers and outcomes to identify potential problems.
Some states, like California, do both. New Mexico does neither.
The federal government does not set standards for NICUs.
A New Mexico In Depth and ProPublica analysis published Tuesday found that an Albuquerque hospital, Lovelace Women’s, had a death rate for extremely preterm babies roughly twice that of Presbyterian, a nearby maternity hospital that has a comparable NICU. Clinicians voiced concern about aspects of neonatal care at Lovelace. The hospital defended the care it delivered and objected to the news organizations’ focus on extremely preterm babies, noting that these newborns represent only 2% of the hospital NICU’s admissions. The hospital also questioned comparing its performance to that of another hospital rather than to national benchmarks. But experts said the disparity warranted further investigation.
It is unclear, however, who would conduct such an inquiry because New Mexico requires little oversight of neonatal intensive care facilities and does not monitor their patients’ outcomes. New Mexico’s hospital regulators have not set foot in Lovelace’s NICU, or the other two Albuquerque NICUs, Health Department spokesperson James Walton acknowledged.
Other states take a variety of steps to ensure the quality of neonatal care. Experts point to Texas and California as gold standards for NICU oversight.
Twenty-two states, including California, Nevada, Utah and Illinois, have legislation or policies describing plans that advise lower-level hospitals on where preterm babies should be sent to receive the best care, according to a 2017 CDC study. But New Mexico has no perinatal-care regionalization plan, Walton said. Medicaid records indicate that some extremely preterm babies wind up at New Mexico hospitals that are not equipped to care for them. Statewide, between 2015 and 2019, more than 300 extremely preterm babies were admitted to hospitals that didn’t have a NICU, according to state Medicaid program records. (More than 70% of births in the state are covered by Medicaid.)
Regional plans allow hospitals to specialize and make better use of their expertise in caring for preterm babies, said Dr. José Antonio Perez, a clinical professor of pediatrics at the University of Washington in Seattle and the NICU medical director at Swedish Issaquah Medical Center.
Lovelace and Presbyterian are both level 3 neonatal intensive care hospitals, which the American Academy of Pediatrics defines as facilities equipped and staffed to care for high-risk infants. In California and Illinois, top-tier, level 4 NICUs, which care for the sickest premature babies, monitor level 3 hospitals. In New Mexico, such an agreement would give University of New Mexico Hospital oversight of Lovelace and Presbyterian.
Some states assemble groups of hospital officials, experts and community members to study and make recommendations about hospital practices and policies. But New Mexico’s version of these perinatal-care collaboratives focuses on maternal rather than neonatal care, noted Dr. Scott A. Lorch, a professor of pediatrics and associate chair of the Division of Neonatology at the Children’s Hospital of Philadelphia, and a NICU oversight and outcomes expert.
In Arizona, Oklahoma, Utah and Texas, officials conduct on-site inspections to confirm each NICU’s level of care.
In Texas, inspections are done before the state officially designates a facility as a level 1, 2, 3 or 4 neonatal hospital. The American Academy of Pediatrics conducts the Texas inspections using teams that include clinicians who care for newborns at similar facilities, including a neonatologist, a NICU nurse and, if surgeries are performed on-site, a pediatric surgeon. The inspections include checking staff credentials and reviewing patient records.
“You can really tell by reading patient charts and seeing what they do, whether they adhere to their own policies, if they’re consistent,” said Harvard Medical School professor Dr. Ann Stark, who pioneered the American Academy of Pediatrics’ guidelines for levels of neonatal care and who leads its NICU Verification Program.
Evaluations are repeated every three years.
“We learn from every survey,” Stark said. “The more you do something, the better you get.”
But in New Mexico, the state government has no legal authority to verify whether hospitals meet specific standards. Any level-of-care requirements, if they exist at all, would be set in contracts between the hospital and Medicaid managed-care organizations hired by the state, according to Jodi McGinnis Porter of the state Human Services Department. Those agreements are secret. Not even the state can access them. “They’re proprietary,” McGinnis Porter said.
For the public, the shortcomings of New Mexico’s system — and the disparity in hospitals’ death rates for extremely preterm infants — are nearly invisible. The state does not analyze or publicly disclose specific hospitals’ outcomes, which could inform parents’ decisions about where to seek care.
Parents facing the birth of an extremely premature baby “literally have no way to tell or to compare” if their baby might do better at another hospital, said a Lovelace clinician who asked not to be named for fear of retribution. Making hospitals’ newborn outcomes public could force them to identify the causes of problems and address them, the clinician said. “Hospital transparency could save babies’ lives and save New Mexico families in the future from devastating heartbreak.”
Lovelace did not respond to questions about lax state oversight and later declined to respond to any comments made by clinicians who had been granted anonymity by New Mexico In Depth and ProPublica.
New Mexico parents are not the only ones in the dark about how well their local neonatal intensive care hospitals perform. Across the country, expectant parents have no way to assess which maternity hospitals have the best newborn outcomes, neonatal hospital experts and clinicians noted.
“A mom comes into labor at 25 weeks, and at one center you have 21% mortality, and at the other one you have 36% mortality. That information is not provided to the family,” said Perez.
For adult patients, a hospital’s survival or success rates for stroke, heart surgery or cesarean sections are available online. But similar information isn’t available for newborns. No government website compares babies’ outcomes like Medicare’s hospital comparison site does for adults. The Vermont Oxford Network, a hospital research collaborative that tracks infant care, does not publicly disclose hospitals’ NICU statistics. U.S. News & World Report has ranked 50 neonatal hospitals, but not Lovelace or Presbyterian.
There’s a “wall of silence that families and the public face with regard to the quality of care in NICUs,” said Dr. David C. Goodman, a professor at the Dartmouth Institute for Health Policy & Clinical Practice at Dartmouth College. Goodman has studied dozens of U.S. hospitals’ track records in caring for extremely preterm babies.
This dearth of information on neonatal hospital care also slows academic research that could improve outcomes, said Lorch and Goodman. (Lorch’s research team was unable to obtain data on outcomes at New Mexico NICU hospitals, data that researchers can readily obtain in other states, thanks to legal restrictions on the disclosure of the patient-level information.)
Experts said expectant parents should not have to wonder about the quality of newborn care when they choose a maternity hospital.
“It points to the need for greater transparency in health care outcomes, particularly for our most vulnerable populations,” Goodman said. “We can only improve care if it’s measured routinely and shared.”
This post was originally published on Articles and Investigations – ProPublica.
A new study released Wednesday morning shows that nearly 50 million Americans would be unable to afford quality healthcare should the need for treatment suddenly arise, a finding seen as further evidence of the immorality of a for-profit insurance system that grants or denies coverage based on a person’s ability to pay.
“People can’t afford their goddamn healthcare,” Tim Faust, a proponent of single-payer healthcare, tweeted in response to the new report. “Families spend less on food so they can make insurance payments. This problem is felt by all, but concentrated among poor people and black people. The American model of health reform — throwing money at private insurers — can not solve it.”
“The rot is pervasive and it runs deep,” Faust added. “People who can’t afford healthcare just don’t get healthcare. Wealthy men get to live fifteen years longer than poor men. We have condemned poor children to die from things which do not kill rich children. In America, sickness makes you poor; poorness makes you sick; then you die.”
According to the report by Gallup and West Health, 18% of U.S. adults — around 46 million people — say that if they needed access to quality healthcare today, they would not be able to cover the costs. The same percentage of adults report that, amid a deadly pandemic, someone in their household has opted to skip needed care over the past year due to inability to pay.
“The chances of any given household suffering from this form of healthcare insecurity are inversely related to annual household income, with 35% of respondents from low-income households — those earning under $24,000 per year — reporting forgoing care in the prior 12 months,” Gallup’s Dan Witters notes in a summary of the study’s findings. “That is five times the rate reported by those from high-income households (7%), defined as earning at least $180,000.”
Dr. Vikas Saini, president of the Lown Institute think tank, told The Guardian on Wednesday that “unfortunately, it’s not surprising that millions of Americans can’t afford healthcare.”
“It is, however, shocking and kind of outrageous,” Saini added. “Our system has been structured for many years on the basis of private health plans and very deep dysfunction politically and within the medical industry. Americans have been facing this mammoth problem. It was there during, and looks like it’s going to be after, the pandemic… Americans want, and need I’d say, a radically better healthcare system.”
The study comes two weeks after a group of House Democrats led by Reps. Pramila Jayapal (D-Wash.) and Debbie Dingell (D-Mich.) unveiled the Medicare for All Act of 2021, sweeping legislation that would transition the U.S. to a single-payer healthcare system over a two-year period. The new system would guarantee comprehensive medical care to every person in the U.S. for free at the point of service, eliminating premiums, co-pays, and deductibles.
According to an analysis released by consumer advocacy group Public Citizen earlier this month, a Medicare for All system likely would have prevented hundreds of thousands of coronavirus deaths in the United States, which has the highest Covid-19 death toll in the world.
“There is a solution to this health crisis — a popular one that guarantees healthcare to every person as a human right and finally puts people over profits and care over corporations,” said Jayapal, chair of the Congressional Progressive Caucus. “That solution is Medicare for All — everyone in, nobody out.”
In their new study, Gallup and West Health show that over 80% of Americans support “setting caps on out-of-pocket costs for both prescription drugs and general healthcare services for those who are insured by Medicare.” Sixty percent of Americans support “making Medicare available to everyone,” according to the report.
The study also finds that 65% of U.S. adults support lowering the Medicare eligibility age from 65 to 60, a proposal that congressional Democrats are reportedly planning to include in a forthcoming legislative package.
This post was originally published on Latest – Truthout.
A New Mexico In Depth and ProPublica investigation found that the tiniest, most premature babies born at Lovelace Women’s Hospital in Albuquerque died at higher rates than they did at a hospital a few miles away, Presbyterian.
The for-profit Lovelace and nonprofit Presbyterian are New Mexico’s largest maternity centers.
The most comprehensive data on newborn hospital outcomes is collected by the Vermont Oxford Network, or VON, an international neonatal intensive care unit research collaborative. VON maintains patient-level intake and care data for member NICUs, including those at Lovelace, Presbyterian and the University of New Mexico Hospital. The data can be used to calculate death rates at individual hospitals. Maternal and newborn demographics, prenatal care, medical procedures and complications, neonatal hospital transfer history and babies’ outcomes are also captured in the data.
VON data, however, is not public; the network discloses outcomes only to member hospitals. The group declined the news organizations’ request for mortality rates of extremely preterm babies at Lovelace and Presbyterian. UNM, which runs the state’s highest-level NICU, shared its de-identified VON database and annual reports in response to a public records request, but neither Lovelace nor Presbyterian would do the same. The hospitals and VON also refused to share the network’s national average death rate for extremely preterm babies.
Since we did not have access to VON data for Lovelace and Presbyterian, the news organizations obtained aggregate birth and death certificate data for extremely premature babies from the state Health Department’s Bureau of Vital Records and Health Statistics. Hospitals submit data on each live birth and in-hospital newborn death for babies born to legal residents of New Mexico. We initially analyzed data for the most recent available five years (2015-2019), broken down by gestational age and birth weight. We used this data to calculate hospital death rates. To do a more detailed secondary analysis, the news organizations obtained data for babies born during the most recent available 10 years, 2010-2019, based on gestational age. Because the longer time period included more births, it allowed comparisons of additional patient subgroups and variables.
Hospitals also report diagnostic and billing code data to the state Health Department’s Hospital Inpatient Discharge Database, or HIDD, which collects diagnosis and treatment information about patients admitted to every hospital in the state, except those operated by the federal government. We obtained aggregate HIDD data from the Health Department.
In devising our analysis, we worked with national experts in neonatal intensive care, including Dr. Scott A. Lorch, a professor of pediatrics and associate chair of the Division of Neonatology at the Children’s Hospital of Philadelphia and a leading authority on NICU outcomes, and Dr. David C. Goodman, a professor at the Dartmouth Institute for Health Policy & Clinical Practice at Dartmouth College. Goodman helped analyze the data, and the analysis was reviewed by Lorch.
Babies born weighing less than 1,000 grams (or about 2 pounds) are called extremely low birth-weight, while those born before 28 weeks of pregnancy are labeled extremely preterm. (A full-term pregnancy is 39–40 weeks.) While most babies born before 28 weeks are also extremely low birth-weight babies, that is not always the case. To account for that, the news organizations initially evaluated death rates using both birth weight and gestational age for the most recent five years for which Health Department data was available: 2015-2019.
Using the Health Department birth and death certificate data, we calculated a neonatal death rate at each hospital, which measured the percentage of live-born babies who died at their birth hospital within 28 days of delivery. We found that:
Hospital-wide death rates were calculated, accounting for deaths regardless of whether babies were admitted to the hospitals’ NICUs. Goodman, who was the lead author of the September 2019 report Dartmouth Atlas of Neonatal Intensive Care, advised New Mexico In Depth and ProPublica that the most accurate comparisons include the deaths of all extremely preterm babies, whether or not they were admitted to a NICU.
Only babies born at each hospital were counted toward the number of births. Only those who died at their birth hospital within 28 days were counted toward the number of deaths. (Including babies who died after being transferred to UNM’s NICU raised Lovelace’s extremely preterm neonatal death rate to 39%. Because Presbyterian transferred only one extremely preterm baby to UNM, in 2013, and they survived, that hospital’s death rate was unaffected.)
The analyses omitted babies considered “pre-viable” (those delivered before 21 weeks of pregnancy or weighing less than 350 grams), because they would likely die regardless of medical intervention, according to the state Health Department.
As discussed, some babies born at Lovelace and Presbyterian were transferred to UNM for care. Additionally, neonatal transport team logs suggest each hospital sent a handful of babies to out-of-state hospitals. The transport team logs were not detailed enough to allow us to remove all extremely preterm babies who were transferred out of state from our death-rate calculations. Therefore, our death rate treated all babies transferred out of Lovelace and Presbyterian as if they had received care at their birth hospital and lived, almost certainly making our death rates underestimates.
In addition to in-hospital deaths, we also examined how frequently Lovelace and Presbyterian transferred newborns to UNM Hospital, the state’s only top-tier, level-4 NICU hospital.
Having the UNM NICU’s VON data allowed us to analyze the frequency of transfers to UNM, and the condition of and outcomes for those transferred babies. We found:
We also found a discrepancy in the number of Lovelace babies diagnosed with NEC when we compared the HIDD data and UNM’s VON intake logs. The hospital reported four cases of neonatal NEC to the state between 2015 and 2019, but the UNM VON data documented the arrival of 11 Lovelace babies with NEC during those years. Lovelace declined to explain the discrepancy.
In addition to comparing Lovelace to Presbyterian, the news organizations sought a national comparison rate for extremely preterm babies’ death rates at level-3 neonatal hospitals, but found a dearth of publicly available data. Most published studies are based on data that is more than a decade old.
In response to questions from the news organizations, however, the Centers for Disease Control and Prevention provided a national death rate for extremely preterm infants. The CDC’s rate included all hospitals, regardless of the facility’s level of care, using the same gestational age and birth weight parameters used in New Mexico In Depth and ProPublica’s analysis. The CDC found a national, hospital-wide extremely preterm neonatal death rate for 2010-2018 of 28%, near the midpoint between Lovelace’s 36% and Presbyterian’s 22% for 2010-2019.
The CDC’s national death rate might be higher than a rate for only level 3 hospitals would be, because it includes hospitals with level 1 and 2 neonatal designations, which are less equipped to care for these babies.
Experts advised against comparing level 3 facilities like Lovelace and Presbyterian to level 4 neonatal hospitals like UNM, because level 4 hospitals treat the sickest newborns and have more medical subspecialists and surgical experts on staff, making it difficult to interpret differences. However, for completeness, we calculated death rates for UNM, using the Health Department data and the same methods described above for Lovelace and Presbyterian. The 2015-2019 death rates for extremely low birth-weight babies and extremely preterm babies born at UNM were 29% and 33%, according to the news organizations’ analysis.
The cause of the disparity in Lovelace’s and Presbyterian’s extremely preterm neonatal death rates is not clear. Possibilities include one hospital having a sicker patient population, differences in patient care, or both.
The Health Department provided additional breakdowns of outcomes by patient demographics and treatment details, none of which alone explained the difference in death rates. The summary-level data did not allow us to examine several variables in combination.
Babies born at 21 to 23 weeks’ gestation are considered “peri-viable” and resuscitation practices for these babies vary between hospitals, experts and Albuquerque clinicians said, which may lead to differing outcomes.
After excluding babies born at 21-23 weeks’ gestation who died without being resuscitated at delivery from the analysis, Lovelace’s extremely preterm neonatal death rate was 29%, compared to 19% at Presbyterian. Excluding all babies who died within an hour of delivery, regardless of gestational age or resuscitation reports, Lovelace’s death rate was 26%, compared to 18% at Presbyterian and a CDC-provided national rate of 22%.
(Goodman warned that resuscitation numbers are unreliable because hospitals frequently fail to report them.)
By 24 weeks’ gestation, resuscitation at delivery is always attempted, experts and clinicians said. When only babies born at 24-27 weeks’ gestation were included in the analysis, the death rate at Lovelace was 23% vs. 9% at Presbyterian for 2010-2019. The CDC-provided national rate for this group was 15%.
Another explanation for the death-rate disparity could have been if Lovelace had a disproportionate number of 21- or 22-week-gestational-age babies, who have poorer outcomes than babies born at 24-27 weeks. But we found that the distributions of births by week of gestation at the two hospitals were very similar.
The state Health Department provided demographic and medical treatment details for extremely preterm babies born at 24-27 weeks’ gestation. Lovelace’s higher death rate persisted in analyses of that data. For example, extremely preterm twins and triplets often fare worse than single-born babies. But this did not explain the hospitals’ death-rate disparity. Nor did maternal race or ethnicity, differences in the proportion of extremely preterm babies who were boys (boys tend to have worse outcomes than girls), or differences in prenatal therapies. Medically induced labor and other risk factors for extremely preterm babies, such as the proportion of teen mothers, mothers who underwent infertility treatment or mothers who had cesarean-section deliveries also did not account for the disparity.
Discrepancies in numbers for NICU admissions and birth defects precluded analysis of that data. All extremely preterm babies who survive delivery should be admitted to the hospitals’ NICUs, clinicians and experts agreed, but there were babies at both hospitals for whom there were neither NICU admissions records nor death certificates. Neither Lovelace nor Presbyterian reported birth defects with extremely preterm babies’ birth certificate data, but a handful of death certificate reports note birth defects as a cause of death. There was only one record of a Lovelace extremely preterm baby being transferred to UNM in the first 24 hours after delivery, so transfers should not explain the missing NICU admissions data. When asked for comment, the hospitals did not acknowledge or explain the discrepancies.
Identifying the causes of the hospitals’ extremely preterm neonatal death rate disparities would require access to patient records or to completely reported, patient-level records, experts said.
Lovelace presented several objections to our analyses. The hospital objected to comparing its extremely preterm newborns’ death rates to those of Presbyterian or any other individual hospital, arguing that comparisons should only be made to national benchmarks.
Goodman defended comparisons of outcomes between nearby level 3 neonatal hospitals: “A comparison within the same community, serving similar populations, operating under similar state policies and regulations, is of the highest value.”
And the news organizations obtained a national rate from the CDC, as described above, which was lower than Lovelace’s death rate.
In addition, the hospital contested the decision to look at hospital-wide outcomes for babies, regardless of whether or not they were admitted to the hospitals’ NICUs. Lovelace asserted that only NICU deaths should be measured because hospital-wide rates include deaths in the delivery room and could include nonviable babies. Presbyterian officials did not object to a hospital-wide comparison.
Lovelace said its NICU-only 2015-2019 death rate for extremely low birth-weight newborns was 22%. They would not say how the 22% NICU-only death rate compared to national rates in the VON. Presbyterian refused to disclose its NICU-only death rate.
Goodman rejected Lovelace’s objection to hospital-wide comparisons, noting that NICU staff should be present at the delivery of extremely preterm babies and that his research team includes “every extremely preterm baby who dies … in our research. They are cared for by the NICU team and are the responsibility of the NICU team whether or not they are administratively admitted to a hospital’s NICU.”
Another objection from Lovelace was the decision to calculate death rates for extremely low birth-weight newborns in the first place, noting that babies born weighing less than 1,000 grams represent only 2% of the hospital’s NICU-admitted babies. “This sample size is too small from which to derive any conclusions about the overall quality of care being provided,” Lovelace Vice President for Marketing Serena Pettes wrote in an email.
But extremely preterm babies are a formally recognized and widely studied patient population at neonatal hospitals. The American College of Obstetricians and Gynecologists defines as extremely preterm babies born before 28 weeks of gestation, the definition we employed. While extremely preterm babies do make up a small portion of all NICU admission, between 2010 and 2019, more than 500 such babies were born at Lovelace and Presbyterian.
ProPublica’s deputy data editor, Hannah Fresques, and a member of ProPublica’s data science advisory board reviewed the analysis
This post was originally published on Articles and Investigations – ProPublica.
Note: This story contains a description of the death of an infant.
It was morning shift change at Lovelace Women’s Hospital in Albuquerque, New Mexico. In the neonatal intensive care unit, the lights were dimmed, as usual. People spoke in hushed tones typical of the NICU. But an arriving clinician knew immediately that something had gone wrong.
A “crash cart” carrying resuscitation equipment was positioned next to a newborn incubator, the enclosed cribs that keep preterm babies warm. Nurses stood nearby with grim expressions.
The incubator light illuminated an infant’s swollen, discolored belly.
“I’ll never forget what this baby looked like,” recalled the Lovelace clinician, who asked not to be identified for fear of retribution. “His abdomen was black and taut and almost the size of a grapefruit.”
The day before, the infant had been a little cold and had spit up, which wasn’t particularly unusual. “It was something to watch, but nothing was horribly wrong,” the clinician said.
Overnight, the baby’s condition had worsened. Now, he was on a ventilator, his tiny heart’s contractions slowing. His swollen abdomen prevented staff from administering chest compressions.
“There was nothing we could do,” the clinician said. “He died.”
The infant’s gut had stopped functioning, clogging his feeding tube with undigested food. That is sometimes a sign of an inflammatory condition of the intestines, called necrotizing enterocolitis or NEC, that’s a leading cause of hospital deaths among extremely preterm babies.
These babies’ problems can spiral into life-threatening conditions in a matter of hours. There’s no indication that Lovelace improperly handled the infant’s treatment. But extremely preterm babies died at the hospital with striking frequency, according to an analysis of state health data by New Mexico In Depth and ProPublica.
A yearlong investigation by the news organizations found that at Lovelace, the tiniest, most premature babies died at up to twice the rate as they did a few miles away, at Presbyterian Hospital, another major maternity and newborn facility.
New Mexico In Depth and ProPublica also found that Lovelace transferred more than three times as many newborns as Presbyterian to the University of New Mexico Hospital, the state’s only top-tier, level-4 regional referral NICU, where the sickest of the state’s newborns are sent for care.
All told, between 2015 and 2019, close to half — 46% — of the 84 extremely preterm babies born at Lovelace either died at the hospital or were transferred to UNM, according to Health Department data and UNM NICU records. Twenty-one percent of the 170 extremely preterm babies born at Presbyterian died, and none was transferred to UNM during those years.
Experts said the findings should be investigated.
The disparity “should be of concern to families, the community, and the state of New Mexico,” said Dr. David C. Goodman, a professor at the Dartmouth Institute for Health Policy & Clinical Practice at Dartmouth College. Goodman, who was the lead author of the September 2019 report Dartmouth Atlas of Neonatal Intensive Care, has studied the track records of dozens of U.S. hospitals that care for extremely preterm babies.
It is also a concern to Albuquerque medical professionals who care for these babies. Three Lovelace and UNM Hospital clinicians who contacted New Mexico In Depth and ProPublica about Lovelace voiced concerns about extremely preterm babies’ outcomes and pointed to broader issues related to their care. Those issues included the lack of an on-site surgeon and other specialists, the timing of transfers to UNM when babies needed higher-level care, and disagreement over how best to care for these fragile newborns.
Lovelace and Presbyterian initially agreed to share detailed data on their neonatal outcomes with New Mexico In Depth and ProPublica, but ultimately refused to provide most of the promised information. To investigate the clinicians’ concerns, the news organizations obtained state Health Department data on these newborns’ deaths.
To better understand the disparity in outcomes between Lovelace and Presbyterian hospitals, New Mexico In Depth and ProPublica also obtained UNM hospital-transfer and intake logs, along with emails and other documents, and interviewed more than two dozen people, including current and former Albuquerque clinicians, neonatal transport team members, hospital officials and nationally recognized NICU experts. NICU administrators at Lovelace and Presbyterian spoke to the news organizations in early 2020. Since then, Lovelace has not made administrators available for comment.
Lovelace rejected any comparison that focused only on extremely preterm babies or that contrasted their death rates to Presbyterian’s.
“Comparing us to only one other hospital as opposed to national benchmarks is flawed and not an appropriate basis for drawing broad conclusions,” Lovelace Vice President for Marketing Serena Pettes wrote in an email.
Pettes said the news organizations were “seeking to undermine our quality of care” through a “misinterpretation of data.” Asked how the hospital’s data had been misinterpreted, she did not respond.
Three experts told New Mexico In Depth and ProPublica that it’s cause for concern when level 3 neonatal hospitals, a designation that covers both Lovelace and Presbyterian, have higher death and transfer rates than neighboring facilities. Without access to patient records, numbers for neighboring hospitals were the best proxy to use in gauging outcomes, they said.
“Anytime you have a hospital that is delivering a lot of tiny babies that it has to send out or that die before you can send them out, you really have to ask the question, ‘Are the mothers delivering at the right place?’” said Dr. Jeffrey B. Gould, a professor of pediatrics at Stanford University. A pioneer in NICU quality improvement, Gould is co-founder and chief executive of the California Perinatal Quality Care Collaborative.
Moreover, lax state oversight and a lack of hospital transparency about outcomes severely curtails the public’s ability to know just how well hospitals are serving this vulnerable population. The state’s loose regulations stand in sharp contrast to other states, like Texas and California, which mandate periodic inspections of neonatal intensive care hospitals and scrutiny of newborn outcomes.
The Lovelace clinician who witnessed the baby boy’s death said New Mexico’s lack of oversight is one reason families are in the dark about extremely preterm babies’ outcomes at the hospital. Another is a culture of silence at the hospital when things go wrong: “We don’t even talk about it within the NICU, but especially to the parents.”
(Photo illustration by Shoshana Gordon/ProPublica, source images: FrankGuido via Flickr and Marjorie Childress/New Mexico in Depth)
Lovelace delivered about 2,700 babies in 2019; nearby Presbyterian delivered about 3,000, making those two hospitals the state’s largest maternity centers. They are also the state’s only level 3 neonatal intensive care hospitals, according to the state Health Department. Together, they delivered 28% of babies born statewide between 2010 and 2019, and 37% of the state’s extremely preterm babies.
“If your pregnancy falls into the high-risk category, you can rest assured you’ll be getting the best medical care available anywhere in the region,” a Lovelace advertisement states.
Overall, Lovelace and Presbyterian had similar newborn death rates, the news organizations found — except when it came to the tiniest and most premature newborns.
Babies weighing less than about 2 pounds at birth are called extremely low birth weight, while those born before 28 weeks of pregnancy are labeled extremely preterm. While most extremely preterm babies are also extremely low birth-weight babies, that is not always the case. To account for all of these vulnerable infants, the news organizations evaluated death rates using both birth weight and gestational age.
Between 2015 and 2019, 34% of Lovelace’s 88 extremely low birth-weight infants died, compared to 17% of Presbyterian’s 197, according to the New Mexico in Depth and ProPublica analysis, which compared birth and death certificate data at the two hospitals. The calculations excluded babies who were born elsewhere and transferred to Lovelace or Presbyterian, and babies born weighing less than 350 grams, who are not considered viable.
The analysis also found a disparity in the death rate when calculated by gestational age, instead of by birth weight. Lovelace’s hospital-wide death rate for extremely preterm babies was 36%, compared to Presbyterian’s 21%.
“The differences are meaningful,” Goodman said of the hospitals’ death rates. “They’re not slight differences. These are large differences.”
“Thirty-six percent is higher than expected for this gestational age group,” Goodman said. “It raises the question as to whether the care provided meets the needs of the newborn patients.”
The news organizations also found that Lovelace transferred 66 infants, both full term and preterm, to the level 4 NICU between 2015 and 2019, while Presbyterian sent 17 babies, none of them preterm, UNM records showed.
“Every time we have a tiny baby, I cringe. We have a terrible track record with them,” said the Lovelace clinician who was present when the baby died.
Another Lovelace NICU clinician voiced similar concerns about extremely preterm babies’ outcomes, both in the delivery room and the NICU.
“They have only rudimentary policies in place for micropreemies, but not nearly as comprehensive as things that I’ve seen at other hospitals,” the second Lovelace clinician said. (A copy of Lovelace’s NICU infant care guidelines, reviewed by the news organizations and dated Feb. 1, 2017, briefly mentions extremely preterm and extremely low birth-weight babies’ care in sections about nurse-to-patient ratios, thermoregulation and water loss, skin care, and body positioning.)
The clinicians were two of eight current and former Lovelace care providers who spoke to New Mexico In Depth and ProPublica about newborn care at the facility on the condition that they remain anonymous because speaking publicly could hurt their employment within New Mexico’s small medical community. Not all of them were critical of the hospital.
“It’s a well-run unit,” a former Lovelace clinician said of the NICU. “I wouldn’t hesitate to have my own child in that unit.”
Pettes declined to respond to clinicians’ concerns and criticized the news organizations’ decision to grant them anonymity. “We are not able to respond to anonymous sources,” she wrote in an email, calling the clinicians’ comments “opinions, and not facts.”
The American Academy of Pediatrics defines level 3 NICU hospitals as facilities equipped to care for high-risk babies. Unlike lower-level hospital nurseries, they are staffed by specialists experienced in treating the most at-risk and medically complex newborns.
In New Mexico, however, there’s no legal definition of what constitutes a level 3 NICU. The state has no NICU-specific legal or regulatory oversight authority. Nor does the state have a role in certifying NICUs or monitoring newborn outcomes. The state has not conducted on-site inspections of any of the three Albuquerque NICU hospitals and has not analyzed neonatal death rates at the facilities, state Health Department spokesperson James Walton acknowledged.
The New Mexico Department of Health collects some details from the hospitals about mothers and newborns, including which mothers received infertility treatments to become pregnant, whether labor was induced and whether the delivery was by cesarean section. But the state cannot impose penalties on hospitals that fail to report such data, Health Department officials confirmed.
For example, New Mexico In Depth and ProPublica identified a discrepancy in Lovelace’s reporting of cases of NEC, the dangerous intestinal condition. Lovelace reported only four neonatal NEC cases to the Health Department between 2015 and 2019, but NICU intake records at UNM showed 11 babies who were transferred from Lovelace with NEC during those years, including four in 2019 alone.
Goodman helped New Mexico In Depth and ProPublica analyze the Health Department’s birth and death data.
The causes of disparities in outcomes between institutions are not always clear. Possibilities include a sicker patient population and less effective care, Goodman said.
Lovelace repeatedly declined to identify demographic or patient factors that might explain the disparity in the hospitals’ extremely preterm neonatal death rates.
Identifying those factors requires careful review of patients’ medical records, experts said. New Mexico In Depth and ProPublica did not have access to patient records. But the news organizations attempted to identify possible explanations using the data Lovelace and Presbyterian reported to the state Health Department from 2010 to 2019.
Babies born at 21 to 23 weeks’ gestation frequently die shortly after delivery, and resuscitation practices for the age group vary, which could lead to differing outcomes. But a 2-to-1 death-rate disparity persisted when the analysis included only babies born at 24-27 weeks’ gestation, who are less likely to die shortly after delivery. The number of extremely preterm twins and triplets, who often fare poorly, also did not explain the death-rate disparity. Nor did differences in maternal race or ethnicity, prenatal therapies or other potential risk factors for extremely preterm babies, including the proportion of boy births, teen mothers, mothers who underwent infertility treatment or induced labor, or mothers who had cesarean-section deliveries.
Pettes claimed that for all NICU-admitted newborns — including lower-risk full-term babies and premature babies — Lovelace’s neonatal death rate is “significantly lower than the national average,” and has declined over time. “As a whole, our mortality rate is less than half of the national NICU average.”
But according to the Health Department data, full-term babies make up a much larger proportion of the hospital’s NICU population than extremely preterm newborns, obscuring the death rate for the hospital’s most at-risk babies.
Pettes declined to share the national benchmark she cited from a neonatal intensive care unit research collaborative, the Vermont Oxford Network. The network discloses outcomes only to member hospitals and declined the news organizations’ request for extremely preterm babies’ mortality rates at Lovelace and Presbyterian.
Pettes also objected to the news organizations’ comparison of hospital-wide death rates.
Pettes disclosed that 22% of Lovelace’s extremely low birth-weight babies died after admission to the NICU during 2015-2019.
But Goodman said NICU-only rates are not a true reflection of a hospital’s outcomes.
“We include every extremely preterm baby who dies … in our research,” said Goodman. “They are cared for by the NICU team and are the responsibility of the NICU team whether or not they are administratively admitted to a hospital’s NICU.”
Lovelace did not provide a hospital-wide death rate for these fragile babies.
Hospital-wide death rates are important indicators because labor and delivery unit practices can also affect survival, and babies who die in the NICU are not always recorded as NICU deaths, a Lovelace clinician noted.
It was impossible for the news organizations to compare NICU-only data between the hospitals. Presbyterian would not provide its NICU-only death rate. In addition, birth and death certificate data showed discrepancies in the Health Department’s data on NICU admissions. Extremely preterm babies who survive delivery should always eventually be admitted to NICUs, experts said, but the news organizations found infants for whom there was no record of a NICU admission or a death certificate.
The hospitals did not acknowledge or explain the discrepancies.
(Photo illustration by Shoshana Gordon/ProPublica, source images: Shaun Griswold and Marjorie Childress/New Mexico in Depth, and burnt in effigy via Flickr)
Lovelace transferred more than three times as many newborns to UNM’s level 4 NICU as did Presbyterian, UNM intake logs show. Ten of the Lovelace transfers were extremely low birth-weight infants, three of whom died at UNM. None of Presbyterian’s transferred babies were extremely preterm or extremely low birth-weight infants.
Information about neonatal transfers can help regulators identify facilities that aren’t meeting babies’ needs or find problems that hospitals should address, experts say.
Comparing UNM NICU intake logs with state data showed that close to 90% of Lovelace and Presbyterian’s transfers to UNM were not captured in Health Department data, because the state only requires hospitals to report transfers occurring in the first 24 hours after delivery.
“If you don’t have the data, you can’t make change,” said Dr. Scott A. Lorch, a professor of pediatrics and associate chair of the Division of Neonatology at the Children’s Hospital of Philadelphia, and a leading authority on NICU outcomes.
At UNM Hospital, babies who arrived in dire condition were sometimes called “Lovelace Specials,” according to two former UNM NICU clinicians who asked not to be named for fear of retribution.
Some of the Lovelace babies who had NEC arrived at UNM without needed X-ray reports, or with X-rays taken from angles that can miss signs of a worsening condition, a UNM pediatric radiologist said.
“That’s what I’ve seen based on imaging: Patients often arrived at UNM in more advanced stages of NEC,” the radiologist said. Unlike UNM and Presbyterian, Lovelace does not have a pediatric radiologist on staff, the radiologist noted. Lovelace declined to comment.
One of the two former UNM clinicians said that when babies arrived from Lovelace, “you just had no idea what you were getting into.”
Clinicians questioned not only the number of newborn transfers but their timing.
Lovelace is sometimes too slow to send babies in crisis to UNM Hospital, where surgery can be performed if needed, four clinicians from both Lovelace and UNM said. Lovelace declined to respond to their allegation.
The pace of transfer matters because NEC can progress in a matter of hours from subtle symptoms to a life-threatening condition requiring emergency surgery. It is not unusual for level 3 NICUs to have surgeons on call or to have a transfer agreement with other hospitals. But if a surgeon cannot perform emergency procedures on-site, timely transfers to surgical hospitals can be a matter of life or death.
Of 18 babies with NEC who were transferred to UNM since 2012, 15 came from Lovelace. There isn’t a hard-and-fast rule about when to transfer a sick infant to a higher-level facility, but transfer logs showed that of the 15 Lovelace babies sent to UNM, 12 were in a condition that required surgery when they got there, and two — a 5-day-old girl and a 12-day-old boy — died within hours of their arrival. Only one Lovelace baby with NEC was transferred and survived without surgery.
When NEC is caught early, it can be treated with antibiotics, a former UNM clinician said. “But you don’t want to wait until they’re so, so, so, so sick and then try to send them,” the clinician said.
“They just wait too long,” said the Lovelace clinician who witnessed the boy’s death, referring to cases the clinician handled. “Babies that might otherwise have survived did not because they didn’t get them to a place where they could have a surgeon if they needed it.”
The former UNM clinician added a key explanation: “That’s really where we get a lot of the kids, especially from Lovelace, is not having those pediatric surgeons available.”
The question of whether Lovelace does, in fact, have an on-site pediatric surgeon, as Presbyterian does, is subject to debate.
In March 2019, the New Mexico Health Department and the Centers for Disease Control and Prevention informed Lovelace that a survey of the state’s maternity and neonatal hospitals had concluded that Lovelace was not operating a level 3 NICU, but instead a level 2 special-care nursery. State officials based their conclusion on the lack of a pediatric surgeon and a pediatric anesthesiologist at Lovelace.
Hospital administrators successfully appealed that determination, claiming in an email obtained by the news organizations that among the “providers available” at Lovelace was a pediatric surgeon and other experts “on site 24/7.”
But Lovelace clinicians told New Mexico In Depth and ProPublica that the claim was misleading.
“They’ve been saying they’re going to have pediatric surgery for almost a decade,” one Lovelace clinician said.
In some states, hospitals are required to support such claims with documentation. But emails indicate the state Health Department’s chief medical officer, Dr. Thomas Massaro, prevented other Health Department staff from asking Lovelace to provide the names and board certifications of medical specialists. Massaro told New Mexico In Depth and ProPublica, “Neither we nor CDC required documentation of any of the hospital claims or submissions.”
There’s a reason hospitals fight for level 3 status.
Lovelace Women’s Hospital opened its $11 million NICU in September 2007, positioning itself to compete with Presbyterian and UNM in the state’s lucrative newborn acute health care market. Lovelace markets itself as a state-of-the-art maternal and newborn hospital. Expectant parents are told that should anything go wrong, maternal and neonatal medical specialists are available to provide expert care. Front and center in that promise is the “Level 3 Neonatal Intensive Care Unit.”
Extremely preterm babies cared for in the NICU are known as “million-dollar babies,” several clinicians said. That’s no exaggeration: Hospital price sheets suggest care for these babies may bring Lovelace more than $1.2 million per baby from insurers.
Newborn intensive care has brought a lot of money to Lovelace and its privately owned parent company, Nashville-based Ardent Health Services. Between 2015 and 2019, Lovelace Women’s 53-bed facility received more than $99 million in payments from Medicaid for NICU patient care, while Presbyterian’s 58-bed NICU received $75 million during the same period, according to state data.
“It is no secret that the NICU is Lovelace Women’s Hospital’s golden goose,” said Wendy Walter, a former adult ICU charge nurse at Lovelace who provided “helping hands” when the NICU was short-staffed. (Walter was fired by the hospital in January for working more hours than authorized. She contends that she worked additional hours at shift’s end to properly document patients’ treatments.)
Months after successfully defending its level 3 status, Lovelace went further, informing the state Health Department last year that the facility merited recognition as a level 4 NICU. That could put it in competition with UNM, where extremely preterm babies can bring in more than $2 million per infant.
In a Jan. 10, 2020, email to Massaro, Lovelace’s director of women’s services, Dr. Abraham Lichtmacher, wrote that the hospital now had “pediatric surgery, which is represented by the pediatric surgeons from UNM as they have finalized and obtained their privileges at Lovelace Women’s Hospital allowing them to perform their procedures on site.”
Three current and former Lovelace clinicians expressed dismay that an administrator at the hospital made such a claim.
“They don’t have surgical support staff, pediatric surgical nurses — or even a place to do baby surgeries,” one said.
A few weeks after Lichtmacher emailed the state, UNM pediatric surgeon Dr. Jason McKee contradicted Lichtmacher’s claim in an interview with New Mexico In Depth and ProPublica. Asked if he had surgical privileges at Lovelace, McKee told the news organizations in early 2020: “I have consulting privileges at Lovelace so I can go and see a child, but as of now we don’t do surgery over there.”
McKee was noncommittal when asked if that would change in the near future, but noted that it would require Lovelace to hire surgical support staff.
Lovelace recently declined to say if any pediatric surgeries have been performed at the hospital or if it has surgical support staff available to perform such operations.
“We have, and continue to maintain, pediatric surgeon availability for our patients but defer to the surgeon’s clinical judgement as to the best place for those surgeries to occur to achieve the best outcomes for the patient,” Pettes, the Lovelace vice president for marketing, wrote in an email. She declined to say if Lovelace employed a pediatric surgeon or pediatric surgery support staff, or if any neonatal surgeries have been conducted at Lovelace in recent years.
Job listings for Lovelace Women’s posted as recently as Feb. 27 stated that the hospital “hopes to establish Pediatric Surgery in the future.”
Lovelace last sought the Health Department’s acknowledgement of its NICU as a level 4 facility in August, according to Walton, the department spokesman.
Lovelace refused to comment on its efforts to be recognized as a level 4 neonatal hospital.
A November 2020 Health Department document still listed Lovelace as a level 3 neonatal facility.
(Photo illustration by Shoshana Gordon/ProPublica, source images: Shaun Griswold and Marjorie Childress/New Mexico in Depth, and Jennifer Pack via Flickr)
One situation that experts say can cause disparities in outcomes at neonatal facilities is the number of patients they treat, or what researchers call “patient volume.”
Hospitals that care for a larger number of high-risk babies have better outcomes, likely the product of their experience, said Lorch, the authority on NICU outcomes. Teams need practice working together to meet the needs of high-risk babies, experts said.
While it is unclear whether patient volume was a factor in higher death rates among the tiniest babies at Lovelace, the hospital had less than half the patient volume of extremely preterm babies that Presbyterian had. Each year, between 2010 and 2019, Lovelace delivered on average 16 extremely preterm babies, compared to 38 at Presbyterian.
Research by Lorch and others shows that patient volume can predict survival rates for more developed “very” preterm babies, those born at 28 to 32 weeks’ gestation.
“You need experience caring for those babies,” said Harvard Medical School professor Dr. Ann Stark, who pioneered the American Academy of Pediatrics’ guidelines for levels of neonatal care.
The role hospitals’ patient volumes plays in survival among extremely preterm babies — those born before 28 weeks of pregnancy — has not been studied. But research has shown that dedicating an expert clinical team to care for extremely preterm babies can improve outcomes. In that light, having three Albuquerque hospitals within a few miles of each other that each care for a relatively small number of extremely preterm babies might not make sense, some experts said.
“Maybe having one high-volume center is better than having two or three centers that take care of those same babies,” said Dr. José Antonio Perez, a clinical professor of pediatrics at the University of Washington in Seattle and the NICU medical director at Swedish Issaquah Medical Center.
One way neonatal hospitals improve the quality of care after things go wrong is by convening formal staff morbidity and mortality, or “M&M,” case reviews. New Mexico regulators do not require M&M case reviews, but NICU staff at both Presbyterian and UNM hold them anyway.
Lovelace officials repeatedly declined to say if they do.
New Mexico In Depth and ProPublica asked eight current and former clinicians who worked at the Lovelace NICU over the past decade if they had participated in M&M case reviews at Lovelace. None had. They spoke with the news organizations without the hospital’s permission.
It would be “egregious” for a facility to not conduct M&M case reviews, Goodman said.
“Each newborn with a significant event, be it death or a significant morbidity that could even possibly be related to the care administered, I think those all require careful discussion to see if there is any systemic cause,” Goodman said.
ProPublica’s deputy data editor, Hannah Fresques, reviewed the analysis.
This post was originally published on Articles and Investigations – ProPublica.
For decades, we have been sold a myth of private health. It is a myth that our health is largely a product of individual choices and personal responsibilities. It is a myth that our healthcare is a service which private corporations can provide, and for which we must pay to survive.
But the Covid-19 pandemic has blown up this myth. Our personal health cannot be separated from the health of our neighbors or our planet. Nor can it be separated from the structural factors and policy decisions that have determined our health outcomes long before we are born.
The post All Health Is Public Health appeared first on PopularResistance.Org.
This post was originally published on PopularResistance.Org.
I recently joined Reps. Pramila Jayapal (D-WA) and Debbie Dingell (D-MI) as they introduced the Medicare for All Act of 2021 in Congress. For me and millions of Americans, this bill’s passage would not only be life-changing—it could be life-saving.
In 2010, I was diagnosed with multiple myeloma, an incurable blood cancer that affects the bone marrow and makes it harder for my body to fight infections. Before I was diagnosed, I was an average 30-something guy who went to the gym and ate right. Today, after 11 years with this disease, I’m still fighting for my life.
The post How Many More People Have To Die Before We Pass Medicare For All? appeared first on PopularResistance.Org.
This post was originally published on PopularResistance.Org.
On February 20, the New York Times published an article titled “Venezuelan Women Lose Access to Contraception, and Control of Their Lives.” This article attempts to distort reality, as it completely ignores the siege and aggressions the Venezuelan people currently subjected to.
For greater context, we should note that in 2012, Venezuela granted completely free access to safe and quality contraceptives, reaching a coverage of 22.16% in the national public health system. Access was nearly universal both due to the purchasing power of Venezuelans at the time and because both private and public health networks were subsidized up to 70% by the government, with funds guaranteed by the country’s foreign income.
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This post was originally published on PopularResistance.Org.
For the Southwest Georgia Regional Medical Center, the last straw was the COVID-19 pandemic, which strained the critical access hospital’s already-precarious finances past the breaking point. In Florida, two hospitals closed inpatient non-emergency services after being bought out by the HCA hospital chain. In Tennessee and West Virginia, financial problems combined with the strain of the pandemic led two more rural hospitals to shut their doors.
Of the 20 rural hospitals that closed in 2020, 13 were in the South, according to data from the Sheps Center at the University of North Carolina at Chapel Hill, which defines a closed hospital as one that no longer offers inpatient services.
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This post was originally published on PopularResistance.Org.
President Biden, the Democratic Party and America’s neoliberal vision of world order is rooted in an economic philosophy of privatization and financialization. To assure privatization goals of the 1% oligarchs, distinguished economist Michael Hudson writes that this is achieved by “conquering the brains of a country by shaping how people think. If you can twist their view into unreality economics, to make them think you are there to help them and not to take money out of them, then you’ve got them hooked.” To maintain corporate control of U.S. health care insurance, our system is privatized and unregulated. Private, big insurance companies are in the business of making money, not providing health care, and when they undertake the latter, it is likely not to be in the best interests of patients or to be efficient.
The post Biden’s Neoliberal Rescue Of For-Profit Health System Proves We Need Medicare For All appeared first on PopularResistance.Org.
This post was originally published on PopularResistance.Org.
Since the start of the pandemic, the most terrifying task in health care was thought to be when a doctor put a breathing tube down the trachea of a critically ill covid patient.
Those performing such “aerosol-generating” procedures, often in an intensive care unit, got the best protective gear even if there wasn’t enough to go around, per Centers for Disease Control and Prevention guidelines. And for anyone else working with covid patients, until a month ago, a surgical mask was considered sufficient.
A new wave of research now shows that several of those procedures were not the most hazardous. Recent studies have determined that a basic cough produces about 20 times more particles than intubation, a procedure one doctor likened to the risk of being next to a nuclear reactor.
Other new studies show that patients with covid simply talking or breathing, even in a well-ventilated room, could make workers sick in the CDC-sanctioned surgical masks. The studies suggest that the highest overall risk of infection was among the front-line workers — many of them workers of color — who spent the most time with patients earlier in their illness and in sub-par protective gear, not those working in the covid ICU.
“The whole thing is upside down the way it is currently framed,” said Dr. Michael Klompas, a Harvard Medical School associate professor who called aerosol-generating procedures a “misnomer” in a recent paper in the Journal of the American Medical Association.
“It’s a huge mistake,” he said.
The growing body of studies showing aerosol spread of covid-19 during choir practice, on a bus, in a restaurant and at gyms have caught the eye of the public and led to widespread interest in better masks and ventilation.
Yet the topic has been highly controversial within the health care industry. For over a year, international and U.S. nurse union leaders have called for health workers caring for possible or confirmed covid patients to have the highest level of protection, including N95 masks.
But a widespread group of experts have long insisted that N95s be reserved for those performing aerosol-generating procedures and that it’s safe for front-line workers to care for covid patients wearing less-protective surgical masks.
Such skepticism about general aerosol exposure within the health care setting have driven CDC guidelines, supported by national and California hospital associations.
The guidelines still say a worker would not be considered “exposed” to covid-19 after caring for a sick covid patient while wearing a surgical mask. Yet in recent months, Klompas and researchers in Israel have documented that workers using a surgical mask and face shield have caught covid during routine patient care.
The CDC said in an email that N95 “respirators have remained preferred over facemasks when caring for patients or residents with suspected or confirmed” covid, “but unfortunately, respirators have not always been available to healthcare personnel due to supply shortages.”
New research by Harvard and Tulane scientists found that people who tend to be super-spreaders of covid — the 20% of people who emit 80% of the tiny particles — tend to be obese or older, a population more likely to live in elder care or be hospitalized.
When highly infectious, such patients emit three times more tiny aerosol particles (about a billion a day) than younger people. A sick super-spreader who is simply breathing can pose as much or more risk to health workers as a coughing patient, said David Edwards, a Harvard faculty associate in bioengineering and an author of the study.
Chad Roy, a co-author who studied primates with covid, said the emitted aerosols shrink in size when the monkeys are most contagious at about Day Six of infection. Those particles are more likely to hang in the air longer and are easier to inhale deep into the lungs, said Roy, a professor of microbiology and immunology at Tulane University School of Medicine.
The study clarifies the grave risks faced by nursing home workers, of whom more than 546,000 have gotten covid and 1,590 have died, per reports nursing homes filed to the Centers for Medicare & Medicaid since mid-May.
Taken together, the research suggests that health care workplace exposure was “much bigger” than what the CDC defined when it prioritized protecting those doing “aerosol-generating” procedures, said Dr. Donald Milton, who reviewed the studies but was not involved in any of them.
“The upshot is that it’s inhalation” of tiny airborne particles that leads to infection, said Milton, a professor at the University of Maryland School of Public Health who studies how respiratory viruses are spread, “which means loose-fitting surgical masks are not sufficient.”
On Feb. 10, the CDC updated its guidance to health care workers, deleting a suggestion that wearing a surgical mask while caring for covid patients was acceptable and urging workers to wear an N95 or a “well-fitting face mask,” which could include a snug cloth mask over a looser surgical mask.
Yet the update came after most of at least 3,500 U.S. health care workers had already died of covid, as documented by KHN and The Guardian in the Lost on the Frontline project.
The project is more comprehensive than any U.S. government tally of health worker fatalities. Current CDC data shows 1,391 health care worker deaths, which is 200 fewer than the total staff covid deaths nursing homes report to Medicare.
More than half of the deceased workers whose occupation was known were nurses or in health care support roles. Such staffers often have the most extensive patient contact, tending to their IVs and turning them in hospital beds; brushing their hair and sponge-bathing them in nursing homes. Many of them — 2 in 3 — were workers of color.
Two anesthetists in the United Kingdom — doctors who perform intubations in the ICU — saw data showing that non-ICU workers were dying at outsize rates and began to question the notion that “aerosol-generating” procedures were the riskiest.
Dr. Tim Cook, an anesthetist with the Royal United Hospitals Bath, said the guidelines singling out those procedures were based on research from the first SARS outbreak in 2003. That framework includes a widely cited 2012 study that warned that those earlier studies were “very low” quality and said there was a “significant research gap” that needed to be filled.
But the research never took place before covid-19 emerged, Cook said, and key differences emerged between SARS and covid-19. In the first SARS outbreak, patients were most contagious at the moment they arrived at a hospital needing intubation. Yet for this pandemic, he said, studies in early summer began to show that peak contagion occurred days earlier.
Cook and his colleagues dove in and discovered in October that the dreaded practice of intubation emitted about 20 times fewer aerosols than a cough, said Dr. Jules Brown, a U.K. anesthetist and another author of the study. Extubation, also considered an “aerosol-generating” procedure, generated slightly more aerosols but only because patients sometimes cough when the tube is removed.
Since then, researchers in Scotland and Australia have validated those findings in a paper pre-published on Feb. 10, showing that two other aerosol-generating procedures were not as hazardous as talking, heavy breathing or coughing.
Brown said initial supply shortages of PPE led to rationing and steered the best respiratory protection to anesthetists and intensivists like himself. Now that it is known emergency room and nursing home workers are also at extreme risk, he said, he can’t understand why the old guidelines largely stand.
“It was all a big house of cards,” he said. “The foundation was shaky and in my mind it’s all fallen down.”
Asked about the research, a CDC spokesperson said via email: “We are encouraged by the publication of new studies aiming to address this issue and better identify which procedures in healthcare settings may be aerosol generating. As studies accumulate and findings are replicated, CDC will update its list of which procedures are considered [aerosol-generating procedures].”
Cook also found that doctors who perform intubations and work in the ICU were at lower risk than those who worked on general medical floors and encountered patients at earlier stages of the disease.
In Israel, doctors at a children’s hospital documented viral spread from the mother of a 3-year-old patient to six staff members, although everyone was masked and distanced. The mother was pre-symptomatic and the authors said in the Jan. 27 study that the case is possible “evidence of airborne transmission.”
Klompas, of Harvard, made a similar finding after he led an in-depth investigation into a September outbreak among patients and staff at Brigham and Women’s Hospital in Boston.
There, a patient who was tested for covid two days in a row — with negative results — wound up developing the virus and infecting numerous staff members and patients. Among them were two patient care technicians who treated the patient while wearing surgical masks and face shields. Klompas and his team used genome sequencing to connect the sick workers and patients to the same outbreak.
CDC guidelines don’t consider caring for a covid patient in a surgical mask to be a source of “exposure,” so the technicians’ cases and others might have been dismissed as not work-related.
The guidelines’ heavy focus on the hazards of “aerosol-generating” procedures has meant that hospital administrators assumed that those in the ICU got sick at work and those working elsewhere were exposed in the community, said Tyler Kissinger, an organizer with the National Union of Healthcare Workers in Northern California.
“What plays out there is there is this disparity in whose exposures get taken seriously,” he said. “A phlebotomist or environmental services worker or nursing assistant who had patient contact — just wearing a surgical mask and not an N95 — weren’t being treated as having been exposed. They had to keep coming to work.”
Dr. Claire Rezba, an anesthesiologist, has scoured the web and tweeted out the accounts of health care workers who’ve died of covid for nearly a year. Many were workers of color. And fortunately, she said, she’s finding far fewer cases now that many workers have gotten the vaccine.
“I think it’s pretty obvious that we did a very poor job of recommending adequate PPE standards for all health care workers,” she said. “I think we missed the boat.”
California Healthline politics correspondent Samantha Young contributed to this report.
This post was originally published on Latest – Truthout.