TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.
This week’s topics include a comprehensive look at kids’ health in the U.S., remaining life expectancy deficits after COVID, heart risk calculators in different ethnicities, and screening for hep C in the ED.
Program notes:
0:40 AHA risk calculator in various ethnicities
1:40 Works well in all of them
2:40 Women and ethnicities
3:00 Hepatitis C screening in EDs
4:01 Many ethnicities represented
5:01 Identified as having the virus
6:01 Once they tested only 24% were referred
7:01 It was free testing
8:41 78% more likely to die in the U.S.
9:41 Some of these are preventable
10:24 Life expectancy after the pandemic
11:24 Remains almost a year deficit
12:24 Deaths from overdose declining
13:17 End
Transcript:
Elizabeth: What’s life expectancy looking like post-pandemic?
Rick: Trends in children’s health in the United States.
Elizabeth: Should we be screening everybody for hepatitis C in emergency departments?
Rick: And do our cardiovascular risk predictions work across different ethnicities?
Elizabeth: That’s what we’re talking about this week on TT HealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.
Elizabeth: Let’s turn first to Nature Medicine. This is a soft toss for you, and it is the summer, so I think it’s okay to have a soft toss. Looking at cardiovascular risk factors, how good are they when we’re looking at different groups?
Rick: What we’d like to be able to do is take a look at an individual and assess, “What’s their risk of developing cardiovascular disease over the next 10 years?” The original risk score was the Framingham Risk Score. That was further refined in what’s called a Pooled Cohort Equation. Well, the American Heart Association came up with the Predicting Risk of Cardiovascular EVENTs, called the PREVENT equations. They predict not only the aggregate cardiovascular risk, but they also do the individual ones.
The PREVENT risk score looks like it’s pretty good, but it’s never been tested in a multiethnic population. So these investigators used the VA health system, which has over 2 million people of different ethnicities. They used the different PREVENT risk scores to say, “OK, they performed well in a white population, but what about Asian, Native Hawaiian, Black, Hispanic, and whites as well?”
Fortunately, it seems to work very well in all of them. It’s a good discriminator. It does a good job of predicting who’s going to be high-risk and low-risk. It does a much better job than the Pooled Cohort Equation that I previously mentioned because that seems to overestimate. This is what I’ll be using when I take care of patients in my clinic. I’d encourage anybody that wants to know what their cardiovascular risk is, you can go online and plug in the data, and it will give you your 10-year risk.
Elizabeth: The VA cohort, of course, is largely male. So I’d sure like to see some reflection of how this thing behaves in women.
Rick: You’re right. It is largely male. When you have about 2.5 million individuals, and if only 5% or 7% are women, there’s still a large population. Your point is well taken, but it seemed to be a good discriminator.
Elizabeth: But also note that with regard to those numbers, irrespective of the fact that that’s how many women were in there, as we break those down with respect to ethnicity, then they’re going to get diluted even further.
Rick: They are, but you’re starting with a population of about 125,000 to 150,000 people. It’s a pretty good group to start with.
Elizabeth: I want to see more. Sorry, I’m vested in these outcomes for women and then let me also note, particularly for postmenopausal women.
Let’s turn to JAMA and let’s take a look at this notion of hepatitis C screening in emergency departments. And I said, “Should it be universal?” And I would have to get all the way to the bottom of this study and say it sure sounds like it ought to be universal.
They were obviously taking a look at screening individuals who came into the ED for hepatitis C. What they did was look at three different urban emergency departments. Patients were randomly assigned to undergo either non-targeted screening, so all comers were offered this, or targeted screening, where they identified risk factors and said, “Oh, we really ought to screen you.”
Their primary outcome was newly diagnosed HCV [hepatitis C virus] infection and then their secondary outcomes were repeated HCV diagnosis, whether or not the patient agreed to be tested, and then other things, like did they follow up. They had a total of 147,000+ patients who were randomized, a lot of ethnicities represented in all of these populations.
Of this number, about 74,000 underwent non-targeted screening. That resulted in 13.4% of them being tested for the virus. They had 154 new diagnoses. In the cohort that underwent targeted screening, they had just, again, shy of 74,000 patients who underwent this screening; 32% of that were identified to have risk factors and that resulted in 6.3% of these patients being tested for hepatitis C and 115 new HCV diagnoses.
So basically, when we look at yield, what we find is that this non-targeted screening is going to result in more people, actually, first of all, in this study, undergoing testing for HCV screening, and then secondly of actually being identified as having the virus. I find it really curious, and I’d like to hear your comments on this, why so many patients declined screening. And then, of course, the things that are really disconcerting are the fact that so few people, between 15.6% and 17.4%, completed treatment for HCV infection, in spite of the fact that the vast majority of almost 95%+ of folks who do get treated will be cleared of the virus.
Rick: Right now, we have about 4 million people in the United States with hepatitis C; 800,000 of those don’t know they have it. And your point is well taken, is now we have treatment. The recommendation now is that everybody have at least one test. How do we get all those people? And the reason why some people decline, I think, is they don’t realize how prevalent it is. They don’t realize we have medications that can treat it, and they don’t realize what the outcomes are if it’s untreated — that is, developing cirrhosis and liver cancer.
Here’s what was disconcerting to me, Elizabeth, is once they tested and they identified people had hepatitis C, only about 20% or 24% of those individuals got referred on to therapy. We dropped the ball on this particular study.
Elizabeth: Well, definitely it’s dropping the ball with regard to provision of healthcare. I still am stymied by the fact that so many patients declined to be tested. And I would think that they would have received the education a priori about, “Hey, here’s why this is important. There’s lots of occult HCV infection out there. You probably don’t even know you’re infected if you are and we have effective treatment that’s going to take care of this if you do have it.” I’m saying this in less than a minute and I feel sure that they were advised about this in the ED.
Rick: Well, when you go to the emergency department and you have chest pain, or you have abdominal pain, or you’ve had trauma, or you broke your leg, and someone says, “Oh, by the way, we can also send off this blood test.” You’re saying, “Hey, pay attention to what I came in with. Okay? Don’t worry about that.” And I think that’s why many individuals didn’t have it done.
Oh, by the way, it was free. Remember that these individuals don’t have a relationship with a person in the emergency department. While I think it’s important to do non-targeted blood testing, the emergency department is probably not the one where you’re going to get the highest yield.
Elizabeth: You’re right, and also given the chaos that I’ve witnessed many times in the ED, I can understand why that would be low in the list of priorities. So, how would you transition this to try to net more people being tested?
Rick: I think every time there’s a touch point, and the emergency department is just one of the touch points, we need to make sure that every primary care physician is aware of this as well.
Elizabeth: Okay. Staying in JAMA then, are we failing U.S. children with regard to mortality, chronic conditions, obesity?
Rick: If you want to have healthy adults, start with healthy children. It doesn’t guarantee it. But if you start with unhealthy children, there’s a high likelihood that you’re more likely to have unhealthy adults.
There has been some suggestion that child health is declining in the United States. How do you measure that against other high-income nations? [There are] 18 different comparator nations as a part of the Organisation for Economic Co-operation and Development. We can look at them and look at us, and see how we’ve been doing, not only now, but really over the last 15 or 16 years.
They used those comparators. They looked at national surveys. They looked at electronic health records from 10 different pediatric health systems, all populations under the age of 20 years old. We’re talking well over 120 million records we’re looking at.
From 2007 to 2022, infants less than 1 year old were 78% more likely to die in the United States than in the other high-income countries. Individuals 1 to 19 years of age, 80% more likely to die if you’re from the U.S. than from the other high-income countries.
What did they die of? Prematurity, sudden unexpected infant death. And for infants who were 12 months or older, the most likely cause of death was firearm-related incidents. In fact, kids in the United States between the ages of 1 and 19 or 1 to 20 were 15 times more likely to die of firearms than in any other of the high-income countries. Motor vehicle crashes, about 2.5 times more likely to die in the United States. Higher rates of obesity, trouble sleeping, limitations in activity, physical symptoms, depressive symptoms, and loneliness.
Elizabeth: Well, now, I am really struggling to even consider how one begins to address this constellation of things that are pointing so clearly to increasing problems.
Rick: What are the major reasons why our kids are dying? And some of these are preventable. Prematurity in terms of good prenatal health. With regard to firearms, motor vehicles, that’s pretty easy. Talk about depression and loneliness. Look at the root causes of that and also make sure that there are enough mental health providers. And this is particularly problematic in kids who may not have insurance. In many of the high-income countries, kids receive care automatically, but not so in the United States, where as many as 40% may not have access to insurance. If we’re going to have healthy adults, we’ve got to start with healthy kids.
Elizabeth: I couldn’t agree more with that and I think that the very comprehensive nature of this is going to make it a particularly daunting situation to address.
Rick: It is, but it’s also essential.
Elizabeth: So finally, remaining in JAMA, let’s take a look at a corollary, sort of, to this particularly daunting study. This is a research letter and it’s reporting on the failure of life expectancy to fully rebound to pre-pandemic levels.
This is data that’s solely from California, so is this representative of the entire country? What they looked at were death data from 2019 through 2024 — “Let’s look at our life expectancy” — and they calculated that for quartiles based on median income in residential census tracts and for four racial and ethnic groups. Those were Hispanic, non-Hispanic Asian, non-Hispanic Black, and non-Hispanic white.
What they found was that life expectancy in California was increasing slightly in the years preceding the pandemic, but decreased sharply after 2019, got to the bottom in 2021, and then has been recovering thereafter. But there remains a deficit of almost a year of life in 2024 relative to 2019 data. It’s those residents of the lowest-income census tract who experienced the largest losses. The life expectancy gap between those folks who were at that lowest level versus those in the highest level remaining actually right about the same, which is just shy of 6 years.
Why are we having this issue? They identified two causes of death — drug overdoses and cardiovascular disease — as accounting for about 20%+ of this deficit in 2020, almost 50% of the deficit in 2023. I think we need a precise understanding of exactly what’s going on, how representative this data is, and then we need to target some of these things. The death data from overdose deaths we know is declining. This question of cardiovascular disease death is really an interesting one, though.
Rick: The cardiovascular disease may not be terribly surprising. The rate of diabetes is increasing. The rate of obesity is increasing. Some of those, by the way, increased substantially during COVID because of inactivity and social isolation. And then there’s some evidence that COVID itself can contribute to cardiovascular disease in the long term. Very disappointing that, despite all that we know and all the advances we have in medical therapy, we’ve still not incorporated it into much of what we did.
Elizabeth: On that very daunting note, that is a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: And I’m Rick Lange. So y’all listen up and make healthy choices.
