Life-saving Programs Research Articles

Systemic barriers to access pharmaceutical-sponsored patient assistance programs: Implications for health equity and care delivery at safety-net systems.

107 Background: The rising cost of cancer care, driven in large by oncology drugs, has a significant impact on access to care and contributes to disparities. Pharmaceutical-sponsored patient assistance programs (PAPs) are intended to improve access to care; however, vulnerable populations may experience delays, denials, and treatment interruptions due to complexity of the application process and variable qualifying requirements. We present the impact of a pharmacy-run process to facilitate access to PAPs at a safety-net institution. Methods: Parkland Health (PH) is the safety-net system for Dallas County, which has one of the highest uninsured rates in the US. PH provides free health care to uninsured patients below 250% of the federal poverty income level. Hematology-Oncology patients who are prescribed medications with an existing PAP are identified in a work queue within the EHR. A team of licensed pharmacy technicians - Medication Access Technicians (MATs) - screen patients and if eligible, assist in filling and submitting the application, and follow up with PAP sponsors to ensure timely review and approvals. MATs also monitor refills and assist in PAP renewals to prevent interruptions in care. In this study, we used the average wholesale price to quantify the value of the medications provided through PAPs. Data for 10/01/22 through 09/30/23 are presented here. Results: During the study period, MATs enrolled 548 uninsured patients (90% Hispanic/Black) in PAPs for 38 unique clinic-administered drugs, with an estimated value of 45.2 million (M), averaging 78,853 per patient. The highest value and most common clinic-administered PAP drugs were pembrolizumab (96 patients, $8 M) and rituximab (159 patients, $5 M), respectively. For oral agents, MATs enrolled 77 uninsured patients (84% Hispanic/Black) in PAPs for 20 unique medications with an estimated value of 8.8 M, averaging 114,711 per patient. Dasatinib was both the most common and highest value PAP oral drug, with 24 patients and an estimated value of 3.6 M. Of the 38 PAPs for clinic-administered drugs, 25 did not include replacement for dispensed medications. Legal US residence was required by 7 PAPs. The institutional investment by PH (MAT salaries) is estimated at 620,000 annually. Conclusions: A dedicated team of MATs at PH facilitated access to care through PAP enrollments, reduced treatment interruptions by renewing applications, and reduced institutional drug expenditure, allowing investment in other care delivery initiatives. PAPs are philanthropic by nature and requirements such as legal residence and no-replacement for dispensed medications may negatively impact specific segments of our communities, or result in treatment delays. Advocacy by professional organization and patient groups is warranted to expand access to these potentially life-saving programs.

Playing the Cards You’re Dealt: Implementing Feline Lifesaving Programs and Practices Despite Restrictive Ordinance Provisions

Trap-neuter-return (TNR) programs enjoy strong public support in the U.S. These programs have been shown to successfully increase live release rates and decrease euthanasia rates of cats in animal shelters. However, local laws can impede the implementation of TNR programs. In cooperation with St. Tammany Parish Department of Animal Services, this community case study describes the results of various programs and practices implemented to increase feline lifesaving despite restrictive ordinance provisions, as well as those associated with subsequent ordinance revisions. The St. Tammany Parish Department of Animal Services provided detailed data for the period of January 2015 through December 2023 (e.g. intake, live outcomes, and euthanasia) and information regarding various programs and practices related to feline lifesaving. The data was then examined for general trends. In addition, St. Tammany Parish’s Ordinance No. 21-4618, which includes both the original provisions and revised provisions, was examined for those likely to affect the shelter’s feline admissions and outcomes. The data suggests that the programs and practices implemented were associated with considerable increases in live outcomes for cats (from 26.4 to 95.4%) and corresponding reductions in euthanasia rates (from 71.1 to 3.0%). The adoption of revised ordinance provisions to reduce barriers for community cat management was associated with relatively little change; however, these provisions were generally positive in nature, removing an apparent requirement to impound at-large cats and facilitating the operation of a community cat program (CCP). This community case study illustrates the potential for animal shelters to substantially improve feline lifesaving regardless of possible legal impediments.

Correlates of Staff Acceptability of a Novel Telemedicine-Delivered Medications for Opioid Use Disorder Program in a Rural Detention Center.

Opioid overdose death is significantly increased immediately following incarceration. Evidence-based medications are underutilized in rural jails and detention centers. We have reported our efforts to address this gap through telemedicine-based medications for opioid use disorder treatment (tele-MOUD) for incarcerated patients. Staff acceptance and perceptions are critically important factors in the assurance of program validation. We assessed tele-MOUD acceptability and perceptions of effectiveness and stigma in one detention center. Overall, we found that jail staff's general acceptability of the program was rather low, as was perceived effectiveness of MOUD, while stigmatizing beliefs were present. Furthermore, tele-MOUD acceptability was positively correlated with perceptions of MOUD effectiveness and negatively correlated with stigmatizing notions of MOUD (p's < 0.001). Findings suggest the need for educational interventions. Future research investigating the potential moderating effects of training on staff acceptability of jail-based tele-MOUD will support the implementation and sustainability of these life-saving programs.

Clinician Views of Proactive Tobacco Treatment Programs: A Qualitative Evaluation.

Proactive tobacco treatment programs are an evidence-based strategy to recruit patients who smoke to make supported quit attempts. However, such programs are rarely implemented. We performed a qualitative assessment of clinicians to inform the creation of a proactive outreach program for patients with chronic obstructive pulmonary disease (COPD) who smoke. Informed by the Consolidated Framework for Implementation Research, we conducted semi-structured interviews to assess clinician views of proactive outreach, including barriers, program structure, and the use of technology. Clinicians included primary and specialty care physicians, nurses and advanced practice providers, pharmacists, respiratory therapists, a psychologist, and relevant members of leadership. Interviews were transcribed and analyzed using directed content analysis. Clinicians in all roles identified that proactive outreach could be an effective use of resources to help patients with COPD who smoke quit with several advantages over the current state. Clinicians disagreed on the priority population (e.g., younger patients, sicker patients), and to some extent on whether proactive outreach is a clinical priority. Though they supported that technology could be part of the outreach program, most advocated for multiple avenues (phone calls, drop-in clinic, texting), as these patients were perceived to be low technology utilizers. The primary implementation barriers were competing priorities and cost, as well as unclear billing and staffing models. Clinicians support proactive outreach for patients with COPD, but the optimal way to structure, staff, and fund such programs remains unclear. Health systems should leverage implementation strategies to speed uptake of these potentially life-saving programs.

Supporting patient access to pharmaceutical-sponsored assistance programs: Implications for health equity and care delivery at safety-net systems.

e13724 Background: The ever-rising cost of cancer care, driven in large by oncology drugs, has a significant impact on access to care and contributes to disparities. Pharmaceutical-sponsored patient assistance programs (PAPs) are intended to improve access to care; however, vulnerable populations may experience delays, denials, and treatment interruptions due to complexity of the application process and variable qualifying requirements. We present the impact of a pharmacy-run process to facilitate access to PAPs at a safety-net institution. Methods: Parkland Health (PH) is the safety-net system for Dallas County, which has one of the highest uninsured rates in the US. PH provides free health care to uninsured patients below 250% of the federal poverty income level. Hematology-Oncology patients who are prescribed medications with an existing PAP are identified in a work queue within the EHR. A team of licensed pharmacy technicians - Medication Access Technicians (MATs) - screen patients and if eligible, assist in filling and submitting the application, and follow up with PAP sponsors to ensure timely review and approvals. MATs also monitor refills and assist in PAP renewals to prevent interruptions in care. In this study, we used the average wholesale price to quantify the value of the medications provided through PAPs. Data for 10/01/22 through 09/30/23 are presented here. Results: During the study period, MATs enrolled 548 uninsured patients (90% Hispanic/Black) in PAPs for 38 unique clinic-administered drugs, with an estimated value of $45.2 million (M), averaging $78,853 per patient. The highest value and most common clinic-administered PAP drugs were pembrolizumab (96 patients, $8 M) and rituximab (159 patients, $5 M), respectively. For oral agents, MATs enrolled 77 uninsured patients (84% Hispanic/Black) in PAPs for 20 unique medications with an estimated value of $8.8 M, averaging $114,711 per patient. Dasatinib was both the most common and highest value PAP oral drug, with 24 patients and an estimated value of $3.6 M. Of the 38 PAPs for clinic-administered drugs, 25 did not include replacement for dispensed medications. Legal US residence was required by 7 PAPs. The institutional investment by PH (MAT salaries) is estimated at $620,000 annually. Conclusions: A dedicated team of MATs at PH facilitated access to care through PAP enrollments, reduced treatment interruptions by renewing applications, and reduced institutional drug expenditure, allowing investment in other care delivery initiatives. PAPs are philanthropic by nature and requirements such as legal residence and no-replacement for dispensed medications may negatively impact specific segments of our communities, or result in treatment delays. Advocacy by professional organization and patient groups is warranted to expand access to these potentially life-saving programs.

Nevada seeks to tackle teen suicide with lifesaving program

The statistics are grim. Death by suicide ranked number 12 on the leading cause of death within the United States in 2020. And in Nevada, there has been an increase in suicide for youth — dropping from age 12 to just 8 years old. The stats are no doubt the impetus behind “Hope Means Nevada,” a community‐based initiative offering year‐round 24/7 support for individuals and their families across the state.

Bush Nippers: Evaluating the effectiveness of the Nipper education program in regional inland Victoria, Australia.

Internationally, inland waterways are identified as leading locations for drowning. 'Nippers' programs provide coastal lifesaving and water safety knowledge and skills to children aged 5-14years in Australia. However, a 49% increase in Victorian inland waterway drowning compared with the 10-year average, necessitated adapting the Nippers water safety program to inland regions: Bush Nippers. Overall, 105 participants from two age groups (under 9 and under 12) were involved across three Bush Nippers programs delivered at river and/or pool locations in regional Victoria, Australia. Surveys and observations assessed participants' water safety knowledge and competencies, and used alongside interviews to obtain program feedback from parents, instructors and communities. Costs were compared to other aquatic programs to determine feasibility of replicating the program. Significant increases in knowledge from pre to immediate posttest were recorded (P<.05) and water competencies were high posttest. Communities were grateful for the regional program delivery and understood the necessity of learning lifesaving skills, particularly in open water environments. Costs were akin to other similar programs indicating program replicability and enhancing likelihood of uptake. Bush Nippers increased water safety knowledge in children and was well received by the community. Wider uptake of the program is encouraged to diversify aquatic education for regional Victorian children. SO WHAT?: Given the high regard and demand for the program, and importance of learning lifesaving skills, provision of a scalable lifesaving program in inland regions may address the drowning trend and improve aquatic participation.

Bridging institutional logics: Implementing naloxone distribution for people exiting jail in three California counties

Drug overdose is the leading cause of death among formerly incarcerated people. Distribution of the opioid overdose medication naloxone to people who use drugs reduces overdose mortality, and officials in many jurisdictions are now considering or implementing programs to offer naloxone to people exiting jails and prisons. The principles and practices of harm reduction programs such as naloxone distribution conflict with those of penal institutions, raising the question of how organizations based on opposing institutional logics can collaborate on lifesaving programs. Using in-depth interviews and observations conducted over four years with 34 penal, medical, public health, and harm reduction practitioners, we introduce and conceptualize two organizational features to explain why this therapeutic intervention was implemented in local jails in two of three California counties. First, interorganizational bridges between harm reduction, medical, and penal organizations facilitated mutual understanding and ongoing collaboration among administrators and frontline workers in different agencies. Second, respected and influential champions within public health and penal organizations put jail-based naloxone distribution on the local agenda and cultivated support among key officials. Our findings offer guidance for future studies of institutional logics and policy responses to the overdose crisis.

Measurement of Life-saving Training Impacts on Health Care Professionals Retention and Competence: and Patients' Outcomes

This review focused on exploring the significance of CPR impacts on health care professionals' retention abilities and the possibilities of transferring the learning to boost their competency while applying CPR. Considering life-saving training as the most prioritized healthcare professional needs signifies the need to evaluate the actual training impacts on the patients' outcomes. The life-saving training impacts evaluation relies on knowledge retention and the ability to show an adequate competency level while practicing in the clinical field. However, the training specialists' and education experts' failure to link the life-saving training to patients' outcomes would lead only to cyclical and traditional training attempts. The paper reviews the approaches for increasing the direct patients' impacts from CPR. It is an instrumental review to magnify the required training and instruction potentials to maximize learning transfer. Many sections in the review explored similar deficits that we would face in the life-saving modules due to focusing on delivery and instruction without aiming at the outcomes and learning transfer to the patients. This review paper provides an evidence-based approach to explore the specific gaps in training life-saving training programs and explore structured mechanisms for providing life-saving training in hospital settings. Keywords : training impacts, training retention, competence, patients' outcomes DOI: 10.7176/JEP/12-10-03 Publication date: April 30 th 2021

Development of a novel mobile application, HBB Prompt, with human factors and user-centred design for Helping Babies Breathe skills retention in Uganda

BackgroundHelping Babies Breathe (HBB) is a life-saving program that has helped reduce neonatal morbidity and mortality, but knowledge and skills retention after training remains a significant challenge for sustainability of impact. User-centred design (UCD) can be used to develop solutions to target knowledge and skills maintenance.MethodsWe applied a process of UCD beginning with understanding the facilitators of, and barriers to, learning and retaining HBB knowledge and skills. HBB Master Trainers and frontline HBB providers participated in a series of focus group discussions (FGDs) to uncover the processes of skills acquisition and maintenance to develop a mobile application called “HBB Prompt”. Themes derived from each FGD were identified and implications for development of the HBB Prompt app were explored, including feasibility of incorporating strategies into the format of an app. Data analysis took place after each iteration in Phase 1 to incorporate feedback and improve subsequent versions of HBB Prompt.ResultsSix HBB trainers and seven frontline HBB providers participated in a series of FGDs in Phase 1 of this study. Common themes included lack of motivation to practise, improving confidence in ventilation skills, ability to achieve the Golden Minute, fear of forgetting knowledge or skills, importance of feedback, and peer-to-peer learning. Themes identified that were not feasible to address pertained to health system challenges. Feedback about HBB Prompt was generally positive. Based on initial and iterative feedback, HBB Prompt was created with four primary functions: Training Mode, Simulation Mode, Quizzes, and Dashboard/Scoreboard.ConclusionsDeveloping HBB Prompt with UCD to help improve knowledge and skills retention was feasible and revealed key concepts, including drivers for successes and challenges faced for learning and maintaining HBB skills. HBB Prompt will be piloted in Phase 2 of this study, where knowledge and skills retention after HBB training will be compared between an intervention group with HBB Prompt and a control group without the app.Trial registration Clinicaltrials.gov (NCT03577054). Retrospectively registered July 5, 2018, https://clinicaltrials.gov/ct2/show/study/NCT03577054.

COVID-19 in Conflict: The devastating impact of withdrawing humanitarian support on universal health coverage in Yemen

The authors warn that, in the context of Yemen, the closure of humanitarian lifesaving programmes and shifting support toward health security, i.e. to support COVID-19 response, at the expense of primary health care support, will undermine existing health system strengthening efforts, worsen the humanitarian crisis and will accentuate the impact of COVID-19. The authors urge the international community and the Government of Yemen to carefully consider a more comprehensive approach to support Yemen’s COVID-19 response while maintaining, and strengthening, essential public health services.

Non-evidence-based beliefs increase inequalities in the provision of infant- and family-centred neonatal care.

To identify barriers that might explain why healthcare staff struggle to implement infant- and family-centred developmental care programmes in two neonatal intensive care units in Mexico. Ethnographic fieldwork over the course of 10months examined interactions among healthcare professionals, parents and babies in two Mexican publicly funded hospitals. Data are drawn from interviews with 29 parents and 34 healthcare professionals and participant observations in the hospitals' neonatal units. Healthcare professionals believed they acted in babies' best interests by excluding parents from the neonatal unit. Professional frustration with working conditions seemed to be increased by the belief that parents were ignorant and unhygienic. Parents were perceived as a source of infection; in contrast, healthcare professionals failed to see themselves as a possible source of cross-contamination. Beliefs and biases increase health inequalities when evidenced-based measures to prevent cross-infection and potentially life-saving programmes, such as kangaroo mother care and breastfeeding, are not implemented. It is imperative to develop context-appropriate education and practice guidelines to implement basic programmes.

A Study on the Development and Effectiveness of Basic Lifesaving training Program for Pre-service Teachers

A Study on the Development and Effectiveness of Basic Lifesaving training Program for Pre-service Teachers

Prenatal diagnosis in rare bleeding disorders-An unresolved issue?

Intracranial haemorrhage (ICH) is the most dreadful complication, and the main cause of death among patients with rare bleeding disorders (RBD) and prenatal diagnosis (PND) is a preventative lifesaving program. A total of 39 PNDs were reported in the literature through a search on PubMed, EMBASE, SCOPUS and Web of Science databases, most often for congenital factor (F) XIII and FVII deficiencies and rarely in FX, FV deficiencies and afibrinogenemia. The main cause to request a PND is ICH and related morbidity and mortality. Different molecular methods including direct sequencing and linkage analysis as well as polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) for a specific mutation are the most common used methods for PND, while factor assay and combination of molecular and factor assay also were used. In this research, 7 severely affected foetuses were identified during PND including 3 foetuses with FXIII deficiency, 3 with FVII deficiency and 1 with FX deficiency. Out of these 7 cases, intrauterine ICH occurred in 1 case with FXIII deficiency, 1 was electively aborted and 1 case with severe FVII deficiency received intrauterine factor transfusion. Postdelivery ICH was reported for 1 patient with severe FVII deficiency within the first month of life. All other pregnancies were uneventful.

When Children Play: The Story of Right To Play by G. McMurchy-Barber

McMurchy-Barber, Gina. When Children Play: The Story of Right To Play. Fitzhenry and Whiteside, 2013. Right To Play is a humanitarian organization whose beginnings stem from the Winter Olympics held in Lillehammer, Norway in 1994. While preparing for this event, the Lillehammer Olympic Organizing Committee became concerned that while favoured youth in the developed nations were training for competition, children in Eastern Europe, Asia, and Africa were perishing in war and famine. Their concern led, in 1992, to the Olympic Aid initiative through which Norwegian athletes—Olympians of past years—raised funds for such organizations as the Red Cross and Save the Children. Following the events in Lillehammer, Olympic Aid’s initiatives were carried on in partnership with UNICEF and the World Health Organization. Finally, in 2000, the initiative evolved into Right To Play (RTP). The emblem of this organization is a red soccer ball on which the words “Look After Yourself: Look After One Another,” are emblazoned. RTP’s motto is profound: “When Children Play, the World Wins.”McMurchy-Barber’s book details the efforts of the “Athlete Ambassadors” who, from the time of RTP’s beginnings to the present day, have championed the right of children to be fed, to be healthy, and to play. These “Ambassadors” have included both elite athletes with world-wide acclaim (e.g., Canadians Wayne Gretzky and Clara Hughes) and local enthusiasts who rise to the cause from the communities being served. Because of its wide based support, RTP is able to distribute not only its red soccer balls (a luxury indeed for children who have nothing with which to play) but also life-saving food supplies and immunization programs. The author details the team-building approaches of the Ambassadors, as well as the hopefulness their participation brings to the lives of the desperate.It is a joy to read McMurchy’s book. Her writing style finds that wonderful middle ground between grammatical perfection and conversational ease. She knows to whom she speaks: children in the upper elementary grades. The information she provides, as well as the examples she chooses, would engage the attention of this age group. Credit goes to the RTP organization for providing the realistic and heart-warming photographs accompanying the text.Highly Recommended: 4 out of 4 starsReviewer: Leslie AitkenLeslie Aitken’s long career in librarianship included selection of children’s literature for school, public, special and academic libraries. She is a former Curriculum Librarian of the University of Alberta.

Guest Editorial: Safety: It’s All About Us - The Human Factors Behind the Statistics

Guest editorial The International Association of Oil &amp; Gas Producers (IOGP) Life-Saving Rules are now considered industry good practice. Each rule has a simple icon and guidance to explain why it is important and on which aspects workers and supervisors should focus. The rules are intended to supplement and support existing company management systems, programs, and policies, but are directed at the actions individual front-line workers and supervisors need to undertake to keep themselves and their workmates safe. Each rule is also linked to controls and barriers which, if used properly, can prevent or avoid fatal incidents. Shell provides an example of how successful and sustainable the implementation of a robust set of Life-Saving Rules can be. The company has seen a 75% reduction in fatalities and a 35% reduction in lost-time injuries since its rules were introduced in 2009. Analysis of 1,484 fatal incidents reported by IOGP member companies over the past 20 years indicates that adopting, conforming to, and enforcing the simple IOGP rules may well have prevented many of these fatalities. While IOGP member companies recognize the value of providing clear and consistent guidelines, efforts to re-energize the Life-Saving Rules program were triggered in 2015, when IOGP reported an increase in industry-related fatalities and fatal incidents, reversing a multiyear trend. Research showed that more than 70% of fatalities in that year could have been attributed to the industry failing to follow IOGP’s rules. Our newly published data for 2016 show only a slight improvement: 58% of the fatal incidents reported could have been avoided by following the rules. This is despite the fact that the causal factors of these incidents have remained broadly unchanged for many years. These include failures in training, competence, hazard identification, risk assessment, inattention, supervision, and procedures (Figs. 1a, 1b). Some may want to pin these issues on squeezed margins, job uncertainty, or doing the same (or more) with less. However, the data do not support that premise, and the hard truth is that commitment to follow the Life-Saving Rules should not be affected or rationalized by market conditions. IOGP data show that there are no “new” accidents; only failures to learn or to implement learnings from previous incidents. The rules have been proven to save lives and the real challenge lies in finding out why these rules are not consistently followed.

Reviewing harm reduction for people who inject drugs in Asia: the necessity for growth.

BackgroundThere is an estimate of three to five million people who inject drugs living in Asia. Unsafe injecting drug use is a major driver of both the HIV and hepatitis C (HCV) epidemic in this region, and an increase in incidence among people who inject drugs continues. Although harm reduction is becoming increasingly accepted, a largely punitive policy remains firmly in place, undermining access to life-saving programmes. The aim of this study is to present an overview of key findings on harm reduction in Asia based on data collected for the Global State of Harm Reduction 2014.MethodsA review of international scientific and grey literature was undertaken between May and September 2014, including reports from multilateral agencies and international non-governmental organisations. A qualitative survey comprising open-ended questions was also administered to civil society, harm reduction networks, and organisations of people who use drugs to obtain national and regional information on key developments in harm reduction. Expert consultation from academics and key thinkers on HIV, drug use, and harm reduction was used to verify findings.ResultsIn 2014, 17 countries in Asia provide needle and syringe programmes (NSP) provision and 15 opioid substitution therapy (OST). It is estimated that between 60 and 90 % of people who use drugs in Asia have HCV; however, treatment still remains out of reach due to cost barriers. TB testing and treatment services are yet to be established for key populations, yet nearly 15 % of the global burden of new cases of HIV-TB co-infection are attributed to southeast Asia. Eighteen percent of the total number of people living with HIV eligible for antiretroviral treatment (ART) accessed treatment. Only Malaysia and Indonesia provide OST in prison, with no NSP provision in prisons in the region.ConclusionTo reduce HIV and viral hepatitis risk among people who inject drugs, there is a necessity to significantly increase harm reduction service provision in Asia. Although there has been progress, work still needs to be done to ensure an appropriate and enabling environment. At present, people who inject drugs are extremely difficult to reach; structural and legal barriers to services must be reduced, integrated holistic services introduced, and further research undertaken.Electronic supplementary materialThe online version of this article (doi:10.1186/s12954-015-0066-x) contains supplementary material, which is available to authorized users.

Handling postpartum haemorrhage- obstetrics between tradition and modernity in post-war Sierra Leone.

How traditional birth attendants (TBAs) in post-war Sierra Leone explain, handle and prevent postpartum haemorrhage (PPH) and their potential role in a better management of PPH to reduce maternal mortality in this low resource setting. Semi-quantitative interviews about knowledge and measures in PPH and participant observation with 140 Sierra Leonean birth attendants, divided in three groups: (A) TBAs who never attended any official training course (n = 82); (B) TBAs who attended at least one official training course (n = 48); and (C) officially trained birth attendants (n = 10). There are several observable gaps in the knowledge of TBAs about PPH compared to modern obstetrics, however similar procedures exist. Herbal medicine is applied; metaphysical convictions about PPH remain present. Training courses show an impact. Officially trained birth attendants demonstrate knowledge deficiencies and lack resources and infrastructure to manage PPH adequately. Morbidity and mortality of PPH in Sierra Leone is related to several factors and not solely to the ignorance of TBAs. TBAs still play an important role for many women there. Hence improvement of the formal health sector should be combined with life-saving programmes integrating TBAs in the care for the pregnant, delivering and breastfeeding mothers.

Bending the value curve.

In health care policy circles, “bending the cost curve down” may qualify as the phrase of the decade. More than 1 million web search references are testament to its widespread use, intended to express a focus on reducing health care costs. Yet it should not surprise anyone familiar with technocratic vocabulary that there is no clear agreement on what the phrase means.1 Nonetheless, with health care spending nearing one-fifth of the nation’s gross domestic product,2 the nationwide clamor to “bend the cost curve down” is understandable. In this commentary, however, we discuss the shortfalls of focusing on costs alone and instead propose a national commitment to “bending the value curve up.” Although finding ways to control health care spending is certainly important, focusing on cost alone is neither sufficient nor appropriate. Calling out costs in isolation may be disconcerting to many stakeholders, including those whose health care services or livelihoods rely on this important sector of the economy. For example, patients might associate cutting costs with decreased access or hastily provided care, and clinicians may fear lower salaries or undue administrative pressures. Moreover, slicing away at high-quality and lifesaving programs for the poor, the young, the disabled, or the elderly or increasing the financial burden for disadvantaged populations is short-sighted and unfair.3,4 Beyond this, focusing on cost alone ignores the benefits to life and well-being that result from high-quality health care spending, even if it is associated with a high price tag. Rather than simply asking whether we are spending too much, we should also ask whether we are achieving the kind of care experiences and outcomes we would expect for the price we are paying. Value is the quality …

Schwartz et al. Respond

As reported in our recent article, which found an association between expansion of methadone and buprenorphine treatment and the reduction in heroin overdose deaths in Baltimore, Maryland, between 1995 and 2009, the distribution of the opioid antagonist naloxone is one of a number of public health strategies being employed in the United States and United Kingdom (among other countries) to reduce opioid overdose deaths.1–4 From 2004 through 2009, the office of the Baltimore City Health Commissioner led an overdose prevention education and naloxone distribution (OPEND) program (J. M. S served as the Health Commissioner during part of that period). The OPEND program was initially funded by a foundation’s Drug Addiction Treatment Program (led by R. P. S.), and was inspired by the Chicago Recovery Alliance’s pioneering overdose prevention program. The program taught drug-addicted individuals and their significant others to identify the symptoms of overdose, to call 911, to provide rescue breathing, and, if available, to inject naloxone while waiting for an ambulance. It is likely that some of the decrease in opioid overdose deaths since the OPEND program was initiated in 2004 was the result of this program’s operation. As noted in our report and in the letter by Sherman et al., approximately 200 to 300 naloxone vials were distributed per year—a relatively modest number. However, Sherman et al. rightly point out that a much larger number of individuals were trained to identify and respond to overdose symptoms, despite not having access to naloxone. We commend the Baltimore City Health Department for having sustained and expanded this life-saving program over the past decade. We wholeheartedly agree with Sherman et al. that expanded access to pharmacotherapy for opioid use disorders (in the community and in jails) and to programs like OPEND should play an important role in comprehensive efforts to reduce mortality from opioid overdoses.