Oral Health, Frailty, and Death; Helping Patients With Prescription Drug Prices

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 fans and core body temperature, strategies to help patients with prescription drug prices, hearing loss and Parkinson’s, and oral health, frailty and death.

Program notes:

0:45 Oral health and other health outcomes

1:45 22,000 participants

2:45 Cancer, cognitive dysfunction related

3:20 Electric fans and core temperature in older adults

4:20 Aging population and climate change

5:18 Hearing loss and Parkinson’s disease

6:18 Categorize severity of hearing loss

7:20 Mechanism for hearing and Parkinson’s disease?

8:21 Current strategies to help with high prescription drug costs

9:25 Major barrier to optimal medical management

10:21 Artificially high prices for generics

11:25 Many patients don’t know about

12:32 End

Transcript:

Elizabeth: Are electric fans any help when older people are in excessive heat?

Rick: Are people with hearing loss at an increased risk of Parkinson’s disease?

Elizabeth: How are we currently helping patients navigate high prescription drug costs?

Rick: And chewing on healthcare.

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, 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: All right. We’re going right to The Lancet, chewing on healthcare or oral health and disability. Go for it.

Rick: Elizabeth, many of our listeners might be surprised to know that oral diseases affect more than 3.5 billion people — that’s billion with a B — worldwide and it’s often been neglected in clinical practice. The World Health Organization has actually set a target of achieving universal health coverage for oral health across its member states by 2030. They call it the 8020 Campaign, for individuals to maintain 20 or more teeth until at least 80 years of age, and they have the concept of what’s called “oral frailty.”

What this study did was it looked at the effects of oral health on functional disability and morbidity in older adults in Japan. They have universal healthcare, so they are able to look at oral health, and also look at functional disability and mortality as well. They looked at all the individuals over the age of 75 who had at least one oral health checkup and they looked at 13 different aspects of their oral health status, like the number of teeth that they have, how well they chew, and the number of decayed teeth.

They had almost 22,000 individuals. There was a significant increased risk of having functional disability associated with all 13 of these different oral health issues. Which one ended up being the most important is really “How well did you chew?” Eleven of these different oral health issues were associated with an increased risk of mortality.

Elizabeth: It’s pretty remarkable, isn’t it? It’s one of those things that’s always struck me as if we could divide the body up and say, “Okay. You’ve got a mouth,” and then that’s the purview of the dentist, and all the rest of your body, except for your feet and your eyes, will go into another specialty or group of specialists. It’s really rather absurd. We have known, for example, for a long time that a lot of the oral flora can be related to atherosclerosis ultimately.

Rick: That’s right. I mean, bad oral hygiene contributes to increased inflammation, activation of the immune system, and not only cardiovascular disease, but poorer oral health is associated with increased risk of hypertension, diabetes, cancer, and cognitive dysfunction. Addressing oral health worldwide could potentially have a significant impact on overall health and mortality.

Elizabeth: Even if we just limit our discussion to here domestically, frequently people don’t have dental insurance or what they do have is really pretty poor at covering the cost of receiving that care, even when it’s prophylaxis.

Rick: Elizabeth, that’s a good point because our Medicare insurance covers a lot of preventive medicine things, but it doesn’t cover oral hygiene. If we’re going to address healthcare in its entirety, we ought to receive dental insurance as well.

Elizabeth: Let’s turn to JAMA. This is a research letter, since we’re talking about older folks and populations, and emerging problems. This is a pretty small study that is looking at the effect of electric fans on body core temperature in older adults who are exposed to extreme indoor heat. Before we started to record, you opined that in fact there really wasn’t much to this study. In fact, it is a very simple study really just saying, “If we put you in front of a fan and this fan has variable speeds, can we cool down your core body temperature?”

They were not able to reduce the core body temperature using an electric fan. I said, “Hey, I think this is important” because I think we’re about to see the impact of two different trends that are absolutely underway. One of them, of course, is climate change — and a lot more extreme heat events that we have seen domestically this year; I expect that we’re going to be seeing a lot more of that — and the aging of the population, where we see the Baby Boomers all moving into that 65+ age range. Older people sweat less and are more susceptible to the impact of heat. I think this is a clarion call to public health officials that we need to consider other strategies for this.

Rick: This study was conducted in Canada, so a shoutout to our friend Tom, who has been a faithful listener for almost the 20 years we have been reporting. Here is the interesting thing. As you mentioned, when it’s hot outside — I live in the Southwest and it typically gets over 100 degrees — and if people don’t have air conditioning, they say, “Put a fan on.”

The interesting thing about this study, as you mentioned, is it doesn’t reduce core temperature, but it made people feel like they were cooler. What it’s doing is it’s blowing the sweat off so you may not feel as hot, but it’s really not being effective in lowering your core temperature. That’s really the key thing, try to prevent heat exhaustion in these individuals.

Elizabeth: A note to public health officials: we probably need to be considering this sooner rather than later.

Rick: Yep. Elizabeth, let’s turn to JAMA Neurology next. Do individuals with hearing loss have an increased risk of Parkinson’s disease? We’ve reported previously that individuals with hearing loss are more likely to have cognitive dysfunction if they allow that hearing loss to continue and they don’t use hearing aids. Parkinson’s disease is a little bit different, but it does carry some key similarities. One is it’s a neurodegenerative disease. It is associated with an increased risk of both social isolation and it appears — at least with overall dementia and Alzheimer’s dementia — treating the underlying hearing loss can actually decrease the ongoing cognitive dysfunction in some way that it decreases the neurodegeneration.

To decide whether there was an association of hearing loss with incident Parkinson’s disease in U.S. veterans, these investigators looked at over 7.3 million veterans who had an audiogram. These veterans are mostly male. The average age is about 67. They asked a simple question: “Do you have normal hearing or do you have any type of hearing loss at all?”

They divided that hearing loss by mild, moderate, moderate to severe, or severe to profound. Then over the course of the follow-up, they asked, “Do they develop Parkinson’s disease?” If there is any hearing loss at all, it increases the risk of Parkinson’s disease; it increases the risk by about 26%. To show that this isn’t just a spurious finding, there is a dose-response curve. The more profound your hearing loss, the more likely they are to have Parkinson’s disease.

If you provided these individuals hearing aids, would that in fact prevent or delay the development of Parkinson’s disease? That’s exactly what happened, because some of these veterans did get hearing aids soon after they were diagnosed with having hearing loss. When they did that, it decreased the risk of Parkinson’s disease. It does appear to be associated with the hearing loss, there is a dose-response curve, and providing hearing aids to those individuals early on in the course can help mitigate the development of Parkinson’s disease.

Elizabeth: Clearly, we have seen that there are beneficial impacts of providing folks with hearing aids when they have hearing loss, including on the development of dementia ultimately. I’m wondering about a mechanism here whereby Parkinson’s disease risk would be ameliorated by correcting somebody’s hearing.

Rick: Yeah. Unfortunately, all we can do is hypothesize. There is nothing in this particular study that provides any insight into that right now. There are several possible explanations. Again, we know that individuals that have hearing loss end up with ongoing neurodegeneration. There is a direct association, again, not just in Parkinson’s, but in Alzheimer’s and Alzheimer’s-related dementias as well. It may be that just stimulation and along specific pathways may affect ongoing cognitive dysfunction.

We do know that hearing loss acts indirectly by limiting social engagement. It can aggravate depression and general functional decline. Just making people more socially engaged and having less depression can actually affect their development of cognitive dysfunction. But in essence, yes, it’s a great question, Elizabeth, and now we need to look at the mechanism.

Elizabeth: Indeed, we’ll be looking for that one.

Finally, then let’s turn to JAMA and this is a special communication that’s looking at currently employed strategies to help patients navigate high prescription drug costs. What they look at are the benefits and limitations of seven separate strategies that are used right now to help patient populations avoid paying ferocious amounts of money for their prescription drugs.

I’m going to name them. These are co-payment cards, patient assistance programs, pharmacy coupons, direct-to-consumer pharmacies, public assistance programs, international online pharmacies, and real-time prescription benefit tools. They take a look at this in all kinds of different scenarios and they also provide a schematic that helps clinicians navigate this and determine which patients would be appropriate, or most appropriate, for different strategies to help them to mitigate some of these costs of prescription drugs.

They start out by noting, of course, that in the U.S. high prescription drug costs are a major barrier to optimal treatment of many health conditions with 3 in 10 adults struggling to afford their medications. Those rates of, “Hey, I can’t afford this,” are even higher among patients with multiple chronic conditions, low socioeconomic status, and those who are from ethnic groups such as Blacks or Latinos. They finally say cost-related medication nonadherence, of course, is associated with worse clinical outcomes.

This is clearly such a big problem. One of the major reasons that we have it is because we say to pharma, “Hey, you develop a new drug. We’re going to give you a patent and you get to just go ahead and charge all kinds of money for it for a pretty prolonged period of time.” Then when the generics are finally able to be formulated and put on the market, then they also have ways to artificially maintain the price of those. I’m going to specifically finger one of my least favorite players in this realm, which is pharmacy benefits managers. So we have got a problem. We’ve known about this for a long time.

Clinicians, among all the things that we’re asking them to do, we’re also asking them to navigate this on the part of specific patients who have unique barriers to their ability to pay for this. I’m going to refer listeners to this article so that they can see all of the different confounders and those things that would make a patient eligible for one strategy over another. I’m ultimately going to once again point to public health officials and say, “Folks, we really need to figure this out.”

Rick: Yep, and Elizabeth it’s complicated. Many patients aren’t aware of the programs that you mentioned. I think that the schematic is helpful because it shows which ones apply to generic drugs or which ones apply to brand-name drugs. Some of these the physician applies for. Some of them the patient applies for.

On the one hand, this is a very enlightening article and very pertinent. On the other hand, it highlights the fact that it’s not as simple as we’d like for it to be.

Elizabeth: Not even close. The one glimmer of light that I like in here is real-time prescription benefit tools because this gives the clinician the information at the time of prescribing by linking electronic health records with patients’ prescription benefit information. That, to me, seems like a fix for being able to navigate this maze.

Rick: I would agree with you. It seems like you ought to be able to do that pretty easily. But as a physician who still provides care to patients in the clinic, I can tell you it depends upon making sure you have the insurance information right and those change from when you see a patient from one month to the next. You have to understand what the benefits programs are and they change as well. Navigating all these things, although the computer makes it easier, it still ain’t easy enough yet.

Elizabeth: On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.

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