Transcranial Stimulation for ASD; Hospital Consultants Worth the Money?

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 Texas Tech Health El Paso, look at the top medical stories of the week.

This week’s topics include outcomes after consultant work in nonprofit hospitals, use of GLP-1s in alcohol use disorder (AUD), a model for predicting benefit from weight loss medicines, and transcranial stimulation for autism spectrum disorder (ASD).

Program notes:

0:40 Transcranial stimulation for ASD

1:40 Used evoked potential and quick pulses

2:41 Motor cortex associated with speech and language

3:27 A model for benefits from GLP-1 use

4:27 Discern who would be most likely to develop obesity complications

5:27 Target to those more likely to have comorbidity

6:10 GLP-1 and AUD

7:10 Followed for 26 weeks

8:10 Side effects when someone doesn’t have obesity

8:30 Consultants and nonprofit hospitals

9:33 Matched with hospitals that did not use

10:33 No benefits related to consultants

11:31 Told you what they knew already

12:55 End

Transcript:

Elizabeth: Is there a model for helping to predict who’s going to benefit most from weight loss interventions?

Rick: Can weight reduction drugs be used to treat alcohol use disorder?

Elizabeth: Is there any benefit to using a consultant for your not-for-profit hospital?

Rick: And using transcranial magnetic stimulation for individuals with autism.

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 Health El Paso.

Elizabeth: Rick, I have to admit that I am most intrigued by the transcranial stimulation notion, and that’s in The Lancet, if we don’t mind taking a look at that first.

Rick: No, let’s do that. This is a study done on children. There are a number of different therapies that have been tried — some of them successfully, some of them not. The one that’s most commonly used is cognitive behavioral therapy. In fact, it’s the only evidence-based treatment for improving both social communication impairment and other issues associated with it.

What we’re calling transcranial magnetic stimulation is a technique that’s been used oftentimes in adults to treat a number of neuropsychiatric disorders. The difficulty with using it in kids is you apply it to a specific area of the brain, and you usually have to have the patient stationary for a period of time to get it both precisely located and delivered. And it’s hard for kids to do that, especially kids that have autism, and many of those kids will have intellectual disabilities as well.

What these individuals in China did was they developed a transcranial magnetic stimulation that did two things differently. Rather than using neuroimaging, they used evoked potentials to identify which part of the motor brain they should apply it, and then they applied 1800 pulses over 120 seconds. They applied 10 of those a day, 5 days a week, over the course of about a month, in 200 kids aged 4 to 10 that all had well-documented autism spectrum disorder, some of whom had intellectual disabilities, IQs below 70. In fact, it did improve their social communication impairment — compared to placebo, by the way — and they also had secondary improvements in language.

Elizabeth: This is a very attractive option with regard to kids on the autism spectrum. I’m wondering about the durability because that is something that has also been an issue with adults where this technique has been attempted.

Rick: Yep. That’s a great question that we don’t know the answer to that. The long-term follow-up should help us. It also doesn’t tell us about best or most effective duration of treatment. It’s not until recently that this M1, or the motor cortex, has been associated with speech and language. We know that TMS [transcranial magnetic stimulation] affects neuroplasticity, and these are kids in whom the neural system is developing. This is one of the first studies that have suggested that it is effective in this group of individuals.

Elizabeth: Per this idea of durability, it is possible that because, as you’ve already cited, this brain is still under a lot of development, that some of those changes that are evoked as a result of this stimulation might actually impact over the long haul. The other thing I’ve seen recently has been these custom-made caps that allow that stimulation after there’s been mapping to be delivered exactly where they need it to be, and the kid could be ambulatory while this was happening.

Rick: A lot of possibilities once you’ve demonstrated that it is effective, and as you mentioned, a lot of studies still to be done.

Elizabeth: Let’s turn to Nature Medicine, data-driven prioritization of high-risk individuals for weight loss interventions. The authors put forward the idea that, “Gosh, everybody’s out there taking GLP-1s. Should we examine those because they’re really expensive for how impactful they’re likely to be for people who are overweight, and can we use a prioritization based on the likelihood that they’re going to develop the many potential complications of obesity?”

They used the data from the UK Biobank. They create a model. They took this sample of about 200,000 people with a BMI that exceeded 27 kg m² and created a framework with the 20 most informative features that predict future onset of 18 of the complications of obesity. Sure enough, with their model, they’re able to discern the folks who would be most likely to develop these complications, and then they opine that this could be used to prescribe those medications, the GLP-1s, to that population. People who turned out to be, for the most part, at risk were those who were sort of in that medium level of obesity, the 27 to 30 range.

Rick: That group seemed to be disproportionately affected by these other comorbidities. It was at that point where those other comorbidities, like age, hemoglobin A1c, cholesterol, your gender, your weight-to-height ratio, your kidney function, ended up playing a more important role. The heavier one is, the more obese they are. Perhaps these other risk factors play a less important role. Nevertheless, as you noted, these are risk factors that altogether are more likely to predict 18 different comorbidities: chronic renal disease, gout, diabetes, cardiovascular mortality, sleep apnea, a number of different things. Hopefully, it will allow us to target our more intensive therapies to those individuals that are more likely to have one of these comorbidities.

Elizabeth: As an individual who may be presenting to the healthcare system, I would hope that the utility of this model would be saying to me, “Wow, here’s where you are with regard to your BMI, and this puts you at very high risk to develop this whole constellation of things.” And that might be really motivating for me to embrace these strategies for weight loss because we know that most of the people who start using these things ultimately stop using them.

Rick: We employ the same strategy for people that haven’t had heart disease yet, but we tell them, “You’re really at high risk.” The same risk assessment that drives therapy and the intensity of it can be done for the same thing for obesity, for the reasons that you mentioned.

Elizabeth: On to your next one, back to The Lancet.

Rick: Using weight reduction drugs to treat individuals that have alcohol use disorder, and that’s a chronic, relapsing brain disorder characterized by loss of control of alcohol consumption and compulsive use.

Interestingly enough, for individuals who have taken the GLP-1 receptor agonist, things like semaglutide, for weight reduction, incidentally, we’ve known in those that drink alcohol, it’s decreased their desire for alcohol. People have said, “Okay, well, if that’s an observation, I wonder if in a general population that has both obesity and alcohol use disorder, where we’re going to treat the obesity with semaglutide, does it, in fact, reduce alcohol use disorder?”

To investigate that, in a 26-week study done at a single center, they randomized individuals that had moderate-to-severe alcohol use and comorbid obesity. They were assigned to receive either once weekly semaglutide or placebo. They followed them over the course of 26 weeks, and all individuals received cognitive behavioral therapy.

Those that received semaglutide, it not only reduced their heavy drinking days, but it led to reductions in alcohol craving, drinks per drinking day, total alcohol consumption, in addition to weight loss in those that received semaglutide.

Elizabeth: I’m just wondering about potential mechanisms whereby this might help.

Rick: It’s possible there are two. The central mechanism, what the effects are in the CNS [central nervous system], because we know that these things affect things in the hypothalamus, and they cause early satiety. Also, peripheral mechanisms — if we stop the medications, do those cravings come back? There are some individuals that did not benefit at all, so understanding what their predictors are. Then finally, should we be using this in people that aren’t obese, just to reduce alcohol use cravings?

Elizabeth: I think we’ve also seen some data, even with regard to other things like cigarette smoking and other things that have a similar mechanism.

Rick: Yes. At least centrally to reduce the craving for these things.

Elizabeth: And I’m also wondering what the untoward side effects would be in somebody who did not have obesity, but wanted to use it primarily for alcohol use disorder.

Rick: Right. And what you’d like to do is to say, “Okay, if you’ve decreased the alcohol use, what about the other consequences of it with regard to heart disease and liver disease, and neurologic disease?” That’s ultimately what you’d like to affect as well.

Elizabeth: Finally then, let us turn to JAMA. And this is a look at something that I’ve observed before, and so I was interested in this exploration, looking at changes in nonprofit hospitals’ finances, operations, and quality of care after they use management consultants. And it turns out that the use of management consultants in the U.S. healthcare industry is now higher than in most other sectors of the U.S. economy, and it has been increasing over recent decades.

Hospitals hire these management consultants for external expertise and advice on strategic planning, organizational change, cost-cutting, and revenue enhancement activities. What is it costing in order to get these opinions and does it really have an impact on any of these bottom lines?

They looked at 306 U.S. nonprofit hospitals — and these were distributed throughout the country — that used a management consultant firm for the first time in the 2010 to 2022 window. And they matched them with 513 hospitals that did not use a management consultant from 2009 to 2023. They were looking at all of these financial performance measures, operational measures, and then patient measures such as 30-day mortality and readmission for acute MI, pneumonia, and stroke.

They found that more than 20% of all nonprofit hospitals did use a management consultant during this study period and that they were paid an average of almost $16 million for their services. Collectively, that meant they spent almost $8 billion on these services in the study period. Despite this investment, they did not show that there was any benefit with regard to substantial, statistically significant, or systemic improvements that were related to engaging these consultants.

It sounds like it’s a lot of money that’s being paid for something that does not have any impact, and in view of the fact that hospitals are enterprises that the public has a vested interest in, brings very clearly into question, for me, anyway, the idea that they ought to be engaging management consultants at all.

Rick: Yeah. Despite spending $8 billion from 2009 to 2023, no improvement in financial performance, operational measures, or quality-of-care measures.

So here’s the difficult thing. We don’t know if they would not have had those consultants, would they have had a decline? Sometimes hospitals use it because they’re lean on management. Sometimes they use them because they’re bloated and they’re trying to get a reduction in it. And unfortunately, this study can’t ascertain why these particular hospitals did it. But Elizabeth, I’ve been through several of these and I’ve always been surprised. But a lot of work, a lot of money spent, and at the end of the day, oftentimes, it told you what you knew already.

Elizabeth: I will note for you that it does say in here that they were able to identify the nature of 108 of these management consultant contracts. Just about 65% were aimed at enhancing financial performance, 28% at integrating or advancing technological capabilities, 24% at improving quality of care, and about 14% at reorganizing staffing, 13% at assisting in a merger or an acquisition. So that clearly was not all of them; it was only a sampling of them. But it demonstrates to me, anyway, that there are a multitude of reasons why people decide to engage a management consultant. Irrespective of their reason, however, none of them are showing a benefit.

Rick: Yeah. Because it was a very comprehensive study conducted over a long period of time, looking at the hospitals’ 990s. They got some really good data. I’m not terribly surprised. I’ve been through this multiple times, and I’ve oftentimes questioned what value they bring. There’s no ambiguity about the results of this particular study.

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.