Study: Living in poor neighborhood can hurt health (AP)

ATLANTA � Back in the 1990s, the federal government tried an unusual social experiment: It offered thousands of poor women in big-city public housing a chance to live in more affluent neighborhoods.

A decade later, the women who relocated had lower rates of diabetes and extreme obesity � differences that are being hailed as compelling evidence that where you live can determine your health.

The experiment was initially aimed at researching whether moving impoverished families to more prosperous areas could improve employment or schooling. But according to a study released Wednesday, the most interesting effect may have been on the women's physical condition.

About 16 percent of the women who moved had diabetes, compared with about 20 percent of women who stayed in public housing. And about 14 percent of those who left the projects were extremely obese, compared with nearly 18 percent of the other women.

The small-but-significant differences offered some of the strongest support yet for the idea that where you live can significantly affect your overall health, especially if your home is in a low-income area with few safe places to exercise, limited food options and meager medical services.

"This study proves that concentrated poverty is not only bad policy, it's bad for your health," Shaun Donovan, secretary of the Department of Housing and Urban Development.

But no one believes the deficit-plagued federal government is going to expand the program and start moving low-income women to better neighborhoods en masse.

"It's not enough to simply move families into different neighborhoods," Donovan said. Instead, new ways must be found to help families "break the cycle of poverty that can quite literally make them sick." He did not mention specific proposals.

Public health experts have long thought that living in poor neighborhoods could ruin a person's health, but this study put the idea to a rigorous test.

Here's how it worked: Women believed to be about the same in most respects were randomly assigned to one group or another and then followed through time, in a model customarily seen in pharmaceutical studies. That makes it more scientifically rigorous than most research linking health problems to a social environment.

The study's good design "provides a basis to infer cause and effect" between poverty and bad health, said Dr. Robert Califf, a noted Duke University cardiologist who is leading a massive study on neighborhoods and health outcomes.

The research was led by Jens Ludwig, a University of Chicago professor of public policy. It was published in Wednesday's New England Journal of Medicine.

The experiment started as a $70 million HUD project in Baltimore, Boston, Chicago, Los Angeles and New York. It morphed into a health study after a variety of other government agencies and private foundations pitched in with an additional $17 million more.

"In terms of scale, it's not soon or ever to be repeated," said Dr. Robert Whitaker, a Temple University pediatrician who was a study co-author.

The study involved women living in public housing in neighborhoods where 40 percent or more of residents were poor � areas like many of those on the South Side of Chicago or in the Bronx in New York City. The women all had children and were considered heads of households.

From 1994 to 1998, nearly 1,800 of them were offered vouchers to subsidize private housing, but the vouchers were only good in higher-income neighborhoods where fewer than 10 percent of the people were considered poor. They were required to live there at least a year.

The rest of the women were divided into two groups. One group got vouchers they could use in any neighborhood. The other women did not receive vouchers, with the expectation that they would stay put.

Ten years later, women in the study were weighed and gave a blood sample to check for diabetes.

The women who moved to richer areas had the lowest rates of extreme obesity and diabetes. The difference suggests that moving to a better neighborhood could help at least 1 in 25 women. Or, in other terms, a person's risk of diabetes or extreme obesity dropped by about 20 percent by moving to a higher-income neighborhood.

(However, even the women who moved were not exactly models of health. About 14 percent of them were extremely obese, which is twice the national average for women.)

The study has some notable flaws.

Because it did not start out looking at health, the women's medical condition and weight were not checked at the outset. The researchers believe the women in the different groups were about the same, because they matched up on more than 50 other indicators, such as age, race, employment and education. But that is an assumption.

Also, only about half the women offered a chance to move to a more prosperous zip code did so. And many who did move left after a year.

What's more, the study was not designed to answer what it is about more affluent neighborhoods that would cause someone to be healthier. But the authors listed four theories:

� The availability of healthier food is worse in lower-income neighborhoods.

� Opportunities for physical exercise are scarcer, and fear of crime can make people afraid to jog or play in parks.

� There may be fewer doctors' offices and other medical services.

� The long-term stress of living in such an environment may alter the hormones that control weight.

Some of those theories were supported by some women who live in the kind of situation targeted in the study.

Vickie Webb lived in the projects in Durham, N.C., for several years before a housing agency helped relocate her and her husband to a better neighborhood.

"There was too much violence, too much going on in the `hood. It wasn't safe," said Webb, who was not part of the study.

Annie Ricks, who lives with her 14-year-old son and two grandchildren in a public housing unit on Chicago's South Side, was not involved in the study either. But she said efforts like the HUD experiment should be expanded.

Local housing authorities paid for her to relocate to the South Side last year as part of its demolition plans for high-rise tenements. But Ricks lost her child-care job after the move, and says her new neighborhood is worse.

At her old building, Ricks could walk across the street to a supermarket. In her new neighborhood, without a car, she has to take public transportation to get groceries or go to the doctor, and Ricks says there's more crime.

"I feel like it would be a blessing" to be able to move to a wealthier area, she said.

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Associated Press writers Alicia Chang in Los Angeles and Lindsey Tanner in Chicago contributed to this report.

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Annual cancer screening tests urged less and less (AP)

Annual cancer tests are becoming a thing of the past. New guidelines out Wednesday for cervical cancer screening have experts at odds over some things, but they are united in the view that the common practice of getting a Pap test every year is too often and probably doing more harm than good.

A Pap smear once every three years is the best way to detect cervical cancer, the U.S. Preventive Services Task Force says. Last week, it recommended against prostate cancer screening with PSA tests, which many men get every year.

Two years ago, it said mammograms to check for breast cancer are only needed every other year starting at age 50, although the American Cancer Society still advises annual tests starting at age 40. Earlier this week, a large study found more false alarms for women getting mammograms every year instead of every other year.

"The more tests that you do, the more likely you are to be faced with a false-positive test" that leads to unnecessary biopsies and possible harm, said Dr. Michael LeFevre, one of the task force leaders and a professor of family and community medicine at the University of Missouri. "We see an emerging consensus that annual Pap tests are not required for us to see the benefits that we have seen" from screening, he said.

Those benefits are substantial. Cervical cancer has declined dramatically in the United States, from nearly 15 cases for every 100,000 women in 1975 to nearly 7 per 100,000 in 2008. About 12,200 new cases and 4,210 deaths from the disease occurred last year, most of them in women who have never been screened or not in the past five years.

The cancer society and other groups say using Pap smears together with tests for HPV, the virus that causes cervical cancer, could improve screening. But the task force concluded the evidence is insufficient "to assess the balance of benefits and harms" of that.

Instead, more lives probably could be saved by reaching women who are not being adequately screened now, the task force says.

And despite what many people suspect, cost has nothing to do with the task force's stance, its leaders said.

"We don't look at cost at all. We really are most concerned about harms," said Dr. Evelyn Whitlock of Kaiser Permanente Northwest's Center for Health Research in Portland, Ore., who led an evidence review for the task force.

Here are some questions and answers about the cervical cancer guidelines.

Q. At what ages should screening start and end?

A. The task force recommends against screening women under 21 or older than 65. Very few cervical cancer cases occur in women under 21, so the old advice to start screening three years after the age of first intercourse has been changed. HPV tests are only approved for women after age 30 because transient infections that don't pose a cancer risk are more common at younger ages.

"We should not be screening teenagers. It's not helping, it's not finding any more cancers and it's creating way too many harms for them," said Debbie Saslow, the cancer society's director of breast and gynecologic cancer.

Q. Should anyone else not be screened?

A. Women who have had their cervix and uterus removed should not be tested, but check with your doctor � not all hysterectomies are complete; some leave the cervix.

Q. What does screening cost?

A. Paps cost $15 to $60; HPV tests run $50 to $100.

Q. Will insurance pay for HPV tests since the government panel doesn't endorse them?

A. Probably. They are included in preventive services that other federal advisers say should be covered under the Affordable Care Act, and the government has continued to pay for mammograms for women who want them even if it is sooner or more often than the task force recommends.

Q. What if I've had the HPV vaccine?

A. Doctors don't know how the vaccine will affect HPV test results or how long the vaccine lasts, so women should still be screened for cervical cancer if they are within the recommended screening ages.

Q. How can I comment on the guidelines?

A. The web site below for the task force tells how. Comments are accepted for a month before guidance is adopted.

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Online:

Task force advice: http://www.uspreventiveservicestaskforce.org/

Cervical cancer science review: http://tinyurl.com/6lc2rzg

CDC on HPV tests: http://www.cdc.gov/hpv/Screening.html

American Cancer Society: http://tinyurl.com/44gnadx

and http://tinyurl.com/257mnge

___

Marilynn Marchione can be followed at http://twitter.com/MMarchioneAP

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Heart failure hospital stays fall, saving billions (AP)

CHICAGO � Hospital stays for heart failure fell a remarkable 30 percent in Medicare patients over a decade, the first such decline in the United States and forceful evidence that the nation is making headway in reducing the billion-dollar burden of a common condition.

But the study of 55 million patients, the largest ever on heart failure trends, found only a slight decline in deaths within a year of leaving the hospital, and progress lagged for black men.

"While heart failure hospitalizations have decreased nationally overall, certain populations haven't seen the full benefit of that decrease," said lead author Dr. Jersey Chen of Yale University School of Medicine.

Possible explanations for the decline in hospital stays abound, including healthier hearts, better control of risk factors like high blood pressure, and more patients treated in emergency rooms and clinics without being admitted to hospitals, said Dr. Mariell Jessup, medical director of the Penn Heart and Vascular Center in Philadelphia.

"I think it's extraordinary news," said Jessup, who wasn't involved in the new research. "Many efforts at changing the natural history of this disease seem to be having an effect, especially with the hospitalization rate. But it's still a very problematic disease."

More than 5 million Americans and 22 million people globally have heart failure. Their hearts strain to pump blood because of damage, often from a heart attack or from high blood pressure. Fluid backing up into the lungs can leave people struggling to breathe.

Heart disease contributes to heart failure. Last week, federal health officials reported that the prevalence of self-reported heart disease in the U.S. decreased from nearly 7 percent to 6 percent from 2006 to 2010.

Fewer hospital stays saves Medicare a lot of money because heart failure is the most common cause of hospitalization in older patients.

From 1998 to 2008, the rate fell from 2,845 hospitalizations per 100,000 Medicare beneficiaries to 2,007 per 100,000, according to research appearing in Wednesday's Journal of the American Medical Association.

If the rate had remained the same, there would have been 229,000 more heart failure hospital stays in 2008 at an additional cost to Medicare of $4.1 billion, Chen said.

Other reasons for declining hospital stays may include specialized pacemakers and better use of medications such as ACE inhibitors that relax blood vessels, diuretics that prevent fluid buildup, digoxin that boosts heartbeat strength and beta blockers that ease strain on the heart.

Shortness of breath sent heart failure patient Maria Marure to several Chicago hospitals this year. In August, the 56-year-old spent a week at Our Lady of the Resurrection Medical Center, where leaders are focused on keeping heart failure patients healthy once they're home and avoiding readmissions. Next year, the nation's new health law begins punishing hospitals with high readmission rates for heart failure by shrinking Medicare payments.

The Chicago hospital made sure Marure had a medical interpreter to translate a nurse's instructions into Spanish and convey her questions. Marure said it was the first time she understood her heart failure and why it was important for her to watch her weight � which can signal excess fluid. The hospital sent her home with a scale, made sure she had home care and a nurse called her periodically.

Even with all that, in less than three weeks, Marure was struggling to breathe again. A doctor sent her to a different hospital, where she was admitted for four days.

That patient's experience illustrates why heart failure is still a challenge, despite the new findings � as does the one-year death rate found in the study. The proportion of patients who died within a year after being discharged fell, but only slightly, from about 32 percent to about 30 percent during the decade.

"The death rate is still unacceptably high," said Dr. Mihai Gheorghiade of Northwestern University's Feinberg School of Medicine in Chicago. Hospitals need to aggressively treat heart failure patients' other ailments and immediately schedule follow-up care after discharge, said Gheorghiade, who wrote an accompanying editorial in the journal.

"It is a sign of hope. However, we are far from achieving our goals," he said.

___

Online:

JAMA: http://jama.ama-assn.org

___

AP Medical Writer Carla K. Johnson can be reached at http://www.twitter.com/CarlaKJohnson

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Study: Vaccine reduces malaria in African children (AP)

ATLANTA � The quest for the world's first malaria vaccine appears to have taken a big step.

The first results from a late-stage test in seven African countries were released Tuesday. They show the experimental shots cut the number of cases of malaria in half in young children.

The vaccine still is at least three years away. More testing must be completed to see how well it works in infants and how long protection lasts. Then the vaccine will be reviewed by government agencies in Europe and in individual African nations.

GlaxoSmithKline developed the vaccine. It targets a malaria parasite found in sub-Saharan Africa. There are no plans to market it in the United States.

The research results were released at a malaria conference in Seattle.

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Doctors: Pap remains best test for cervical cancer (AP)

There's more news on cancer screening tests � this time for women.

Scientists advising the government say a Pap test is a good way to screen young and middle-aged women for cervical cancer, and it's only needed once every three years. But they say there is not enough evidence yet to back testing for HPV, the virus that causes the disease.

That's at odds with the American Cancer Society and other groups, which have long said that using both tests can be an option for women over 30.

Those groups and the government advisory task force separately plan to release proposed new guidelines for cervical cancer screening on Wednesday and invite public comment. The task force is the same group that recommended against routine PSA tests to screen for prostate cancer, saying they were doing more harm than good for men at average risk.

Cervical cancer screening is a success story. In the United States, cases and death rates have been cut more than in half since the 1970s because of Pap smears � lab exams of cells scraped from the cervix, the gateway to the uterus. The test can find early signs of this slow-growing cancer and treat them before a tumor has a chance to develop.

So "the bar is set pretty high" for a test to replace or supplement Paps, said Dr. Evelyn Whitlock of Kaiser Permanente Northwest's Center for Health Research in Portland, Ore.

Not enough is known about the benefits and especially the harms of HPV testing, concludes the scientific review she led that was published on Monday. The task force that asked for the review voted unanimously in March that there was insufficient evidence to recommend for or against HPV testing, but has continued to discuss the issue and will give its advice on Wednesday.

Here's the dilemma: Infections with HPV, the human papillomavirus, are very common especially in young women. They usually go away on their own and only pose a cancer risk when they last a year or more.

Tests that find these infections might lead many women to more invasive follow-up tests that can weaken the cervix and cause problems having children later. No big studies measure these harms, and a test that flags more potential cancers might not be better.

"A lot of people use the word `superior' to mean it catches more cancer. But the other side of it is, does it catch more things that are not cancer? You have to weigh benefits versus harms for any screening test," said Debbie Saslow, the cancer society's director of breast and gynecologic cancer.

The evidence review finds little risk of cervical cancer in women under 21 and says screening below that age may be harmful. It also says screening can stop at age 65 if a woman has had adequate screening in the past and is not otherwise at high risk.

The review was published Monday in the Annals of Internal Medicine.

The same journal also published a study on another women's cancer issue � breast cancer screening. That research supports having mammograms every other year instead of annually. Over time, there are more false alarms with annual screening, and going every two years does not significantly raise the risk of a late-stage cancer being found, researchers report.

Breast cancer screening has been an emotional issue since 2009 when the government task force said women at average risk of the disease don't need mammograms until age 50 and then just every other year to age 74. The cancer society and others still advise annual tests starting at age 40.

The federally funded study gives a real-world view of the downside of screening � the worry, expense and medical risks of biopsies and other tests that ultimately prove unnecessary. It looked at false alarms at various intervals of screening for nearly 170,000 women ages 40 to 59 in ordinary community settings, plus nearly 4,500 other women with invasive breast cancer.

About 61 percent of women who get a mammogram every year for a decade will be called back at least once for extra tests that turn out not to show breast cancer, the study found.

Screening every other year drops this false alarm rate to 42 percent without a big risk of cancer being discovered at a late stage. And a tip for women: If you changed where you go for mammograms, bringing or having doctors send your last one to be compared to the new one cuts in half the chance of a false alarm.

Women who started having mammograms in their 40s versus their 50s were more likely to have a false alarm just because they were having more tests � not because mammography is less accurate in that age group.

False alarms "are part of the price to pay for early detection," said study leader Rebecca Hubbard of Group Health Research Institute, part of a Seattle-based managed care system. Women need to know how common they are, and "if it happens to them they will feel less anxiety," she said.

Dr. Robert Smith, the cancer society's director of cancer screening, said the study should have more precisely defined intervals � it called annual screening an interval of 9 to 18 months, and biennial screening, 19 to 30 months.

"A false positive is commonly discussed as if it were a catastrophic event. For the large majority of women, it isn't," and surveys say women will accept the risk in return for finding cancer early, he said.

.___

Online:

Journal studies: http://www.annals.org

Cervical cancer science review: http://tinyurl.com/6lc2rzg

Task force advice: http://www.ahrq.gov/clinic/pocketgd1011/gcp10s2.htm

CDC on HPV tests: http://www.cdc.gov/hpv/Screening.html

Cancer Society: http://tinyurl.com/44gnadx

and http://tinyurl.com/257mnge

___

Marilynn Marchione can be followed at http://twitter.com/MMarchioneAP

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CDC: Add $2 per drink for US excessive drinking (AP)

ATLANTA � The toll of excessive drinking works out to about $2 per drink, in terms of medical expenses and other costs to society, according to a new federal research.

The Centers for Disease Control and Prevention study calculated societal costs from binge and heavy drinking beyond what consumers pay at the bar or liquor store. It's the first such federal estimate in more than a dozen years.

The study looked at costs that included � among other things � lost work productivity, property damage from car crashes, expenditures for liver cirrhosis and other alcohol-associated medical problems, and money spent on incarceration of drunk drivers and criminals using alcohol.

The CDC estimated excessive drinking cost society nearly $224 billion in 2006, the most recent year for which all necessary statistics were available. That worked out to about $1.90 per drink, 80 cents of which was spent by federal, state or local governments, the researchers estimated. The rest came from drinkers, their families, private health insurers, employers, crime victims and others.

Most of that was related to binge drinking, in which four or five alcoholic beverages are consumed on one occasion.

"Binge drinking results in binge spending," said CDC Director Dr. Thomas Frieden.

CDC officials noted that while some health benefits have been associated with, say, a glass of wine each day, there are no health benefits linked to excessive drinking. They also said the new study likely represents an underestimate of the total cost.

Smoking has been estimated to cost society about $193 billion annually. An older study estimated the cost of not exercising to be around $150 billion.

The study was released Monday by the American Journal of Preventive Medicine.

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