Lisa Rapaport

(Reuters Health) - Medicaid, the U.S. health program for the poor, pays far less for common surgical procedures in many states than does Medicare, the federal insurance plan for the elderly, according to a new study.

Some of the discounts are so steep that they may threaten access to care, the authors argue.

Medicaid is the biggest public health program in the U.S. and currently accounts for about $1 out of every $6 spent on medical care. Medicaid expenditures also represent almost half of all federal funds spent by states.

When Medicaid fees are too low relative to payments from Medicare, doctors may refuse to treat Medicaid patients, potentially making it much harder for poor people to get treatment, argue Dr. Charles Mabry of the University of Arkansas in Little Rock and colleagues in a paper released online January 13 in the Journal of the American College of Surgeons.

"Lack of proper payment can cause some Medicaid patients to have needed surgical procedures delayed," Mabry told Reuters Health by email. "Our hope was that by researching and publishing on these wide variations in payment, it would spur states to rethink the methodology for how they determine payment."

Even though the federal government picks up part of the tab for care, Medicaid payment rates as well as enrollment eligibility and covered benefits are determined by individual states.

To assess the degree of variation between Medicare and Medicaid payments for surgery, Mabry and colleagues calculated how much fees varied for some of the most common procedures done by general surgeons in nearly every state across the country.

The analysis excluded only Kansas and Tennessee.

The largest discount they found was in New Jersey, where Medicaid paid $1,011 (about 933 euros) less than Medicare for surgery to remove all or part of the small intestine.

At the other extreme, the biggest premium was in Alaska, which paid $1,382 more for insertion of a tunneled central venous port under Medicaid than Medicare would pay for the procedure.

When they looked at mastectomy, Medicaid paid $226.47 in Connecticut, 69% less than the $725.35 Medicare payment for the same procedure in the same state.

For an enterectomy, New Jersey's Medicaid payment of $332 was 75% less than the $1,343.16 payment under Medicare.

To fix a ventral hernia, Medicaid in New Hampshire pays $300, 61% less than the $762.28 Medicare payment in the state.

The analysis has several limitations, including the narrow focus on a handful of surgical procedures and the reliance on published payment schedules in each state, which may not necessarily reflect what surgeons actually get paid, the authors note. The analysis also lacked data on certain bulk payments or additional funds paid by Medicaid that might minimize the apparent discounts in some cases.

The paper didn't examine how access to care might be adversely affected by steep discounts in Medicaid payments relative to Medicare or private insurance. But, the authors conclude, it's likely some people struggle to find surgeons or experience delays in care as a direct result of low fees that motivate doctors to refuse Medicaid patients.

One woman with sickle-cell disease and Medicaid coverage is a case-in-point for Dr. Constantine Manthous, who retired from Yale University and works in private practice in New London, Connecticut.

He recalled meeting her after she had spent a decade in a wheelchair because she couldn't find a surgeon to repair her hip. She didn't receive surgery until the hip fell out of its socket, requiring constant hospitalization and morphine.

"By that time she was so ill she died of late complications from the decade delay," Manthous, who wasn't involved in the study, said by email. "You and I would have gotten the hip immediately."

(Reuters Health) - Medicaid, the U.S. health program for the poor, pays far less for common surgical procedures in many states than does Medicare, the federal insurance plan for the elderly, according to a new study.

Some of the discounts are so steep that they may threaten access to care, the authors argue.

Medicaid is the biggest public health program in the U.S. and currently accounts for about $1 out of every $6 spent on medical care. Medicaid expenditures also represent almost half of all federal funds spent by states.

When Medicaid fees are too low relative to payments from Medicare, doctors may refuse to treat Medicaid patients, potentially making it much harder for poor people to get treatment, argue Dr. Charles Mabry of the University of Arkansas in Little Rock and colleagues in a paper released online January 13 in the Journal of the American College of Surgeons.

"Lack of proper payment can cause some Medicaid patients to have needed surgical procedures delayed," Mabry told Reuters Health by email. "Our hope was that by researching and publishing on these wide variations in payment, it would spur states to rethink the methodology for how they determine payment."

Even though the federal government picks up part of the tab for care, Medicaid payment rates as well as enrollment eligibility and covered benefits are determined by individual states.

To assess the degree of variation between Medicare and Medicaid payments for surgery, Mabry and colleagues calculated how much fees varied for some of the most common procedures done by general surgeons in nearly every state across the country.

The analysis excluded only Kansas and Tennessee.

The largest discount they found was in New Jersey, where Medicaid paid $1,011 (about 933 euros) less than Medicare for surgery to remove all or part of the small intestine.

At the other extreme, the biggest premium was in Alaska, which paid $1,382 more for insertion of a tunneled central venous port under Medicaid than Medicare would pay for the procedure.

When they looked at mastectomy, Medicaid paid $226.47 in Connecticut, 69% less than the $725.35 Medicare payment for the same procedure in the same state.

For an enterectomy, New Jersey's Medicaid payment of $332 was 75% less than the $1,343.16 payment under Medicare.

To fix a ventral hernia, Medicaid in New Hampshire pays $300, 61% less than the $762.28 Medicare payment in the state.

The analysis has several limitations, including the narrow focus on a handful of surgical procedures and the reliance on published payment schedules in each state, which may not necessarily reflect what surgeons actually get paid, the authors note. The analysis also lacked data on certain bulk payments or additional funds paid by Medicaid that might minimize the apparent discounts in some cases.

The paper didn't examine how access to care might be adversely affected by steep discounts in Medicaid payments relative to Medicare or private insurance. But, the authors conclude, it's likely some people struggle to find surgeons or experience delays in care as a direct result of low fees that motivate doctors to refuse Medicaid patients.

One woman with sickle-cell disease and Medicaid coverage is a case-in-point for Dr. Constantine Manthous, who retired from Yale University and works in private practice in New London, Connecticut.

He recalled meeting her after she had spent a decade in a wheelchair because she couldn't find a surgeon to repair her hip. She didn't receive surgery until the hip fell out of its socket, requiring constant hospitalization and morphine.

"By that time she was so ill she died of late complications from the decade delay," Manthous, who wasn't involved in the study, said by email. "You and I would have gotten the hip immediately."

(Reuters Health) - Medicaid, the U.S. health program for the poor, pays far less for common surgical procedures in many states than does Medicare, the federal insurance plan for the elderly, according to a new study.

Some of the discounts are so steep that they may threaten access to care, the authors argue.

Medicaid is the biggest public health program in the U.S. and currently accounts for about $1 out of every $6 spent on medical care. Medicaid expenditures also represent almost half of all federal funds spent by states.

When Medicaid fees are too low relative to payments from Medicare, doctors may refuse to treat Medicaid patients, potentially making it much harder for poor people to get treatment, argue Dr. Charles Mabry of the University of Arkansas in Little Rock and colleagues in a paper released online January 13 in the Journal of the American College of Surgeons.

"Lack of proper payment can cause some Medicaid patients to have needed surgical procedures delayed," Mabry told Reuters Health by email. "Our hope was that by researching and publishing on these wide variations in payment, it would spur states to rethink the methodology for how they determine payment."

Even though the federal government picks up part of the tab for care, Medicaid payment rates as well as enrollment eligibility and covered benefits are determined by individual states.

To assess the degree of variation between Medicare and Medicaid payments for surgery, Mabry and colleagues calculated how much fees varied for some of the most common procedures done by general surgeons in nearly every state across the country.

The analysis excluded only Kansas and Tennessee.

The largest discount they found was in New Jersey, where Medicaid paid $1,011 (about 933 euros) less than Medicare for surgery to remove all or part of the small intestine.

At the other extreme, the biggest premium was in Alaska, which paid $1,382 more for insertion of a tunneled central venous port under Medicaid than Medicare would pay for the procedure.

When they looked at mastectomy, Medicaid paid $226.47 in Connecticut, 69% less than the $725.35 Medicare payment for the same procedure in the same state.

For an enterectomy, New Jersey's Medicaid payment of $332 was 75% less than the $1,343.16 payment under Medicare.

To fix a ventral hernia, Medicaid in New Hampshire pays $300, 61% less than the $762.28 Medicare payment in the state.

The analysis has several limitations, including the narrow focus on a handful of surgical procedures and the reliance on published payment schedules in each state, which may not necessarily reflect what surgeons actually get paid, the authors note. The analysis also lacked data on certain bulk payments or additional funds paid by Medicaid that might minimize the apparent discounts in some cases.

The paper didn't examine how access to care might be adversely affected by steep discounts in Medicaid payments relative to Medicare or private insurance. But, the authors conclude, it's likely some people struggle to find surgeons or experience delays in care as a direct result of low fees that motivate doctors to refuse Medicaid patients.

One woman with sickle-cell disease and Medicaid coverage is a case-in-point for Dr. Constantine Manthous, who retired from Yale University and works in private practice in New London, Connecticut.

He recalled meeting her after she had spent a decade in a wheelchair because she couldn't find a surgeon to repair her hip. She didn't receive surgery until the hip fell out of its socket, requiring constant hospitalization and morphine.

"By that time she was so ill she died of late complications from the decade delay," Manthous, who wasn't involved in the study, said by email. "You and I would have gotten the hip immediately."

(Reuters Health) - The causes of acute myocardial infarction(MI) and the warning symptoms that can signal the need for immediate medical attention are different in women than in men, according to a scientific statement issued today by the American Heart Association.

When women don't recognize this, they may suffer worse outcomes, a fate that is even more likely in black and Hispanic women, according to the AHA.

The AHA published its first comprehensive statement on gender differences in acute MI patients in Circulation, January 25.

"Women seem to do worse for several reasons," said Dr. Laxmi Mehta, the lead author of the recommendations and the director of women's cardiovascular health at Ohio State University in Columbus.

Importantly, people don't realize that while both sexes may experience chest pain before or during a heart attack, women maybe more likely to have unusual symptoms instead, such as shortness of breath, nausea or vomiting, and back or neck pain.

Then, when they do get to a hospital, women may be less likely than men to receive medications that help to prevent clots, decrease the heart's workload and lower blood pressure or cholesterol.

"There is a lot at stake for women when there is a delay in treatment or lack of adherence to recommended therapies," Mehta added by email. "Women face higher rates of being readmitted to the hospital, heart failure and death."

Biology is also part of the problem. Even though both women and men suffer MI caused by blockages in the main arteries leading to the heart, the way the clots develop may differ, according to the scientific statement.

Men tend to have a more "classic" type of blockage where plaque ruptures off the artery wall, forms a blood clot and causes a complete halt of blood flow through the artery to the heart, said Dr. Sheila Sahni, chief fellow in cardiovascular disease at the David Geffen School of Medicine at the University of California Los Angeles.

"Women, more often, tend to have a plaque erosion where smaller pieces of plaque break off, become exposed and cause the formation of smaller blood clots which may or may not cause total occlusions all at once, leading to a more subtle presentation," Sahni, who wasn't involved in the study, said by email.

In addition, women tend to be about a decade older than men when they suffer acute MI, potentially making them frailer and more likely to suffer from other health problems such as diabetes that can make their treatment more complicated, Sahni added.

Risk factors also differ by gender, with hypertension more strongly associated with MI in women than in men. For young women with diabetes, the risk for heart disease is four to five times higher than it would be for a similar young man.

Race, too, is an issue. Compared to white women, black women have a higher incidence of MI in all age categories and young black women have greater odds of dying before they leave the hospital. Black and Hispanic women are also more likely to have

heart-related risk factors such as diabetes, obesity and hypertension at the time of their MI.

Once a heart attack begins, the best way for women to minimize damage is to get help quickly, said Dr. Leslie Cho, director of the women's cardiovascular center at the Cleveland Clinic and Clinic in Ohio.

"Time is muscle," Cho, who wasn't involved in the study, said by email. "If women are diagnosed and treated later in the course of the heart attack, they can suffer from irreversible heart damage."

(Reuters Health) - The causes of acute myocardial infarction(MI) and the warning symptoms that can signal the need for immediate medical attention are different in women than in men, according to a scientific statement issued today by the American Heart Association.

When women don't recognize this, they may suffer worse outcomes, a fate that is even more likely in black and Hispanic women, according to the AHA.

The AHA published its first comprehensive statement on gender differences in acute MI patients in Circulation, January 25.

"Women seem to do worse for several reasons," said Dr. Laxmi Mehta, the lead author of the recommendations and the director of women's cardiovascular health at Ohio State University in Columbus.

Importantly, people don't realize that while both sexes may experience chest pain before or during a heart attack, women maybe more likely to have unusual symptoms instead, such as shortness of breath, nausea or vomiting, and back or neck pain.

Then, when they do get to a hospital, women may be less likely than men to receive medications that help to prevent clots, decrease the heart's workload and lower blood pressure or cholesterol.

"There is a lot at stake for women when there is a delay in treatment or lack of adherence to recommended therapies," Mehta added by email. "Women face higher rates of being readmitted to the hospital, heart failure and death."

Biology is also part of the problem. Even though both women and men suffer MI caused by blockages in the main arteries leading to the heart, the way the clots develop may differ, according to the scientific statement.

Men tend to have a more "classic" type of blockage where plaque ruptures off the artery wall, forms a blood clot and causes a complete halt of blood flow through the artery to the heart, said Dr. Sheila Sahni, chief fellow in cardiovascular disease at the David Geffen School of Medicine at the University of California Los Angeles.

"Women, more often, tend to have a plaque erosion where smaller pieces of plaque break off, become exposed and cause the formation of smaller blood clots which may or may not cause total occlusions all at once, leading to a more subtle presentation," Sahni, who wasn't involved in the study, said by email.

In addition, women tend to be about a decade older than men when they suffer acute MI, potentially making them frailer and more likely to suffer from other health problems such as diabetes that can make their treatment more complicated, Sahni added.

Risk factors also differ by gender, with hypertension more strongly associated with MI in women than in men. For young women with diabetes, the risk for heart disease is four to five times higher than it would be for a similar young man.

Race, too, is an issue. Compared to white women, black women have a higher incidence of MI in all age categories and young black women have greater odds of dying before they leave the hospital. Black and Hispanic women are also more likely to have

heart-related risk factors such as diabetes, obesity and hypertension at the time of their MI.

Once a heart attack begins, the best way for women to minimize damage is to get help quickly, said Dr. Leslie Cho, director of the women's cardiovascular center at the Cleveland Clinic and Clinic in Ohio.

"Time is muscle," Cho, who wasn't involved in the study, said by email. "If women are diagnosed and treated later in the course of the heart attack, they can suffer from irreversible heart damage."

(Reuters Health) - The causes of acute myocardial infarction(MI) and the warning symptoms that can signal the need for immediate medical attention are different in women than in men, according to a scientific statement issued today by the American Heart Association.

When women don't recognize this, they may suffer worse outcomes, a fate that is even more likely in black and Hispanic women, according to the AHA.

The AHA published its first comprehensive statement on gender differences in acute MI patients in Circulation, January 25.

"Women seem to do worse for several reasons," said Dr. Laxmi Mehta, the lead author of the recommendations and the director of women's cardiovascular health at Ohio State University in Columbus.

Importantly, people don't realize that while both sexes may experience chest pain before or during a heart attack, women maybe more likely to have unusual symptoms instead, such as shortness of breath, nausea or vomiting, and back or neck pain.

Then, when they do get to a hospital, women may be less likely than men to receive medications that help to prevent clots, decrease the heart's workload and lower blood pressure or cholesterol.

"There is a lot at stake for women when there is a delay in treatment or lack of adherence to recommended therapies," Mehta added by email. "Women face higher rates of being readmitted to the hospital, heart failure and death."

Biology is also part of the problem. Even though both women and men suffer MI caused by blockages in the main arteries leading to the heart, the way the clots develop may differ, according to the scientific statement.

Men tend to have a more "classic" type of blockage where plaque ruptures off the artery wall, forms a blood clot and causes a complete halt of blood flow through the artery to the heart, said Dr. Sheila Sahni, chief fellow in cardiovascular disease at the David Geffen School of Medicine at the University of California Los Angeles.

"Women, more often, tend to have a plaque erosion where smaller pieces of plaque break off, become exposed and cause the formation of smaller blood clots which may or may not cause total occlusions all at once, leading to a more subtle presentation," Sahni, who wasn't involved in the study, said by email.

In addition, women tend to be about a decade older than men when they suffer acute MI, potentially making them frailer and more likely to suffer from other health problems such as diabetes that can make their treatment more complicated, Sahni added.

Risk factors also differ by gender, with hypertension more strongly associated with MI in women than in men. For young women with diabetes, the risk for heart disease is four to five times higher than it would be for a similar young man.

Race, too, is an issue. Compared to white women, black women have a higher incidence of MI in all age categories and young black women have greater odds of dying before they leave the hospital. Black and Hispanic women are also more likely to have

heart-related risk factors such as diabetes, obesity and hypertension at the time of their MI.

Once a heart attack begins, the best way for women to minimize damage is to get help quickly, said Dr. Leslie Cho, director of the women's cardiovascular center at the Cleveland Clinic and Clinic in Ohio.

"Time is muscle," Cho, who wasn't involved in the study, said by email. "If women are diagnosed and treated later in the course of the heart attack, they can suffer from irreversible heart damage."

Families may spend almost twice as much caring for dementia patients at the end of life than they might if their loved one suffered from a different disease, a U.S. study suggests.

Costs paid by Medicare, the U.S. health insurance program for the elderly, were similar over the final five years of life for patients with dementia, heart disease, cancer and other conditions, according to the study published in the Annals of Internal Medicine.

But the average out-of-pocket costs absorbed by families of dementia patients totaled $61,522 over those five years, far greater than the typical tab of $34,068 for patients without dementia.

"Many costs related to daily care for patients with dementia are not covered by health insurance, and these care needs, including everything from supervision to bathing and feeding, may span several years," lead author Dr. Amy Kelley of the Icahn School of Medicine at Mount Sinai in New York said by email.

To assess the financial toll dementia takes on families, Dr. Kelley and colleagues analyzed Medicare spending and out-of-pocket costs for about 1,700 people aged 70 and older who died between 2005 and 2010.

Over the five years prior to each patient's date of death, the average total cost, including what Medicare covered as well as what families paid, was about $287,000 for dementia patients. That compares with roughly $175,000 for heart disease, $173,000 for cancer, and $197,000 for people who died of other causes.

Families caring for dementia patients also spent a greater proportion of their wealth than families helping loved ones with other conditions. The financial burden as a proportion of wealth was even more pronounced for patients who were black, had less than a high school education, or were unmarried or widowed women.

Shortcomings of the study include the possibility that insurance payments may have been underestimated as well as the lack of data on wages family members may have lost while caring for their loved ones, the authors acknowledge.

In addition, researchers measured only the probability of dementia and not whether the patients actually had dementia, the authors note. Few death certificates for patients with dementia will list that as the primary cause; instead, they report the problem that actually caused the patient to die, such as pneumonia.

Even so, the study findings highlight a financial burden posed by end-of-life care for elderly dementia patients that care reverberate through multiple generations, noted Carol Levine, director of the Families and Health Care Project at the United Hospital Fund, an independent policy group in New York City.

"There is a cascading effect: the financial drain for the older person's care means fewer resources not only for the caregiver but also for the younger generation's education and future prospects," Levine, who wasn't involved in the study, said by email.

"The immediate need for assistance is so compelling that future needs are often disregarded," Levine added. "The impact is greatest on families with the fewest resources to start with."

Many families also run into financial trouble because they mistakenly believe Medicare will pay for long term care services, said Dr. Mark Lachs, an expert in aging and finances at Weill Cornell Medical College in New York who wasn't involved in the study.

Families may consider long term care insurance to cover this gap in Medicare benefits, Dr. Lachs said by email.

Policy changes that might pay family members to be dementia caregivers would also help ease the financial strain, Dr. Lachs added.

Families may spend almost twice as much caring for dementia patients at the end of life than they might if their loved one suffered from a different disease, a U.S. study suggests.

Costs paid by Medicare, the U.S. health insurance program for the elderly, were similar over the final five years of life for patients with dementia, heart disease, cancer and other conditions, according to the study published in the Annals of Internal Medicine.

But the average out-of-pocket costs absorbed by families of dementia patients totaled $61,522 over those five years, far greater than the typical tab of $34,068 for patients without dementia.

"Many costs related to daily care for patients with dementia are not covered by health insurance, and these care needs, including everything from supervision to bathing and feeding, may span several years," lead author Dr. Amy Kelley of the Icahn School of Medicine at Mount Sinai in New York said by email.

To assess the financial toll dementia takes on families, Dr. Kelley and colleagues analyzed Medicare spending and out-of-pocket costs for about 1,700 people aged 70 and older who died between 2005 and 2010.

Over the five years prior to each patient's date of death, the average total cost, including what Medicare covered as well as what families paid, was about $287,000 for dementia patients. That compares with roughly $175,000 for heart disease, $173,000 for cancer, and $197,000 for people who died of other causes.

Families caring for dementia patients also spent a greater proportion of their wealth than families helping loved ones with other conditions. The financial burden as a proportion of wealth was even more pronounced for patients who were black, had less than a high school education, or were unmarried or widowed women.

Shortcomings of the study include the possibility that insurance payments may have been underestimated as well as the lack of data on wages family members may have lost while caring for their loved ones, the authors acknowledge.

In addition, researchers measured only the probability of dementia and not whether the patients actually had dementia, the authors note. Few death certificates for patients with dementia will list that as the primary cause; instead, they report the problem that actually caused the patient to die, such as pneumonia.

Even so, the study findings highlight a financial burden posed by end-of-life care for elderly dementia patients that care reverberate through multiple generations, noted Carol Levine, director of the Families and Health Care Project at the United Hospital Fund, an independent policy group in New York City.

"There is a cascading effect: the financial drain for the older person's care means fewer resources not only for the caregiver but also for the younger generation's education and future prospects," Levine, who wasn't involved in the study, said by email.

"The immediate need for assistance is so compelling that future needs are often disregarded," Levine added. "The impact is greatest on families with the fewest resources to start with."

Many families also run into financial trouble because they mistakenly believe Medicare will pay for long term care services, said Dr. Mark Lachs, an expert in aging and finances at Weill Cornell Medical College in New York who wasn't involved in the study.

Families may consider long term care insurance to cover this gap in Medicare benefits, Dr. Lachs said by email.

Policy changes that might pay family members to be dementia caregivers would also help ease the financial strain, Dr. Lachs added.

Families may spend almost twice as much caring for dementia patients at the end of life than they might if their loved one suffered from a different disease, a U.S. study suggests.

Costs paid by Medicare, the U.S. health insurance program for the elderly, were similar over the final five years of life for patients with dementia, heart disease, cancer and other conditions, according to the study published in the Annals of Internal Medicine.

But the average out-of-pocket costs absorbed by families of dementia patients totaled $61,522 over those five years, far greater than the typical tab of $34,068 for patients without dementia.

"Many costs related to daily care for patients with dementia are not covered by health insurance, and these care needs, including everything from supervision to bathing and feeding, may span several years," lead author Dr. Amy Kelley of the Icahn School of Medicine at Mount Sinai in New York said by email.

To assess the financial toll dementia takes on families, Dr. Kelley and colleagues analyzed Medicare spending and out-of-pocket costs for about 1,700 people aged 70 and older who died between 2005 and 2010.

Over the five years prior to each patient's date of death, the average total cost, including what Medicare covered as well as what families paid, was about $287,000 for dementia patients. That compares with roughly $175,000 for heart disease, $173,000 for cancer, and $197,000 for people who died of other causes.

Families caring for dementia patients also spent a greater proportion of their wealth than families helping loved ones with other conditions. The financial burden as a proportion of wealth was even more pronounced for patients who were black, had less than a high school education, or were unmarried or widowed women.

Shortcomings of the study include the possibility that insurance payments may have been underestimated as well as the lack of data on wages family members may have lost while caring for their loved ones, the authors acknowledge.

In addition, researchers measured only the probability of dementia and not whether the patients actually had dementia, the authors note. Few death certificates for patients with dementia will list that as the primary cause; instead, they report the problem that actually caused the patient to die, such as pneumonia.

Even so, the study findings highlight a financial burden posed by end-of-life care for elderly dementia patients that care reverberate through multiple generations, noted Carol Levine, director of the Families and Health Care Project at the United Hospital Fund, an independent policy group in New York City.

"There is a cascading effect: the financial drain for the older person's care means fewer resources not only for the caregiver but also for the younger generation's education and future prospects," Levine, who wasn't involved in the study, said by email.

"The immediate need for assistance is so compelling that future needs are often disregarded," Levine added. "The impact is greatest on families with the fewest resources to start with."

Many families also run into financial trouble because they mistakenly believe Medicare will pay for long term care services, said Dr. Mark Lachs, an expert in aging and finances at Weill Cornell Medical College in New York who wasn't involved in the study.

Families may consider long term care insurance to cover this gap in Medicare benefits, Dr. Lachs said by email.

Policy changes that might pay family members to be dementia caregivers would also help ease the financial strain, Dr. Lachs added.

While smoking is linked to an increased risk of developing diabetes, this risk appears to drop over the long term once cigarette use stops, a review of evidence suggests.

Researchers analyzed data on almost 5.9 million people in 88 previous studies examining the connection between smoking, second-hand smoke exposure and diabetes. They estimated that roughly 28 million type 2 diabetes cases worldwide - or about 11.7 percent of cases in men and 2.4 percent in women - could be attributed to active smoking.

The more cigarettes smokers consumed, the more their odds of getting diabetes increased.

If they quit, ex-smokers initially faced an even higher risk of diabetes, but as more years pass without cigarette use their odds of getting the disease gradually diminished, the analysis found.

"The diabetes risk remains high in the recent quitters," said lead study author An Pan, of Huazhong University of Science and Technology in China. Weight gain linked to smoking cessation may be at least partly to blame for the heightened diabetes risk in those first months after giving up cigarettes, Pan added.

"However, the diabetes risk is reduced substantially after five years," Pan said by email. "The long-term benefits - including benefits for other diseases like cancer and heart disease - clearly outweigh the short-term higher risk."

Worldwide, nearly one in 10 adults had diabetes in 2014, and the disease will be the seventh leading cause of death by 2030, according to the World Health Organization.

Most of these people have type 2 diabetes, which is associated with obesity and aging and happens when the body can't properly use or make enough of the hormone insulin to convert blood sugar into energy. Left untreated, diabetes can lead to nerve damage, amputations, blindness, heart disease and strokes.

Plenty of research has established a connection between smoking and diabetes, although the reason is still unclear.

For the current analysis, Pan and colleges focused on exploring the link between the amount and type of smoke exposure and diabetes risk, as well as the potential for this risk to diminish with smoking cessation.

Overall, the pooled data from all the studies showed the risk of diabetes was 37 percent higher for smokers than non-smokers, the study team reports in The Lancet Diabetes and Endocrinology.

Exactly how smoking might lead to diabetes isn't firmly established, but it's possible smoking might cause inflammation, which in turn boosts the risk for diabetes, Dr. Abbas Dehghan, of Erasmus University Medical Center in Rotterdam, The Netherlands.

"The more one smokes, the more chronic inflammation there will be, and the higher the risk of diabetes will be," Dehghan, who wasn't involved in the study, said by email.

Occasional smokers were 21 percent more likely to have diabetes than people who never picked up the habit, while the increased risk was 57 percent for heavy smokers.

People exposed to second-hand smoke were 22 percent more likely to develop diabetes than people who never smoked, the study also found.

If smokers quit, their risk of diabetes over the next five years was 54 percent higher than for people who never smoked. After that, the increased risk dropped to 18 percent over the following five-year period. Remaining abstinent for a decade or more, however, reduced the extra risk to 11 percent.

While the connection between smoking and diabetes is nowhere near as strong as the link between cigarettes and lung cancer, the findings still suggest that doctors should add diabetes to the list of risks they warn smokers about, Amy Taylor of the University of Bristol in the U.K. and colleagues note in an accompanying editorial.

The short-term increase in diabetes risk after quitting shouldn't deter smokers' cessation efforts, they argue. Instead, smokers should remember that cigarettes are tied to lower weight and cessation can lead some people to eat or drink more, leading to weight gain.

While smoking is linked to an increased risk of developing diabetes, this risk appears to drop over the long term once cigarette use stops, a review of evidence suggests.

Researchers analyzed data on almost 5.9 million people in 88 previous studies examining the connection between smoking, second-hand smoke exposure and diabetes. They estimated that roughly 28 million type 2 diabetes cases worldwide - or about 11.7 percent of cases in men and 2.4 percent in women - could be attributed to active smoking.

The more cigarettes smokers consumed, the more their odds of getting diabetes increased.

If they quit, ex-smokers initially faced an even higher risk of diabetes, but as more years pass without cigarette use their odds of getting the disease gradually diminished, the analysis found.

"The diabetes risk remains high in the recent quitters," said lead study author An Pan, of Huazhong University of Science and Technology in China. Weight gain linked to smoking cessation may be at least partly to blame for the heightened diabetes risk in those first months after giving up cigarettes, Pan added.

"However, the diabetes risk is reduced substantially after five years," Pan said by email. "The long-term benefits - including benefits for other diseases like cancer and heart disease - clearly outweigh the short-term higher risk."

Worldwide, nearly one in 10 adults had diabetes in 2014, and the disease will be the seventh leading cause of death by 2030, according to the World Health Organization.

Most of these people have type 2 diabetes, which is associated with obesity and aging and happens when the body can't properly use or make enough of the hormone insulin to convert blood sugar into energy. Left untreated, diabetes can lead to nerve damage, amputations, blindness, heart disease and strokes.

Plenty of research has established a connection between smoking and diabetes, although the reason is still unclear.

For the current analysis, Pan and colleges focused on exploring the link between the amount and type of smoke exposure and diabetes risk, as well as the potential for this risk to diminish with smoking cessation.

Overall, the pooled data from all the studies showed the risk of diabetes was 37 percent higher for smokers than non-smokers, the study team reports in The Lancet Diabetes and Endocrinology.

Exactly how smoking might lead to diabetes isn't firmly established, but it's possible smoking might cause inflammation, which in turn boosts the risk for diabetes, Dr. Abbas Dehghan, of Erasmus University Medical Center in Rotterdam, The Netherlands.

"The more one smokes, the more chronic inflammation there will be, and the higher the risk of diabetes will be," Dehghan, who wasn't involved in the study, said by email.

Occasional smokers were 21 percent more likely to have diabetes than people who never picked up the habit, while the increased risk was 57 percent for heavy smokers.

People exposed to second-hand smoke were 22 percent more likely to develop diabetes than people who never smoked, the study also found.

If smokers quit, their risk of diabetes over the next five years was 54 percent higher than for people who never smoked. After that, the increased risk dropped to 18 percent over the following five-year period. Remaining abstinent for a decade or more, however, reduced the extra risk to 11 percent.

While the connection between smoking and diabetes is nowhere near as strong as the link between cigarettes and lung cancer, the findings still suggest that doctors should add diabetes to the list of risks they warn smokers about, Amy Taylor of the University of Bristol in the U.K. and colleagues note in an accompanying editorial.

The short-term increase in diabetes risk after quitting shouldn't deter smokers' cessation efforts, they argue. Instead, smokers should remember that cigarettes are tied to lower weight and cessation can lead some people to eat or drink more, leading to weight gain.

While smoking is linked to an increased risk of developing diabetes, this risk appears to drop over the long term once cigarette use stops, a review of evidence suggests.

Researchers analyzed data on almost 5.9 million people in 88 previous studies examining the connection between smoking, second-hand smoke exposure and diabetes. They estimated that roughly 28 million type 2 diabetes cases worldwide - or about 11.7 percent of cases in men and 2.4 percent in women - could be attributed to active smoking.

The more cigarettes smokers consumed, the more their odds of getting diabetes increased.

If they quit, ex-smokers initially faced an even higher risk of diabetes, but as more years pass without cigarette use their odds of getting the disease gradually diminished, the analysis found.

"The diabetes risk remains high in the recent quitters," said lead study author An Pan, of Huazhong University of Science and Technology in China. Weight gain linked to smoking cessation may be at least partly to blame for the heightened diabetes risk in those first months after giving up cigarettes, Pan added.

"However, the diabetes risk is reduced substantially after five years," Pan said by email. "The long-term benefits - including benefits for other diseases like cancer and heart disease - clearly outweigh the short-term higher risk."

Worldwide, nearly one in 10 adults had diabetes in 2014, and the disease will be the seventh leading cause of death by 2030, according to the World Health Organization.

Most of these people have type 2 diabetes, which is associated with obesity and aging and happens when the body can't properly use or make enough of the hormone insulin to convert blood sugar into energy. Left untreated, diabetes can lead to nerve damage, amputations, blindness, heart disease and strokes.

Plenty of research has established a connection between smoking and diabetes, although the reason is still unclear.

For the current analysis, Pan and colleges focused on exploring the link between the amount and type of smoke exposure and diabetes risk, as well as the potential for this risk to diminish with smoking cessation.

Overall, the pooled data from all the studies showed the risk of diabetes was 37 percent higher for smokers than non-smokers, the study team reports in The Lancet Diabetes and Endocrinology.

Exactly how smoking might lead to diabetes isn't firmly established, but it's possible smoking might cause inflammation, which in turn boosts the risk for diabetes, Dr. Abbas Dehghan, of Erasmus University Medical Center in Rotterdam, The Netherlands.

"The more one smokes, the more chronic inflammation there will be, and the higher the risk of diabetes will be," Dehghan, who wasn't involved in the study, said by email.

Occasional smokers were 21 percent more likely to have diabetes than people who never picked up the habit, while the increased risk was 57 percent for heavy smokers.

People exposed to second-hand smoke were 22 percent more likely to develop diabetes than people who never smoked, the study also found.

If smokers quit, their risk of diabetes over the next five years was 54 percent higher than for people who never smoked. After that, the increased risk dropped to 18 percent over the following five-year period. Remaining abstinent for a decade or more, however, reduced the extra risk to 11 percent.

While the connection between smoking and diabetes is nowhere near as strong as the link between cigarettes and lung cancer, the findings still suggest that doctors should add diabetes to the list of risks they warn smokers about, Amy Taylor of the University of Bristol in the U.K. and colleagues note in an accompanying editorial.

The short-term increase in diabetes risk after quitting shouldn't deter smokers' cessation efforts, they argue. Instead, smokers should remember that cigarettes are tied to lower weight and cessation can lead some people to eat or drink more, leading to weight gain.

When patients are hospitalized more than once in the same month, it may have more to do with their income or education levels than the quality of care they received, a U.S. study suggests.

Perhaps unsurprisingly, patients 85 and older are more likely to return to the hospital within 30 days of being sent home than people a decade or two younger, according to the analysis of data from Medicare, the U.S. health program for the elderly and disabled.

But patients also have higher odds of returning soon after discharge if they lack a high school diploma, have limited income and assets or have health benefits from Medicaid, the U.S. health program for the poor.

The findings suggest that Medicare penalties for what's known as readmissions under the Affordable Care Act may in some instances mete out punishment for outcomes that are beyond doctors' control, said lead study author Dr. Michael Barnett and senior author Dr. Michael McWilliams, colleagues at Harvard Medical School and Brigham and Women's Hospital in Boston.

"Hospitals are being penalized to a large extent based on the patients they serve," the doctors said by email. "Patients admitted to hospitals with higher readmission rates are sicker and more socially disadvantaged in a variety of ways than patients admitted to hospitals with lower readmission rates."

Under the current penalty system, Medicare deducts 3 percent from inpatient payments to hospitals with higher than expected readmission rates, the researchers report in JAMA Internal Medicine. Expected rates are only adjusted for patients' age, sex and recent diagnoses including the one from their hospital stay.

In 2014, the second year of the program, about 2,600 hospitals were fined a combined $428 million for excessive readmissions, the authors report.

To get a better understanding of how individual patient characteristics might influence repeat hospitalizations, the researchers examined several other variables Medicare doesn't consider in determining expected readmission rates - such as education and income levels, marital status, employment, race and ethnicity, smoking status and drinking habits.

They linked records from a nationwide health and retirement survey of Americans over 50 collected between 2000 and 2010 to data from Medicare claims from 2000 to 2012. The combined analysis assessed more than 8,000 hospital admissions.

The researchers sorted hospitals into quintiles based on readmission rates. They found that at least half of the observed difference in the probability of repeat hospitalizations between hospitals with the highest and lowest readmission rates might be accounted for by patient characteristics not currently considered by Medicare.

When researchers only used Medicare's criteria comparing readmission rates, they found the probability of repeat hospitalization was about 15 percent at facilities with the lowest rates and about 19.5 percent at hospitals with the highest rates.

But when they took another look using more criteria on patients' medical, social and economic characteristics, the gap between hospitals with the lowest and the highest readmission rates narrowed to 16 percent and 18.4 percent, respectively, odds of repeat hospitalization.

One limitation of the study, the authors acknowledge, is the data didn't allow them to calculate how considering individual patient characteristics might impact readmission rates at specific hospitals.

Even so, the findings suggest that the current Medicare penalty system for repeat hospitalizations may put facilities serving poor communities at a distinct financial disadvantage, Dr. Carl van Walraven, a senior scientist at the Ottawa Hospital Research Institute in Canada, noted in an accompanying editorial.

"Differences between hospitals in readmissions may be due to who is treated rather than how they're treated," van Walraven said by email.

When patients are hospitalized more than once in the same month, it may have more to do with their income or education levels than the quality of care they received, a U.S. study suggests.

Perhaps unsurprisingly, patients 85 and older are more likely to return to the hospital within 30 days of being sent home than people a decade or two younger, according to the analysis of data from Medicare, the U.S. health program for the elderly and disabled.

But patients also have higher odds of returning soon after discharge if they lack a high school diploma, have limited income and assets or have health benefits from Medicaid, the U.S. health program for the poor.

The findings suggest that Medicare penalties for what's known as readmissions under the Affordable Care Act may in some instances mete out punishment for outcomes that are beyond doctors' control, said lead study author Dr. Michael Barnett and senior author Dr. Michael McWilliams, colleagues at Harvard Medical School and Brigham and Women's Hospital in Boston.

"Hospitals are being penalized to a large extent based on the patients they serve," the doctors said by email. "Patients admitted to hospitals with higher readmission rates are sicker and more socially disadvantaged in a variety of ways than patients admitted to hospitals with lower readmission rates."

Under the current penalty system, Medicare deducts 3 percent from inpatient payments to hospitals with higher than expected readmission rates, the researchers report in JAMA Internal Medicine. Expected rates are only adjusted for patients' age, sex and recent diagnoses including the one from their hospital stay.

In 2014, the second year of the program, about 2,600 hospitals were fined a combined $428 million for excessive readmissions, the authors report.

To get a better understanding of how individual patient characteristics might influence repeat hospitalizations, the researchers examined several other variables Medicare doesn't consider in determining expected readmission rates - such as education and income levels, marital status, employment, race and ethnicity, smoking status and drinking habits.

They linked records from a nationwide health and retirement survey of Americans over 50 collected between 2000 and 2010 to data from Medicare claims from 2000 to 2012. The combined analysis assessed more than 8,000 hospital admissions.

The researchers sorted hospitals into quintiles based on readmission rates. They found that at least half of the observed difference in the probability of repeat hospitalizations between hospitals with the highest and lowest readmission rates might be accounted for by patient characteristics not currently considered by Medicare.

When researchers only used Medicare's criteria comparing readmission rates, they found the probability of repeat hospitalization was about 15 percent at facilities with the lowest rates and about 19.5 percent at hospitals with the highest rates.

But when they took another look using more criteria on patients' medical, social and economic characteristics, the gap between hospitals with the lowest and the highest readmission rates narrowed to 16 percent and 18.4 percent, respectively, odds of repeat hospitalization.

One limitation of the study, the authors acknowledge, is the data didn't allow them to calculate how considering individual patient characteristics might impact readmission rates at specific hospitals.

Even so, the findings suggest that the current Medicare penalty system for repeat hospitalizations may put facilities serving poor communities at a distinct financial disadvantage, Dr. Carl van Walraven, a senior scientist at the Ottawa Hospital Research Institute in Canada, noted in an accompanying editorial.

"Differences between hospitals in readmissions may be due to who is treated rather than how they're treated," van Walraven said by email.

When patients are hospitalized more than once in the same month, it may have more to do with their income or education levels than the quality of care they received, a U.S. study suggests.

Perhaps unsurprisingly, patients 85 and older are more likely to return to the hospital within 30 days of being sent home than people a decade or two younger, according to the analysis of data from Medicare, the U.S. health program for the elderly and disabled.

But patients also have higher odds of returning soon after discharge if they lack a high school diploma, have limited income and assets or have health benefits from Medicaid, the U.S. health program for the poor.

The findings suggest that Medicare penalties for what's known as readmissions under the Affordable Care Act may in some instances mete out punishment for outcomes that are beyond doctors' control, said lead study author Dr. Michael Barnett and senior author Dr. Michael McWilliams, colleagues at Harvard Medical School and Brigham and Women's Hospital in Boston.

"Hospitals are being penalized to a large extent based on the patients they serve," the doctors said by email. "Patients admitted to hospitals with higher readmission rates are sicker and more socially disadvantaged in a variety of ways than patients admitted to hospitals with lower readmission rates."

Under the current penalty system, Medicare deducts 3 percent from inpatient payments to hospitals with higher than expected readmission rates, the researchers report in JAMA Internal Medicine. Expected rates are only adjusted for patients' age, sex and recent diagnoses including the one from their hospital stay.

In 2014, the second year of the program, about 2,600 hospitals were fined a combined $428 million for excessive readmissions, the authors report.

To get a better understanding of how individual patient characteristics might influence repeat hospitalizations, the researchers examined several other variables Medicare doesn't consider in determining expected readmission rates - such as education and income levels, marital status, employment, race and ethnicity, smoking status and drinking habits.

They linked records from a nationwide health and retirement survey of Americans over 50 collected between 2000 and 2010 to data from Medicare claims from 2000 to 2012. The combined analysis assessed more than 8,000 hospital admissions.

The researchers sorted hospitals into quintiles based on readmission rates. They found that at least half of the observed difference in the probability of repeat hospitalizations between hospitals with the highest and lowest readmission rates might be accounted for by patient characteristics not currently considered by Medicare.

When researchers only used Medicare's criteria comparing readmission rates, they found the probability of repeat hospitalization was about 15 percent at facilities with the lowest rates and about 19.5 percent at hospitals with the highest rates.

But when they took another look using more criteria on patients' medical, social and economic characteristics, the gap between hospitals with the lowest and the highest readmission rates narrowed to 16 percent and 18.4 percent, respectively, odds of repeat hospitalization.

One limitation of the study, the authors acknowledge, is the data didn't allow them to calculate how considering individual patient characteristics might impact readmission rates at specific hospitals.

Even so, the findings suggest that the current Medicare penalty system for repeat hospitalizations may put facilities serving poor communities at a distinct financial disadvantage, Dr. Carl van Walraven, a senior scientist at the Ottawa Hospital Research Institute in Canada, noted in an accompanying editorial.

"Differences between hospitals in readmissions may be due to who is treated rather than how they're treated," van Walraven said by email.

After a heart attack, black patients typically don't live as long as whites - a racial difference that is starkest among the affluent - according to a new U.S. study.

Researchers evaluated data on more than 132,000 white heart attack patients and almost 9,000 black patients covered by Medicare, the government health program for the elderly and disabled. They used postal codes to assess income levels in patients' communities.

After 17 years of follow-up, the overall survival rate was 7.4 percent for white patients and 5.7 percent for black patients, according to the results published in Circulation, the journal of the American Heart Association.

On average, across all ages, white patients in low-income areas lived longer after a heart attack - about 5.6 years compared with 5.4 years for black patients. But in high-income communities, the gap widened to a life expectancy of seven years for white people and 6.3 years for black individuals.

"We found that socioeconomic status did not explain the racial disparities in life expectancy after a heart attack," lead study author Dr. Emily Bucholz of Boston Children's Hospital said by email.

"Contrary to common belief, this suggests that improving socioeconomic standing may improve outcomes for black and white patients globally but is unlikely to eliminate racial disparities in health," Bucholz added.

To see how race and class impact heart attack outcomes, Bucholz and colleagues reviewed health records collected from 1994 to 1996 for patients aged 65 to 90 years.

Just 6.3 percent of the patients were black, and only 6.8 percent lived in low-income communities, based on the typical household income in their postal codes.

Among white patients under 80, life expectancy was longest for patients in the most affluent neighborhoods and it got progressively shorter for middle-income and poor communities, the study found.

By contrast, life expectancy was similar for black patients residing in poor and middle-income communities across all ages. Only black patients under age 75 living in affluent areas had a survival advantage compared with their peers in less wealthy neighborhoods.

One shortcoming of the study is that it included a small proportion of black and poor patients, the authors acknowledge. It's also possible that using postal codes to assess income may have led to some instances where income levels were inflated or underestimated, the authors note.

It's possible that black patients living in affluent areas don't fare as well as white patients because they don't have the same amount of social support from their peers, said Dr. Joaquin Cigarroa, a cardiovascular medicine researcher at Oregon Health & Science University in Portland.

In poor neighborhoods, black patients may face additional challenges to surviving a heart attack, added Cigarroa, who wasn't involved in the study.

"They more often live in low socioeconomic segments of our community that often have less access to health care resources and less access to stores with good nutrition," Cigarroa said by email. "In addition, these segments of our community are often not ideally configured for promoting physical activity with parks, sidewalks, bike lanes, etc."

The study findings highlight a need to improve outcomes among poor and black patients and suggest some differences in heart attack survival may come down to disparities in quality of care, said senior study author Dr. Harlan Krumholz of Yale University School of Medicine in New Haven, Connecticut.

Because black patients have a greater burden of heart disease than white people, doctors may also need to focus more on prevention in this community, Krumholz said by email.

"Healthy heart habits may be even more important for African-Americans, for whom avoiding a heart attack is even more important given their worse outcomes after the event," Krumholz said.

After a heart attack, black patients typically don't live as long as whites - a racial difference that is starkest among the affluent - according to a new U.S. study.

Researchers evaluated data on more than 132,000 white heart attack patients and almost 9,000 black patients covered by Medicare, the government health program for the elderly and disabled. They used postal codes to assess income levels in patients' communities.

After 17 years of follow-up, the overall survival rate was 7.4 percent for white patients and 5.7 percent for black patients, according to the results published in Circulation, the journal of the American Heart Association.

On average, across all ages, white patients in low-income areas lived longer after a heart attack - about 5.6 years compared with 5.4 years for black patients. But in high-income communities, the gap widened to a life expectancy of seven years for white people and 6.3 years for black individuals.

"We found that socioeconomic status did not explain the racial disparities in life expectancy after a heart attack," lead study author Dr. Emily Bucholz of Boston Children's Hospital said by email.

"Contrary to common belief, this suggests that improving socioeconomic standing may improve outcomes for black and white patients globally but is unlikely to eliminate racial disparities in health," Bucholz added.

To see how race and class impact heart attack outcomes, Bucholz and colleagues reviewed health records collected from 1994 to 1996 for patients aged 65 to 90 years.

Just 6.3 percent of the patients were black, and only 6.8 percent lived in low-income communities, based on the typical household income in their postal codes.

Among white patients under 80, life expectancy was longest for patients in the most affluent neighborhoods and it got progressively shorter for middle-income and poor communities, the study found.

By contrast, life expectancy was similar for black patients residing in poor and middle-income communities across all ages. Only black patients under age 75 living in affluent areas had a survival advantage compared with their peers in less wealthy neighborhoods.

One shortcoming of the study is that it included a small proportion of black and poor patients, the authors acknowledge. It's also possible that using postal codes to assess income may have led to some instances where income levels were inflated or underestimated, the authors note.

It's possible that black patients living in affluent areas don't fare as well as white patients because they don't have the same amount of social support from their peers, said Dr. Joaquin Cigarroa, a cardiovascular medicine researcher at Oregon Health & Science University in Portland.

In poor neighborhoods, black patients may face additional challenges to surviving a heart attack, added Cigarroa, who wasn't involved in the study.

"They more often live in low socioeconomic segments of our community that often have less access to health care resources and less access to stores with good nutrition," Cigarroa said by email. "In addition, these segments of our community are often not ideally configured for promoting physical activity with parks, sidewalks, bike lanes, etc."

The study findings highlight a need to improve outcomes among poor and black patients and suggest some differences in heart attack survival may come down to disparities in quality of care, said senior study author Dr. Harlan Krumholz of Yale University School of Medicine in New Haven, Connecticut.

Because black patients have a greater burden of heart disease than white people, doctors may also need to focus more on prevention in this community, Krumholz said by email.

"Healthy heart habits may be even more important for African-Americans, for whom avoiding a heart attack is even more important given their worse outcomes after the event," Krumholz said.

After a heart attack, black patients typically don't live as long as whites - a racial difference that is starkest among the affluent - according to a new U.S. study.

Researchers evaluated data on more than 132,000 white heart attack patients and almost 9,000 black patients covered by Medicare, the government health program for the elderly and disabled. They used postal codes to assess income levels in patients' communities.

After 17 years of follow-up, the overall survival rate was 7.4 percent for white patients and 5.7 percent for black patients, according to the results published in Circulation, the journal of the American Heart Association.

On average, across all ages, white patients in low-income areas lived longer after a heart attack - about 5.6 years compared with 5.4 years for black patients. But in high-income communities, the gap widened to a life expectancy of seven years for white people and 6.3 years for black individuals.

"We found that socioeconomic status did not explain the racial disparities in life expectancy after a heart attack," lead study author Dr. Emily Bucholz of Boston Children's Hospital said by email.

"Contrary to common belief, this suggests that improving socioeconomic standing may improve outcomes for black and white patients globally but is unlikely to eliminate racial disparities in health," Bucholz added.

To see how race and class impact heart attack outcomes, Bucholz and colleagues reviewed health records collected from 1994 to 1996 for patients aged 65 to 90 years.

Just 6.3 percent of the patients were black, and only 6.8 percent lived in low-income communities, based on the typical household income in their postal codes.

Among white patients under 80, life expectancy was longest for patients in the most affluent neighborhoods and it got progressively shorter for middle-income and poor communities, the study found.

By contrast, life expectancy was similar for black patients residing in poor and middle-income communities across all ages. Only black patients under age 75 living in affluent areas had a survival advantage compared with their peers in less wealthy neighborhoods.

One shortcoming of the study is that it included a small proportion of black and poor patients, the authors acknowledge. It's also possible that using postal codes to assess income may have led to some instances where income levels were inflated or underestimated, the authors note.

It's possible that black patients living in affluent areas don't fare as well as white patients because they don't have the same amount of social support from their peers, said Dr. Joaquin Cigarroa, a cardiovascular medicine researcher at Oregon Health & Science University in Portland.

In poor neighborhoods, black patients may face additional challenges to surviving a heart attack, added Cigarroa, who wasn't involved in the study.

"They more often live in low socioeconomic segments of our community that often have less access to health care resources and less access to stores with good nutrition," Cigarroa said by email. "In addition, these segments of our community are often not ideally configured for promoting physical activity with parks, sidewalks, bike lanes, etc."

The study findings highlight a need to improve outcomes among poor and black patients and suggest some differences in heart attack survival may come down to disparities in quality of care, said senior study author Dr. Harlan Krumholz of Yale University School of Medicine in New Haven, Connecticut.

Because black patients have a greater burden of heart disease than white people, doctors may also need to focus more on prevention in this community, Krumholz said by email.

"Healthy heart habits may be even more important for African-Americans, for whom avoiding a heart attack is even more important given their worse outcomes after the event," Krumholz said.

Diabetes affects up to 14 percent of the U.S. population - an increase from nearly 10 percent in the early 1990s - yet over a third of cases still go undiagnosed, according to a new analysis.

Screening seems to be catching more cases, accounting for the general rise over two decades, the study authors say, but mainly whites have benefited; for Hispanic and Asian people in particular, more than half of cases go undetected.

"We need to better educate people on the risk factors for diabetes - including older age, family history and obesity - and improve screening for those at high risk," lead study author Andy Menke, an epidemiologist at Social and Scientific Systems in Silver Spring, Maryland, said by email.

Globally, about one in nine adults has diagnosed diabetes, and the disease will be the seventh leading cause of death by 2030, according to the World Health Organization.

Most of these people have Type 2, or adult-onset, diabetes, which happens when the body can't properly use or make enough of the hormone insulin to convert blood sugar into energy. Left untreated, diabetes can lead to nerve damage, amputations, blindness, heart disease and strokes.

Average blood sugar levels over the course of several months can be estimated by measuring changes to the hemoglobin molecule in red blood cells. The hemoglobin A1c test measures the percentage of hemoglobin - the protein in red blood cells that

carries oxygen - that is coated with sugar, with readings of 6.5 percent or above signaling diabetes.

People with A1c levels between 5.7 percent and 6.4 percent aren't diabetic, but because this is considered elevated it is sometimes called "pre-diabetes" and considered a risk factor for going on to develop full-blown diabetes.

Menke and colleagues estimated the prevalence of diabetes and pre-diabetes using data from the National Health and Nutrition Examination Survey (NHANES) collected on 2,781 adults in 2011 to 2012 and an additional 23,634 adults from 1988 to 2010.

While the prevalence of diabetes increased over time in the overall population, gains were more pronounced among racial and ethnic minorities, the study found.

About 11 percent of white people have diabetes, the researchers calculated, compared with 22 percent of non-Hispanic black participants, 21 percent of Asians and 23 percent of Hispanics.

Among Asians, 51 percent of those with diabetes were unaware of it, and the same was true for 49 percent of Hispanic people with the condition.

An additional 38 percent of adults fell into the pre-diabetes category. Added to the prevalence of diabetes, that means more than half of the U.S. population has diabetes or is at increased risk for it, the authors point out.

The good news, however, is fewer people are undiagnosed than in the past, Dr. William Herman and Dr. Amy Rothberg of the University of Michigan in Ann Arbor note in commentary accompanying the study in JAMA.

In it, they note that the increase in diabetes prevalence between 1988 and 2012 seen in the study was due to an increase in diagnosed cases, and that overall undiagnosed cases fell from 40 percent in 1988-1994 to 31 percent in 2008-2012.

This "likely reflects increased awareness of the problem of undiagnosed diabetes and increased testing," they said by email.

The drop in undiagnosed cases, they added, may be due in part to the newer, simpler A1c test, which doesn't require fasting or any advance preparation.

It's also possible that new cases of diabetes are starting to fall for the first time in decades because more people are getting the message about lifestyle choices that can contribute to diabetes, noted Dr. David Nathan, director of the diabetes center at Massachusetts General Hospital in Boston and a professor at Harvard Medical School.

In particular, more patients now understand that being overweight or obese increases the risk for diabetes, Nathan, author of a separate report in JAMA on advances in diagnosis and treatment, said by email.

"Behavioral changes, including healthy eating and more activity can prevent, or at least ameliorate, the diabetes epidemic," Nathan said.

Diabetes affects up to 14 percent of the U.S. population - an increase from nearly 10 percent in the early 1990s - yet over a third of cases still go undiagnosed, according to a new analysis.

Screening seems to be catching more cases, accounting for the general rise over two decades, the study authors say, but mainly whites have benefited; for Hispanic and Asian people in particular, more than half of cases go undetected.

"We need to better educate people on the risk factors for diabetes - including older age, family history and obesity - and improve screening for those at high risk," lead study author Andy Menke, an epidemiologist at Social and Scientific Systems in Silver Spring, Maryland, said by email.

Globally, about one in nine adults has diagnosed diabetes, and the disease will be the seventh leading cause of death by 2030, according to the World Health Organization.

Most of these people have Type 2, or adult-onset, diabetes, which happens when the body can't properly use or make enough of the hormone insulin to convert blood sugar into energy. Left untreated, diabetes can lead to nerve damage, amputations, blindness, heart disease and strokes.

Average blood sugar levels over the course of several months can be estimated by measuring changes to the hemoglobin molecule in red blood cells. The hemoglobin A1c test measures the percentage of hemoglobin - the protein in red blood cells that

carries oxygen - that is coated with sugar, with readings of 6.5 percent or above signaling diabetes.

People with A1c levels between 5.7 percent and 6.4 percent aren't diabetic, but because this is considered elevated it is sometimes called "pre-diabetes" and considered a risk factor for going on to develop full-blown diabetes.

Menke and colleagues estimated the prevalence of diabetes and pre-diabetes using data from the National Health and Nutrition Examination Survey (NHANES) collected on 2,781 adults in 2011 to 2012 and an additional 23,634 adults from 1988 to 2010.

While the prevalence of diabetes increased over time in the overall population, gains were more pronounced among racial and ethnic minorities, the study found.

About 11 percent of white people have diabetes, the researchers calculated, compared with 22 percent of non-Hispanic black participants, 21 percent of Asians and 23 percent of Hispanics.

Among Asians, 51 percent of those with diabetes were unaware of it, and the same was true for 49 percent of Hispanic people with the condition.

An additional 38 percent of adults fell into the pre-diabetes category. Added to the prevalence of diabetes, that means more than half of the U.S. population has diabetes or is at increased risk for it, the authors point out.

The good news, however, is fewer people are undiagnosed than in the past, Dr. William Herman and Dr. Amy Rothberg of the University of Michigan in Ann Arbor note in commentary accompanying the study in JAMA.

In it, they note that the increase in diabetes prevalence between 1988 and 2012 seen in the study was due to an increase in diagnosed cases, and that overall undiagnosed cases fell from 40 percent in 1988-1994 to 31 percent in 2008-2012.

This "likely reflects increased awareness of the problem of undiagnosed diabetes and increased testing," they said by email.

The drop in undiagnosed cases, they added, may be due in part to the newer, simpler A1c test, which doesn't require fasting or any advance preparation.

It's also possible that new cases of diabetes are starting to fall for the first time in decades because more people are getting the message about lifestyle choices that can contribute to diabetes, noted Dr. David Nathan, director of the diabetes center at Massachusetts General Hospital in Boston and a professor at Harvard Medical School.

In particular, more patients now understand that being overweight or obese increases the risk for diabetes, Nathan, author of a separate report in JAMA on advances in diagnosis and treatment, said by email.

"Behavioral changes, including healthy eating and more activity can prevent, or at least ameliorate, the diabetes epidemic," Nathan said.

Diabetes affects up to 14 percent of the U.S. population - an increase from nearly 10 percent in the early 1990s - yet over a third of cases still go undiagnosed, according to a new analysis.

Screening seems to be catching more cases, accounting for the general rise over two decades, the study authors say, but mainly whites have benefited; for Hispanic and Asian people in particular, more than half of cases go undetected.

"We need to better educate people on the risk factors for diabetes - including older age, family history and obesity - and improve screening for those at high risk," lead study author Andy Menke, an epidemiologist at Social and Scientific Systems in Silver Spring, Maryland, said by email.

Globally, about one in nine adults has diagnosed diabetes, and the disease will be the seventh leading cause of death by 2030, according to the World Health Organization.

Most of these people have Type 2, or adult-onset, diabetes, which happens when the body can't properly use or make enough of the hormone insulin to convert blood sugar into energy. Left untreated, diabetes can lead to nerve damage, amputations, blindness, heart disease and strokes.

Average blood sugar levels over the course of several months can be estimated by measuring changes to the hemoglobin molecule in red blood cells. The hemoglobin A1c test measures the percentage of hemoglobin - the protein in red blood cells that

carries oxygen - that is coated with sugar, with readings of 6.5 percent or above signaling diabetes.

People with A1c levels between 5.7 percent and 6.4 percent aren't diabetic, but because this is considered elevated it is sometimes called "pre-diabetes" and considered a risk factor for going on to develop full-blown diabetes.

Menke and colleagues estimated the prevalence of diabetes and pre-diabetes using data from the National Health and Nutrition Examination Survey (NHANES) collected on 2,781 adults in 2011 to 2012 and an additional 23,634 adults from 1988 to 2010.

While the prevalence of diabetes increased over time in the overall population, gains were more pronounced among racial and ethnic minorities, the study found.

About 11 percent of white people have diabetes, the researchers calculated, compared with 22 percent of non-Hispanic black participants, 21 percent of Asians and 23 percent of Hispanics.

Among Asians, 51 percent of those with diabetes were unaware of it, and the same was true for 49 percent of Hispanic people with the condition.

An additional 38 percent of adults fell into the pre-diabetes category. Added to the prevalence of diabetes, that means more than half of the U.S. population has diabetes or is at increased risk for it, the authors point out.

The good news, however, is fewer people are undiagnosed than in the past, Dr. William Herman and Dr. Amy Rothberg of the University of Michigan in Ann Arbor note in commentary accompanying the study in JAMA.

In it, they note that the increase in diabetes prevalence between 1988 and 2012 seen in the study was due to an increase in diagnosed cases, and that overall undiagnosed cases fell from 40 percent in 1988-1994 to 31 percent in 2008-2012.

This "likely reflects increased awareness of the problem of undiagnosed diabetes and increased testing," they said by email.

The drop in undiagnosed cases, they added, may be due in part to the newer, simpler A1c test, which doesn't require fasting or any advance preparation.

It's also possible that new cases of diabetes are starting to fall for the first time in decades because more people are getting the message about lifestyle choices that can contribute to diabetes, noted Dr. David Nathan, director of the diabetes center at Massachusetts General Hospital in Boston and a professor at Harvard Medical School.

In particular, more patients now understand that being overweight or obese increases the risk for diabetes, Nathan, author of a separate report in JAMA on advances in diagnosis and treatment, said by email.

"Behavioral changes, including healthy eating and more activity can prevent, or at least ameliorate, the diabetes epidemic," Nathan said.

NEW YORK—Smokers who switch to e-cigarettes - even if only some of the time - may dramatically reduce their exposure to air pollutants including carbon monoxide and acrolein, a British study suggests.

Researchers gave e-cigarettes to 40 smokers who said they wanted to quit. After four weeks, the 16 participants using only e-cigarettes had about an 80% drop in exposure both to carbon monoxide and to acrolein, a harmful breakdown product that is also in some e-cigarettes' vapor. Acrolein is known to irritate exposed tissues and can destroy cilia.

The 17 participants who swapped some regular cigarettes for the electronic version had a 52% decline in carbon monoxide exposure and a 60% decline for acrolein, according to a report online September 3 in Cancer Prevention Research.

To get the most benefit from switching to e-cigarettes, smokers need to completely give up traditional cigarettes, lead study author Dr. Hayden McRobbie, of the Wolfson Institute of Preventive Medicine at Queen Mary University of London, said by email.

"Smokers may get some encouragement from the finding that there is some potential health benefit as soon as they start the process," Dr. McRobbie said.

While tobacco control advocates fear that e-cigarettes may give rise to a new generation of nicotine addicts who eventually transition to conventional cigarettes, the current study adds to a small but growing body of evidence suggesting the devices might benefit the health of people who already smoke.

An international analysis of published research by the Cochrane Review in December concluded the devices could help smokers quit but said much of the existing research on e-cigarettes was thin.

Even though the current study points to another potential benefit of e-cigarettes, more evidence is still needed from longer and larger trials before scientists can draw firm conclusions about any safety advantages, Dr. Nancy Rigotti, director of tobacco research at Massachusetts General Hospital in Boston, said by email.

"It is exactly the type of incremental, careful work that is needed but it is not yet a definitive study," Rigotti, who wasn't involved in the study, said.

Study participants were typically in their 40s and had attempted to quit at least twice before joining the trial. All of them were offered the same type of e-cigarette and encouraged to completely abandon traditional cigarettes.

Researchers measured carbon monoxide in participants' breath one week before switching to e-cigarettes, on the day they switched, and again four weeks later. They followed the same schedule for testing urine for exposure to acrolein.

A limitation of the study, the authors acknowledged, is that it only included people with a desire to quit smoking, making it possible the results would be different for smokers with no intention of quitting. It's also possible that the specific model of e-cigarette used in the study might not be representative of other devices.

Still, the findings suggest smokers should be told e-cigarettes may curb their exposure to toxic chemicals, Dr. Riccardo Polosa, head of the tobacco research center at the University of Catania in Italy, said by email.

"This study adds to the evidence that e-cigarettes are much less harmful compared to conventional cigarettes," said Polosa, who wasn't involved in the study.

NEW YORK—Smokers who switch to e-cigarettes - even if only some of the time - may dramatically reduce their exposure to air pollutants including carbon monoxide and acrolein, a British study suggests.

Researchers gave e-cigarettes to 40 smokers who said they wanted to quit. After four weeks, the 16 participants using only e-cigarettes had about an 80% drop in exposure both to carbon monoxide and to acrolein, a harmful breakdown product that is also in some e-cigarettes' vapor. Acrolein is known to irritate exposed tissues and can destroy cilia.

The 17 participants who swapped some regular cigarettes for the electronic version had a 52% decline in carbon monoxide exposure and a 60% decline for acrolein, according to a report online September 3 in Cancer Prevention Research.

To get the most benefit from switching to e-cigarettes, smokers need to completely give up traditional cigarettes, lead study author Dr. Hayden McRobbie, of the Wolfson Institute of Preventive Medicine at Queen Mary University of London, said by email.

"Smokers may get some encouragement from the finding that there is some potential health benefit as soon as they start the process," Dr. McRobbie said.

While tobacco control advocates fear that e-cigarettes may give rise to a new generation of nicotine addicts who eventually transition to conventional cigarettes, the current study adds to a small but growing body of evidence suggesting the devices might benefit the health of people who already smoke.

An international analysis of published research by the Cochrane Review in December concluded the devices could help smokers quit but said much of the existing research on e-cigarettes was thin.

Even though the current study points to another potential benefit of e-cigarettes, more evidence is still needed from longer and larger trials before scientists can draw firm conclusions about any safety advantages, Dr. Nancy Rigotti, director of tobacco research at Massachusetts General Hospital in Boston, said by email.

"It is exactly the type of incremental, careful work that is needed but it is not yet a definitive study," Rigotti, who wasn't involved in the study, said.

Study participants were typically in their 40s and had attempted to quit at least twice before joining the trial. All of them were offered the same type of e-cigarette and encouraged to completely abandon traditional cigarettes.

Researchers measured carbon monoxide in participants' breath one week before switching to e-cigarettes, on the day they switched, and again four weeks later. They followed the same schedule for testing urine for exposure to acrolein.

A limitation of the study, the authors acknowledged, is that it only included people with a desire to quit smoking, making it possible the results would be different for smokers with no intention of quitting. It's also possible that the specific model of e-cigarette used in the study might not be representative of other devices.

Still, the findings suggest smokers should be told e-cigarettes may curb their exposure to toxic chemicals, Dr. Riccardo Polosa, head of the tobacco research center at the University of Catania in Italy, said by email.

"This study adds to the evidence that e-cigarettes are much less harmful compared to conventional cigarettes," said Polosa, who wasn't involved in the study.

NEW YORK—Smokers who switch to e-cigarettes - even if only some of the time - may dramatically reduce their exposure to air pollutants including carbon monoxide and acrolein, a British study suggests.

Researchers gave e-cigarettes to 40 smokers who said they wanted to quit. After four weeks, the 16 participants using only e-cigarettes had about an 80% drop in exposure both to carbon monoxide and to acrolein, a harmful breakdown product that is also in some e-cigarettes' vapor. Acrolein is known to irritate exposed tissues and can destroy cilia.

The 17 participants who swapped some regular cigarettes for the electronic version had a 52% decline in carbon monoxide exposure and a 60% decline for acrolein, according to a report online September 3 in Cancer Prevention Research.

To get the most benefit from switching to e-cigarettes, smokers need to completely give up traditional cigarettes, lead study author Dr. Hayden McRobbie, of the Wolfson Institute of Preventive Medicine at Queen Mary University of London, said by email.

"Smokers may get some encouragement from the finding that there is some potential health benefit as soon as they start the process," Dr. McRobbie said.

While tobacco control advocates fear that e-cigarettes may give rise to a new generation of nicotine addicts who eventually transition to conventional cigarettes, the current study adds to a small but growing body of evidence suggesting the devices might benefit the health of people who already smoke.

An international analysis of published research by the Cochrane Review in December concluded the devices could help smokers quit but said much of the existing research on e-cigarettes was thin.

Even though the current study points to another potential benefit of e-cigarettes, more evidence is still needed from longer and larger trials before scientists can draw firm conclusions about any safety advantages, Dr. Nancy Rigotti, director of tobacco research at Massachusetts General Hospital in Boston, said by email.

"It is exactly the type of incremental, careful work that is needed but it is not yet a definitive study," Rigotti, who wasn't involved in the study, said.

Study participants were typically in their 40s and had attempted to quit at least twice before joining the trial. All of them were offered the same type of e-cigarette and encouraged to completely abandon traditional cigarettes.

Researchers measured carbon monoxide in participants' breath one week before switching to e-cigarettes, on the day they switched, and again four weeks later. They followed the same schedule for testing urine for exposure to acrolein.

A limitation of the study, the authors acknowledged, is that it only included people with a desire to quit smoking, making it possible the results would be different for smokers with no intention of quitting. It's also possible that the specific model of e-cigarette used in the study might not be representative of other devices.

Still, the findings suggest smokers should be told e-cigarettes may curb their exposure to toxic chemicals, Dr. Riccardo Polosa, head of the tobacco research center at the University of Catania in Italy, said by email.

"This study adds to the evidence that e-cigarettes are much less harmful compared to conventional cigarettes," said Polosa, who wasn't involved in the study.