Adult ADHD; Encouraging Advance Care Planning; Hospital Closures in the U.S.

— Also in TTHealthWatch: HPV vaccines and pregnancy outcomes

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of Texas Tech Health El Paso, look at the top medical stories of the week.

This week's topics include a review of adult attention deficit-hyperactivity disorder (ADHD), hospital closures nationwide, encouraging advance care planning, and human papillomavirus (HPV) vaccination and pregnancy outcomes.

Program notes:

0:36 HPV vaccines and pregnancy outcomesopens in a new tab or window

1:36 600,000+ births

2:36 What is the mechanism?

3:30 Adult ADHD

4:30 May see underperformance

5:30 Almost always methylphenidate or amphetamine

6:30 Public health significance

7:01 Hospital closures in the U.S.

8:01 Safety-net, non-teaching hospitals closed more

9:03 Advance care planning (ACP) in Black and white older adults

10:04 Racially concordant or discordant facilitator

11:08 Self-guided planning

12:10 Not doing a good job offering ACP

13:59 End

Transcript:

Elizabeth: A comprehensive look at adult [ADHD].

Rick: Hospital closures and openings in the U.S.

Elizabeth: How can we encourage advanced care planning for Black and white older adults with serious illness?

Rick: And human papillomavirus vaccination and pregnancy outcomes.

Elizabeth: That's what we're talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I'm Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: And I'm Rick Lange, president of Texas Tech Health El Paso.

Elizabeth: So Rick, I'm going to pitch the ball to you and let's go to The BMJ, looking at what looks to be yet one more benefit of HPV vaccination.

Rick: We are well aware of the benefits of HPV vaccination in preventing cervical cancer. I wasn't aware, however, that it could potentially improve pregnancy outcomes. We're talking about preterm birth, which is one of the leading global causes of both newborn mortality, and it also contributes to major medical and social impairments in adulthood. We know that individuals that have HPV infection are more likely to have preterm birth. And those that have had a high degree of cervical dysplasia oftentimes have cervical procedures that also lead to preterm birth. If you give HPV vaccination before pregnancy, can it actually lower the risk of preterm birth?

This is a study done from Sweden from 2006, when HPV vaccination was first available, to 2023. They looked at singleton births, and there were over 600,000 in women that had not had kids before. They were age 16 to 35, and about 15% of them had received the HPV vaccination before pregnancy. And they matched those 10 to one to those that hadn't. The women who had received the HPV vaccination had a lower incidence of preterm birth of less than 37 weeks by about 5%, those kids born 28 to 31 weeks by 15%, preterm labor rupture of membranes decreased, severe small for gestational age by about 5 to 10%. Women that received the most benefit were those that had it earliest, and that is before the age of 17.

Elizabeth: And along with all the rest of the multitude of positive outcomes we see, it absolutely argues for routine administration way before young girls become sexually active. What I'm interested in is if you haven't received a vaccine and you're contemplating pregnancy, does it make sense to go ahead and get it based on these kinds of data? Gosh, what in the world would be the mechanism whereby avoiding HPV infection helps to ameliorate these outcomes of pregnancy that everyone would like to avoid?

Rick: I think the guidelines are pretty clear for preventing cervical cancer. And whether that helps preterm outcomes even later is really up for grabs. But nevertheless, it's thoroughly beneficial. With regard to mechanism, infection with HPV may do two things. One is it affects embryonic development. But more importantly, it actually affects trophoblast differentiation, that is the placental development. If the placenta doesn't develop normally, it leads to preterm birth.

Elizabeth: I would like to see additional study on whether administration of the vaccine prior to pregnancy, or even in early pregnancy, would help to ameliorate some of these outcomes because we're well aware of the strategy of catching women up who've missed that vaccination window as young teenagers later on, and that there is a benefit to that.

Rick: Yeah.

Elizabeth: Let's turn to the New England Journal of Medicine. And I picked this one, even though it's a review paper, because it is something that is of enormous public health interest: the management of adult attention deficit-hyperactivity disorder, ADHD.

This paper reminds us that over 5% of children do have ADHD. And what's interesting is that that number reduces to about half of that as people age. And so we see it in about 2.5% of young adults. There was a disparity in males versus females in children, but race among men and women are approximately equal in adulthood.

Lots of symptoms of adult ADHD are differentiated from those that occur in children: underperformance at work or in higher education, problems in interpersonal relationships, impaired parenting, financial problems, accident proneness. When ADHD occurs in people of higher intellectual ability, we often see underperformance relative to the person's cognitive potential. The bad news is, of course, that for women, the diagnosis is missed until things get to a point where there's other circumstances that bring it to the fore. There are also other conditions that seem to sort with ADHD in adults that can kind of be confounders when it comes to making the diagnosis.

OK. What do we do? ADHD is a clinical diagnosis, so there's no objective test that's going to be able to say you got it. They identify a particular challenge of assessing adults is that they have an inconsistent recall of their childhood symptoms.

Once that clinical diagnosis is made, most of the time a medication is going to be indicated, and that's almost always with psychostimulants -- methylphenidate and amphetamine -- although there are other medicines that have been approved by the FDA that are not stimulants that may also be helpful. There's also benefit in employing things like cognitive behavioral therapy and conclude that it's often misdiagnosed, underdiagnosed, or diagnosed later in life. And it can really impact on somebody's ability to negotiate their adult life effectively.

Rick: So Elizabeth, besides, what I'm going to say, the softer things you mentioned, many people aren't aware that ADHD is also associated with increased risk of obesity, cardiovascular disease, diabetes, and immune and inflammatory conditions. But 80% of it's heritable.

And as you mentioned, I was unaware it's less often diagnosed in women or diagnosed later. And that's because girls are less disruptive than boys, they oftentimes compensate, and they're misdiagnosed with having anxiety and depression rather than ADHD, and the treatment is very different between the two. For the 20-plus years, we've done this we've probably reported on a handful of review articles, but you picked this one and I think for the reasons that we've mentioned.

Elizabeth: Yep. It almost suggests, with 2.5% of adults having this condition, that there ought to be some quick screen for it that could be performed in primary care.

Rick: You need to do two things. One is you have to interview the patient. Secondly is you have to interview people they interact with. You're talking about coworkers, family members, spouses that provide additional information about how the condition ADHD can affect their interpersonal relationships. But there are a lot of other things that mimic it.

Elizabeth: OK. Let's turn to JAMA.

Rick: Hospital closures and openings. There's been a lot of focus on hospital closures, particularly in rural areas across the U.S., and whether they actually are concentrated in rural areas remains unknown. These investigators looked at all closures and openings between 2010 and 2025. They used the American Hospital Association annual survey to determine this.

They define a hospital closure as loss of inpatient services because they completely close or they convert it to a non-acute care, about 8.7%, or 432, closed and only 216 opened. That's about 5% of hospitals, over 24,000 beds. They noted the hospital closures increased by 4% year-over-year and hospital openings decreased by 3% year-over-year. There was no difference between rural and urban hospitals. For-profit hospitals closed more than three times as often and safety-net, non-teaching, and smaller hospitals closed more often as well. Primarily socially vulnerable counties and in states that never expanded Medicare.

Elizabeth: We know that there has been a lot of loss of obstetric services. That's something, of course, that's absolutely impacted by this.

Rick: Right. This just talked about total hospital closures. But as you mentioned, there are hospitals that close services and so individuals have to travel, at least in parts where I'm at, in West Texas, can travel 2 or 3 or 4 hours to receive the care they need.

Elizabeth: If you were the king of the forest, how would you address this issue?

Rick: We need to specifically fund rural hospitals. Secondly is we need to support primary care physicians in those areas with telehealth. And then when all else fails, we need to have point-of-contact, kind of a spoke-and-hub distribution where those individuals can be rapidly stabilized and transferred to a center. In the urban areas, we just need to provide funding.

Elizabeth: And would that beg the question then of Medicare for all?

Rick: We certainly need to provide funding for all patients.

Elizabeth: Remaining in JAMA then, let's take a look at an issue that's near and dear to my heart, that's advanced care planning. And this study is examining that strategy for both Black and white older adults with serious illness.

Previous research has shown us that many people do not participate in advanced care planning, and Black adults are less likely than white adults to do so. So they wanted to take a look at two different strategies for encouraging ACP, advanced care planning, in both of these populations. One of them was facilitated -- so they had a person who was helping people negotiate their way through this whole thing and get them educated, and then help them complete it. And the other one was self-guided.

This was a cluster randomized trial conducted in 10 primary care and geriatrics clinics in the South of the United States. Among their participants were all community-dwelling Black and white adults, 65 years and older, with serious illness. And they were randomized to this racially concordant -- someone who was the same race as themselves -- or discordant ACP facilitator.

The two strategies that they employed are one that's called Respecting Choices First Steps, that's the facilitated approach, or Five Wishes that's been around for quite a while, which is the self-guided approach. And these ACP facilitators, who were lay people, were engaged in this process. And as I said, some racially concordant and some discordant.

They had 791 participants; 427 were Black, 409 in clinics with the facilitated approach, and 382 with the self-guided approach. Among their Black participants, 71% of those folks in the facilitated clinics completed their advanced care planning and 62% of the self-guided clinics completed it within 1 year. Interestingly, among their white participants, 68% of them completed in the facilitated clinics while 78% completed it among the self-guided clinics.

They had just shy of 70% of these folks complete their advanced care planning, which I have to say, I think that's really great. And it would be wonderful if we could get to 100%. Clearly, the self-guided approach among the white participants was perfectly fine and more of them did it, while the facilitated approach among the Black participants appeared to be better. The racial concordance of the facilitator had no impact.

Rick: You and I frequently use this term, but some of our listeners may not realize when we talk about advanced care planning we're talking about two things: helping adults understand what their goals are, but then communicating those goals and their preferences for future care. That is, do you want to be resuscitated? Do you want to be on a respirator? And you communicate it. And sometimes that's by putting an advanced directive in the chart. Other times, it's informing your family members.

And what this study tells me is the fact that there's a huge disparity, where African Americans are less likely to have ACP, tells me we're just not offering it to them. As a society, we're not doing a very good job. At least that's my take. What's yours, Elizabeth?

Elizabeth: I think that it's important to target the information to people where they are. And so making sure that it's understandable and that they understand why it's relevant to them, that this is an opportunity for them to say, "Look, here's what I want." I think it's just absolutely foundational.

Personally, I would get this started really super early. And we've cited before your fine state of Texas. If I were the king of the forest, people would be doing this when they got a driver's license.

Rick: I agree. It needs to be where the person is at. Sixty to 70% of African Americans, regardless of which technique you use, will be involved with ACP if it's either facilitated or at least offered to them where they can do it.

Elizabeth: I would note, finally, we need to do this repetitively so that if somebody doesn't do anything about advanced care planning within a year, I think that we need to say it to them again. The way I talk about this with people in the chaplain role is by pointing out that when somebody's illness progresses and a family member needs to be making decisions for them when they die, there is going to be grief and there is going to be loss, but they can make sure there's not guilt by saying, "Look, here are the things that I want and don't want."

Rick: Right. I mean, it takes the onus and burden off the family member to make that decision because the patient has already made that decision. They're just saying, please carry it out. I totally agree with you, Elizabeth.

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

Rick: And I'm Rick Lange. Y'all listen up and make healthy choices... and advance directives.