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The American Heart Association will release a new clinical tool that removes race as a factor in predicting who will have heart attacks or strokes.Doctors have long relied on a few key patient characteristics to assess risk of a heart attack or stroke, using a calculus that considers blood pressure, cholesterol, smoking and diabetes status, as well as demographics: age, sex and race.Now, the American Heart Association is taking race out of the equation.The overhaul of the widely used cardiac-risk algorithm is an acknowledgment that, unlike sex or age, race identification in and of itself is not a biological risk factor.The scientists who modified the algorithm decided from the start that race itself did not belong in clinical tools used to guide medical decision making, even though race might serve as a proxy for certain social circumstances, genetic predispositions or environmental exposures that raise the risk of cardiovascular disease.The revision comes amid rising concern about health equity and racial bias within the U.S. health care system, and is part of a broader trend toward removing race from a variety of clinical algorithms.“We should not be using race to inform whether someone gets a treatment or doesn’t get a treatment,” said Dr. Sadiya Khan, a preventive cardiologist at Northwestern University Feinberg School of Medicine, who chaired the statement writing committee for the American Heart Association, or A.H.A.The statement was published on Friday in the association’s journal, Circulation. An online calculator using the new algorithm, called PREVENT, is still in development.“Race is a social construct,” Dr. Khan said, adding that including race in clinical equations “can cause significant harm by implying that it is a biological predictor.”That doesn’t mean that Black Americans are not at higher risk of dying of cardiovascular disease than white Americans, she said. They are, and life expectancy of Black Americans is shorter as well, she added.But race has been used in algorithms as a stand-in for a range of factors that are working against Black Americans, Dr. Khan said. It’s not clear to scientists what all of those risks are. If they were better understood, “we could address them and work to modify them,” she said.The heart-risk assessment has also been improved in several other significant ways. It can be used by people as young as 30, unlike the earlier algorithm, which was only valid for those 40 and over, and estimates the 10-year and 30-year total cardiovascular risk.The assessment has been redesigned, for the first time, to estimate an individual’s risk of developing heart failure, not just heart attack and stroke. That is important because heart failure has been on the rise in recent years with the aging of the population and the high prevalence of obesity. The condition can lead to a severe deterioration in quality of life.Also for the first time, the new calculator takes kidney function into account when predicting risk, as kidney disease puts people at higher risk of heart disease, heart attacks, heart failure and stroke.In recent years, there has been growing recognition of the strong connection between cardiovascular disease, kidney disease and metabolic disease (which includes Type 2 diabetes and obesity). Last month, scientific advisers to the association defined a new disorder called cardiovascular-kidney-metabolic syndrome, or C.K.M.“C.K.M. is associated with significantly premature mortality, mostly from cardiovascular disease,” said Dr. Chiadi Ndumele, a cardiologist at Johns Hopkins Medicine who was also an author of the new scientific statement.“It is disproportionately present when there are any adverse social determinants of health,” he said, which include “the social context in which we eat, work, learn and play.”The new equation also has options for including a measure of blood sugar control, called hemoglobin A1C, in people with Type 2 diabetes, and for incorporating a factor called the Social Deprivation Index, which includes poverty, unemployment, education and other factors.The changes are “great news,” said Dr. David S. Jones, a psychiatrist and professor of the history of medicine at Harvard, who wrote a paper about the use of race in myriad medical decision-making algorithms that was published in the New England Journal of Medicine in 2020.The paper described how race has been used in a broad array of clinical algorithms relied upon to make medical judgments about conditions as diverse as urinary tract infections, vaginal birth after cesarean sections, breast cancer, lung function and kidney function.“It’s been hugely gratifying to see how medical thinking has shifted about this issue over the past three to five years,” Dr. Jones said.While there are racial gaps on many health measures, scientists must conduct research to understand exactly what is causing the differences, he said, adding, “You can’t just divide the world into Black and white people, and say that all the white people get this and all the Black people get that.”Putting the changes into effect can be difficult, however, he said.Two years ago, a scientific task force of the National Kidney Foundation and American Society of Nephrology called for jettisoning a measure of kidney function that adjusted results by race, often making Black patients seem less ill than they are and leading to delays in treatment.Within 18 months, about 65 percent of all lab facilities had adopted the new approach, said Dr. Neil Powe, chief of medicine at Zuckerberg San Francisco General Hospital and a professor of medicine at University of California, San Francisco.Dr. Powe said he shared a concern that was raised by the authors of the A.H.A. scientific statement: What exactly lies at the root of racial health disparities?“I have said many times that we need to do more research to understand what race is capturing and what the substitute for it is,” Dr. Powe said.Many physicians do not know whether or to what degree their patients are experiencing social stressors that affect their health. Research on maternal deaths, for example, has shown that wealth and higher education do not compensate for the ill health effects associated with being Black in America.Although the wealthiest mothers and their babies are most likely to survive the year after childbirth, a California study found that the same was not true for Black women — the wealthiest Black mothers and their babies are twice as likely to die, compared with the richest white mothers and their babies.

The NewsThe gap in life expectancy between men and women in the United States grew to its widest in nearly 30 years, driven mainly by more men dying of Covid and drug overdoses, according to a new study in the journal JAMA Internal Medicine.In 2021, women had a life expectancy of 79.3 years, compared with 73.5 years for men, the study found.“It was unsettling to see,” said Dr. Brandon Yan, a resident physician at the University of California, San Francisco, and lead author of the study, which analyzed death data from the Centers for Disease Control and Prevention.“We need to understand which groups are particularly losing out on years of life expectancy so interventions can be at least partially focused on these groups,” Dr. Yan said.A Covid patient in an intensive care unit in Queens in 2020. Between 2019 and 2021, the overall life expectancy in the United States dropped from around 79 to 76 years.Victor J. Blue for The New York TimesBackground: The life expectancy gap has substantially widened — and shrunk — before.At the turn of the 20th century, women had a life expectancy just two years higher than men, Dr. Yan said. But over the next 75 years, that gap began to widen, largely because more men smoked and developed cardiovascular disease or lung cancer.As smoking rates declined, excess deaths reduced among men, in particular.But in 2010, that gender gap began to widen yet again, this time driven by opioid overdose death rates, which are more than twice as high for men. That year, the life expectancy for men was 76.3 years, while for women it was 78.1.Men had a greater risk of developing diabetes and heart disease, and also faced higher rates of homicide and suicide.The Findings: Covid caused huge drops in life expectancy across the board.More than 1.1 million people in the United States have died of Covid, a staggering death toll that has caused precipitous declines in life expectancy. Between 2019 and 2021, the life expectancy in the United States dropped from around 79 to 76 years.But men have died of Covid at a higher rate than women. The reasons for this are complicated. Biological factors, like differences in inflammation and immune responses, likely played a significant role.But social and behavioral differences mattered, too. Men are more likely to work in industries with higher rates of Covid exposure and fatalities, including transportation, agriculture and construction, or to experience incarceration or homelessness. Women are also more likely to be vaccinated.From 2019 to 2021, Covid was the leading contributor to the widening gap in life expectancy between men and women, contributing nearly 40 percent of the difference in years lost.Overdose and homicide deaths increased, too.Unintentional injuries — mostly drug overdoses — contributed to more than 30 percent of the life expectancy gap between men and women. But more men also died by homicide or suicide between 2019 and 2021.“All of these point to a picture of worsening mental health across the board, but particularly among men,” Dr. Yan said.Dr. Yan noted that his analysis did not include transgender or other gender identities, because death certificates do not record that information.

Margaret Newcomb, 69, a retired French teacher, is desperately trying to protect her retirement savings by caring for her 82-year-old husband, who has severe dementia, at home in Seattle. She used to fear his disease-induced paranoia, but now he’s so frail and confused that he wanders away with no idea of how to find his way home. He gets lost so often that she attaches a tag to his shoelace with her phone number.Feylyn Lewis, 35, sacrificed a promising career as a research director in England to return home to Nashville after her mother had a debilitating stroke. They ran up $15,000 in medical and credit card debt while she took on the role of caretaker.Sheila Littleton, 30, brought her grandfather with dementia to her family home in Houston, then spent months fruitlessly trying to place him in a nursing home with Medicaid coverage. She eventually abandoned him at a psychiatric hospital to force the system to act.“That was terrible,” she said. “I had to do it.”Millions of families are facing such daunting life choices — and potential financial ruin — as the escalating costs of in-home care, assisted-living facilities and nursing homes devour the savings and incomes of older Americans and their relatives.“People are exposed to the possibility of depleting almost all their wealth,” said Richard W. Johnson, director of the program on retirement policy at the Urban Institute.The prospect of dying broke looms as an imminent threat for the boomer generation, which vastly expanded the middle class and looked hopefully toward a comfortable retirement on the backbone of 401(k)s and pensions. Roughly 10,000 of them will turn 65 every day until 2030, expecting to live into their 80s and 90s as the price tag for long-term care explodes, outpacing inflation and reaching a half-trillion dollars a year, according to federal researchers.The challenges will only grow. By 2050, the population of Americans 65 and older is projected to increase by more than 50 percent, to 86 million, according to census estimates. The number of people 85 or older will nearly triple to 19 million.Those who needed long-term care were more likely to die brokeAmong Americans who had $171,365 to $1.8 million in savings at age 65, those with greater long-term care needs were much more likely to deplete their savings than those who did not need long-term care.

Notes: The percent who died broke is the percent of each group of people who reported a net worth of less than $3,000 by the time they died. Groups of people were those who at age 65 reported to the Health and Retirement Study a net worth in the 50th to 95th percentile, or $171,365 to $1,827,765 in 2020 inflation adjusted dollars, and who subsequently either needed or did not need long-term care. Read the full methodology.Source: New York Times/KFF Health News analysis of Health and Retirement Study data from 2000 to 2021.By The New York TimesThe United States has no coherent system of long-term care, mostly a patchwork. The private market where a minuscule portion of families buy long-term care insurance has shriveled, reduced over years of giant rate hikes by insurers that had underestimated how much care people would actually use. Labor shortages have left families searching for workers willing to care for their elders in the home. And the cost of a spot in an assisted-living facility has soared to an unaffordable level for most middle-class Americans. They have to run out of money to qualify for nursing home care paid for by the government.For an examination of the crisis in long-term care, The New York Times and KFF Health News interviewed families across the nation as they struggled to obtain care; examined companies that provide it; and analyzed data from the federally funded Health and Retirement Study, the most authoritative national survey of older people about their long-term care needs and financial resources.The nursing home room of Gay Glenn’s mother in Topeka, Kan. Her mother had to pay the home more than $10,000 a month until she qualified for Medicaid.Arin Yoon for The New York TimesAn old photo of Annie Reid and her mother, Frances Sampogna, at her mother’s house in Silver Spring, Md. Ms. Reid moved home to care for her mother, who had dementia.Shuran Huang for The New York TimesPictures of Dottye Burt and her husband, Stan Markowitz, in their home in Baltimore. Mr. Markowitz, who had Parkinson’s disease, eventually moved to a nursing home.Shuran Huang for The New York TimesAbout eight million people 65 and over reported that they had dementia or difficulty with basic daily tasks like bathing and feeding themselves — and nearly three million of them had no assistance at all, according to an analysis of the survey data. Most people relied on spouses, children, grandchildren or friends.The United States devotes a smaller share of its gross domestic product to long-term care than do most other wealthy countries, including Britain, France, Canada, Germany, Sweden and Japan, according to the Organization for Economic Cooperation and Development. The United States lags its international peers in another way: It dedicates far less of its overall health spending toward long-term care.“We just don’t value elders the way that other countries and other cultures do,” said Dr. Rachel M. Werner, the executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania. “We don’t have a financing and insurance system for long-term care,” she said. “There isn’t the political will to spend that much money.”Many older adults struggled with basic tasksAlmost 20 percent of those 65 and older reported having difficulty with one or more basic daily tasks. Of those, many were not receiving help.

Source: New York Times/KFF Health News analysis of Health and Retirement Study data from 2020 and 2021By The New York TimesDespite medical advances that have added years to the average life span and allowed people to survive decades more after getting cancer or suffering from heart disease or strokes, federal long-term care for older people has not fundamentally changed in the decades since President Lyndon Johnson signed Medicare and Medicaid into law in 1965. From 1960 to 2021, the number of Americans age 85 and older increased at more than six times the rate of the general population, according to census records.Medicare, the federal health insurance program for Americans 65 and older, covers the costs of medical care, but generally pays for a home aide or a stay in a nursing home only for a limited time during a recovery from a surgery or a fall or for short-term rehabilitation.Medicaid, the federal-state program, covers long-term care, usually in a nursing home, but only for the poor. Middle-class people must exhaust their assets to qualify, forcing them to sell much of their property and to empty their bank accounts. If they go into a nursing home, they are permitted to keep a pittance of their retirement income: $50 or less a month in a majority of states. And spouses can hold onto only a modest amount of income and assets, often leaving their children and grandchildren to shoulder some of the financial burden.“You basically want people to destitute themselves and then you take everything else that they have,” said Gay Glenn, whose mother lived in a nursing home in Kansas until she died in October at age 96.Her mother, Betty Mae Glenn, had to spend down her savings, paying the home more than $10,000 a month, until she qualified for Medicaid. Ms. Glenn, 61, relocated from Chicago to Topeka more than four years ago, moving into one of her mother’s two rental properties and overseeing her care and finances.Ms. Glenn, outside her mother’s home in Topeka, moved to Kansas from Chicago more than four years ago to oversee her mother’s care and finances.Arin Yoon for The New York TimesMs. Glenn visiting with her mother and brother in a skilled nursing facility in Kansas. Ms. Glenn sold her mother’s house, right, shortly before her mother died in October.Under the state Medicaid program’s byzantine rules, she had to pay rent to her mother and that income went toward her mother’s care. Ms. Glenn sold the family’s house just before her mother’s death. Her lawyer told her the estate had to pay Medicaid back about $20,000 from the proceeds.A play she wrote about her relationship with her mother, titled “If You See Panic in My Eyes,” was read this year at a theater festival.At any given time, skilled nursing homes house roughly 630,000 older residents whose average age is about 77, according to recent estimates. A long-term resident’s care can easily cost more than $100,000 a year without Medicaid coverage at these institutions, which are supposed to provide round-the-clock nursing coverage.Nine of 10 people said it would be impossible or very difficult to pay that much, according to a KFF public opinion poll conducted during the pandemic.Efforts to create a national long-term care system have repeatedly collapsed. Democrats have argued that the federal government needs to take a much stronger hand in subsidizing care. The Biden administration sought to improve wages and working conditions for paid caregivers. But a $150 billion proposal in the Build Back Better Act for in-home and community-based services under Medicaid was dropped to lower the price tag of the final legislation.“This is an issue that’s coming to the front door of members of Congress,” said Senator Bob Casey, Democrat of Pennsylvania and chairman of the Senate Special Committee on Aging. “No matter where you’re representing — if you’re representing a blue state or red state — families are not going to settle for just having one option,” he said, referring to nursing homes funded under Medicaid. “The federal government has got to do its part, which it hasn’t.”But leading Republicans in Congress say the federal government cannot be expected to step in more than it already does. Americans need to save for when they will inevitably need care, said Senator Mike Braun of Indiana, the ranking Republican on the aging committee.“So often people just think it’s just going to work out,” he said. “Too many people get to the point where they’re 65 and then say, ‘I don’t have that much there.’”Private Companies’ Prices Keep ClimbingThe boomer generation is jogging and cycling into retirement, equipped with hip and knee replacements that have slowed their aging. And they are loath to enter the institutional setting of a nursing home.But they face major expenses for the in-between years: falling along a spectrum between good health and needing round-the-clock care in a nursing home.That has led them to assisted-living centers run by for-profit companies and private equity funds enjoying robust profits in this growing market. Some 850,000 people age 65 or older now live in these facilities that are largely ineligible for federal funds and run the gamut, with some providing only basics like help getting dressed and taking medication and others offering luxury amenities like day trips, gourmet meals, yoga and spas.The bills can be staggering.Rising costs for long-term careThe median annual cost of all types of long-term care has risen faster than inflation over the last two decades.

Notes: Costs are adjusted for inflation and shown in 2021 dollars. Home health aide figures for 2005 to 2007 are omitted because of a change in methodology.Source: Genworth Cost of Care StudyBy The New York TimesHalf of the nation’s assisted-living facilities cost at least $54,000 a year, according to Genworth, a long-term care insurer. That rises substantially in many metropolitan areas with lofty real estate prices. Specialized settings, like locked memory care units for those with dementia, can cost twice as much.Home care is costly, too. Agencies charge about $27 an hour for a home health aide, according to Genworth. Hiring someone who spends six or seven hours a day cleaning and helping an older person get out of bed or take medications can add up to $60,000 a year.As Americans live longer, the number who develop dementia, a condition of aging, has soared, as have their needs. Five million to seven million Americans over age 65 have dementia, and their ranks are projected to grow to nearly 12 million by 2040. The condition robs people of their memories, mars the ability to speak and understand, and can alter their personalities.In Seattle, Margaret and Tim Newcomb sleep on separate floors of their two-story cottage, with Ms. Newcomb ever-mindful that her husband, who has dementia, can hallucinate and become aggressive if medication fails to tame his symptoms.“The anger has diminished from the early days,” she said last year.But earlier on, she had resorted to calling the police when he acted erratically.“He was hating me and angry, and I didn’t feel safe,” she said.Margaret Newcomb cares for her husband, Tim, who has dementia, at home, partly in an effort to protect their retirement savings.Ruth Fremson/The New York TimesShe considered memory care units, but the least expensive option cost around $8,000 a month and some could reach nearly twice that amount. The couple’s monthly income, with his pension from Seattle City Light, the utility company, and their combined Social Security, is $6,000.Placing her husband in such a place would have gutted the $500,000 they had saved before she retired from 35 years teaching art and French at a parochial school.“I’ll let go of everything if I have to, but it’s a very unfair system,” she said. “If you didn’t see ahead or didn’t have the right type of job that provides for you, it’s tough luck.”In the last year, medication has quelled Mr. Newcomb’s anger, but his health has also declined so much that he no longer poses a physical threat. Ms. Newcomb says she’s reconciled to caring for him as long as she can.“When I see him sitting out on the porch and appreciating the sun coming on his face, it’s really sweet,” she said.The financial threat posed by dementia also weighs heavily on adult children who have become guardians of aged parents and have watched their slow, expensive declines.Claudia Morrell, 64, of Parkville, Md., estimated her mother, Regine Hayes, spent more than $1 million during the eight years she needed residential care for dementia. That was possible only because her mother had two pensions, one from her husband’s military service and another from his job at an insurance company, plus savings and Social Security.Ms. Morrell paid legal fees required as her mother’s guardian, as well as $6,000 on a special bed so her mother wouldn’t fall out and more on private aides after she suffered repeated small strokes. Her mother died last December at age 87.“I will never have those kinds of resources,” Ms. Morrell, an education consultant, said. “My children will never have those kinds of resources. We didn’t inherit enough or aren’t going to earn enough to have the quality of care she got. You certainly can’t live that way on Social Security.”Women Bear the Burden of CareAnnie Reid moved back into her childhood bedroom and lived there for years to take care of her mother, who had dementia.Shuran Huang for The New York TimesFor seven years, Annie Reid abandoned her life in Colorado to sleep in her childhood bedroom in Maryland, living out of her suitcase and caring for her mother, Frances Sampogna, who had dementia. “No one else in my family was able to do this,” she said.“It just dawned on me, I have to actually unpack and live here,” Ms. Reid, 61, remembered thinking. “And how long? There’s no timeline on it.”After Mrs. Sampogna died at the end of September 2022, her daughter returned to Colorado and started a furniture redesign business, a craft she taught herself in her mother’s basement. Ms. Reid recently had her knee replaced, something she could not do in Maryland because her insurance didn’t cover doctors there.“It’s amazing how much time went by,” she said. “I’m so grateful to be back in my life again.”Most people were cared for by family, not professionalsPartners and daughters were the most common caregivers for people who needed help with daily activities.

Note: For those 65 and older who needed and received long-term care in 2020 and 2021.Source: New York Times/KFF Health News analysis of Health and Retirement Study data for 2020 and 2021By The New York TimesStudies are now calculating the toll of caregiving on children, especially women. The median lost wages for women providing intensive care for their mothers is $24,500 over two years, according to a study led by Norma Coe, an associate professor at the Perelman School of Medicine at the University of Pennsylvania.Ms. Lewis moved back from England to Nashville to care for her mother, a former nurse who had a stroke that put her in a wheelchair.“I was thrust back into a caregiving role full time,” she said. She gave up a post as a research director for a nonprofit organization. She is also tending to her 87-year-old grandfather, ill with prostate cancer and kidney disease.Making up for lost income seems daunting while she continues to support her mother.But she is regaining hope: She was promoted to assistant dean for student affairs at Vanderbilt School of Nursing and was recently married. She and her husband plan to stay in the same apartment with her mother until they can save enough to move into a larger place.Feylyn Lewis making a cup of tea for her mother, who needed a wheelchair after she had a stroke. “I was thrust back into a caregiving role full time,” she said.William DeShazer for The New York TimesGovernment Solutions Are ElusiveOver the years, lawmakers in Congress and government officials have sought to ease the financial burdens on individuals, but little has been achieved.The CLASS Act, part of the Obamacare legislation of 2010, was supposed to give people the option of paying into a long-term insurance program. It was repealed two years later amid compelling evidence that it would never be economically viable.Two years ago, another proposal, called the WISH Act, outlined a long-term care trust fund, but it never gained traction.On the home care front, the scarcity of workers has led to a flurry of attempts to improve wages and working conditions for paid caregivers. A provision in the Build Back Better Act to provide more funding for home care under Medicaid was not included in the final Inflation Reduction Act, a less costly version of the original bill that Democrats sought to pass last year.The labor shortages are largely attributed to low wages for difficult work. In the Medicaid program, demand has clearly outstripped supply, according to a recent analysis. While the number of home aides in the Medicaid program has increased to 1.4 million in 2019 from 840,000 in 2008, the number of aides per 100 people who qualify for home or community care has declined nearly 12 percent.In April, President Biden signed an executive order calling for changes to government programs that would improve conditions for workers and encourage initiatives that would relieve some of the burdens on families providing care.Turning to Medicaid, a Shredded Safety NetThe only true safety net for many Americans is Medicaid, which represents, by far, the largest single source of funding for long-term care.More than four of five middle-class people over 65 who need long-term care for five years or more will eventually enroll, according to an analysis for the federal government by the Urban Institute. Almost half of upper-middle-class couples with lifetime earnings of more than $4.75 million will also end up on Medicaid.But gaps in Medicaid coverage leave many people without care. Under federal law, the program is obliged to offer nursing home care in every state. In-home care, which is not guaranteed, is provided under state waivers, and the number of participants is limited. Many states have long waiting lists, and it can be extremely difficult to find aides willing to work at the low-paying Medicaid rate.Qualifying for a slot in a nursing home paid by Medicaid can be formidable, with many families spending thousands of dollars on lawyers and consultants to navigate state rules. Homes may be sold or couples may contemplate divorce to become eligible.Ms. Burt caring for her husband in October 2022, at the nursing home he moved into in Baltimore. Mr. Markowitz had to contribute $2,700 a month to the nursing home, which ate up 45 percent of the couple’s retirement income. His wife rented a modest apartment near the home, all she could afford on what was left of their income.Shuran Huang for The New York TimesAnd recipients and their spouses may still have to contribute significant sums. After Stan Markowitz, a former history professor in Baltimore with Parkinson’s disease, and his wife, Dottye Burt, 78, exhausted their savings on his two-year stay in an assisted-living facility, he qualified for Medicaid and moved into a nursing home.He was required to contribute $2,700 a month, which ate up 45 percent of the couple’s retirement income. Ms. Burt, who was a racial justice consultant for nonprofits, rented a modest apartment near the home, all she could afford on what was left of their income.Mr. Markowitz died in September at age 86, easing the financial pressure on her. “I won’t be having to pay the nursing home,” she said.Even finding a place willing to take someone can be a struggle. Harold Murray, Sheila Littleton’s grandfather, could no longer live safely in rural North Carolina because his worsening dementia led him to wander. She brought him to Houston in November 2020, then spent months trying to enroll him in the state’s Medicaid program so he could be in a locked unit at a nursing home.She felt she was getting the runaround. Nursing home after nursing home told her there were no beds, or quibbled over when and how he would be eligible for a bed under Medicaid. In desperation, she left him at a psychiatric hospital so it would find him a spot.“I had to refuse to take him back home,” she said. “They had no choice but to place him.”He was finally approved for coverage in early 2022, at age 83.A few months later, he died.Reporting was contributed by Kirsten Noyes and Albert Sun, Holly K. Hacker of KFF Health News that is part of the organization formerly known as the Kaiser Family Foundation, and JoNel Aleccia, formerly of KFF Health News.

An explanation of the findings from the federally financed survey to assess long-term care needs and finances of those 65 and older.The Times/KFF Health News data analysis was based on the Health and Retirement Study, a nationally representative longitudinal survey of about 20,000 people over age 50. The analysis defined people ages 65 and above as likely to need long-term care if they were assessed to have dementia, or if they reported having difficulty with two or more out of six activities of daily living. The six activities are bathing, dressing, eating, getting in and out of bed, walking across a room and using the toilet. The Langa-Weir classification of cognitive function, a related data set, was used to identify respondents with dementia. The analysis’ definition of needing long-term care assistance is conservative and is in line with criteria most long-term care insurers use in determining whether they will pay for services.People were described as recipients of long-term care help if they reported receiving assistance in the month before the survey interview or if they lived in a nursing home. The analysis was developed in consultation with Norma Coe, an associate professor of medical ethics and health policy at the Perelman School of Medicine at the University of Pennsylvania.The financial toll on middle-class and upper-income people needing long-term care was examined by reviewing data that the H.R.S. collected between 2000 and 2021 on wealthy Americans, those whose net worth at age 65 was in the 50th to 95th percentile, totaling anywhere from $171,365 to $1,827,765 in inflation-adjusted 2020 dollars. This group excludes the super-wealthy. Each individual’s wealth at age 65 was compared with their wealth just before they died to calculate the percentage of affluent people who exhausted their financial resources and the likelihood that would occur among different groups.To calculate how many people were likely to need long-term care, how many people needing long-term care services were receiving them, and who was providing care to people receiving help, we looked at people ages 65 and older of all wealth levels in the 2020-21 survey, the most recent.The U.S. Health and Retirement Study is conducted by the University of Michigan, and funded by the National Institute on Aging and the Social Security Administration.The analysis was conducted by Albert Sun, a graphics editor for The Times, and Holly K. Hacker, a data editor for KFF Health News, part of the organization formerly known as the Kaiser Family Foundation.

Most countries spend more than the United States on care, but middle class and affluent people still bear a substantial portion of the costs.Around the world, wealthy countries are struggling to afford long-term care for rapidly aging populations. Most spend more than the United States through government funding or insurance that individuals are legally required to obtain. Some protect individuals from exhausting all their income or wealth paying for long-term care. But as in the United States, middle-class and affluent individuals in many countries can bear a substantial portion of the costs.The U.S. spends less as a share of G.D.P. on long-term care than most other wealthy countries

Notes: Figures show government funding and compulsory insurance spending on long-term care as a percentage of gross domestic product. Figures are for 2021 spending for all countries except Japan and Australia, which use 2020 figures.Source: Organization for Economic Cooperation and DevelopmentBy The New York TimesHere’s how five other countries pay for long-term care.🇯🇵JAPAN. Long-term care insurance is mandatory for Japanese citizens age 40 and over, while in the United States only a small portion of people voluntarily obtain coverage. Half the funding for Japan’s program comes from tax revenues and half from premiums. Older adults contribute 10 to 30 percent of the cost of services, depending on their income, and insurance picks up the rest. There is a maximum amount people have to spend from their income before the insurance covers the remainder of the cost. Workers can also take up to 93 days of paid leave to help relatives with long-term care needs. Japan assigns a care manager to each person using services; each manager oversees about 40 older adults. In 2020, Japan spent 2 percent of its gross domestic product on long-term care, 67 percent more than the United States spent that year.🇳🇱THE NETHERLANDS. The Dutch have included long-term care in their universal health care system since 1968. One public insurance program pays for nursing homes and other institutional settings, and another pays for nursing and personal care at home. Enrollment is mandatory. Dutch taxpayers contribute nearly 10 percent of their income toward insurance premiums, up to a set amount. Out-of-pocket payments amount to about 7 percent of the cost of institutional care. General taxes pay for a third program in which municipalities provide financial assistance and social support for older people living at home. There is no private long-term care insurance. The Netherlands spent 4.1 percent of its gross domestic product on long-term care in 2021, more than any other country tracked by the Organization for Economic Cooperation and Development, and four times the amount the United States spent.🇨🇦CANADA. Provinces and territories fund long-term care services through general tax revenue. Money budgeted is not always enough to cover all services, and some localities give priority to those with the greatest needs. The amount of subsidies people can receive, the costs they have to pay out of pocket and the availability of services vary by province and territory, as they do in the United States with state Medicaid programs. The mix of providers also varies regionally: For instance, nursing home care in Quebec is mostly run by a public system while homes in Ontario are mostly for-profit. Notably, Canada’s long-term care system is separate from its national health care system, which pays for hospitals and doctors with no out-of-pocket costs to patients. In 2021, Canada spent 1.8 percent of its G.D.P. on long-term care, 80 percent more than the United States spent.🇬🇧BRITAIN. Local authorities pay for most long-term care through taxes and central government grants. Private providers usually supply services. Government contributions are based on financial need, with co-payments usually required. As in the United States, middle-class and wealthy people pay most or all of the costs themselves. Unlike in the United States, the government provides payments directly to lower-income people so they can hire workers to care for them in their homes. Britain has also taken steps to shield people from losing all of their wealth to pay for long-term care. It subsidizes care for people with savings and property of less than about $30,000, while in the United States most people don’t qualify for Medicaid until they have run through all but $2,000 to $3,000 of their assets. In 2022, the government proposed extending subsidies to people who have as much as $105,000 of wealth and property, with a lifetime cap of about $100,000 on how much anyone spends on long-term medical care, excluding room and board in a nursing home. But the plan has been postponed to 2025. In 2021, Britain spent 1.8 percent of its G.D.P. on long-term care, 80 percent more than the United States did.🇸🇬SINGAPORE. Singapore recently instituted a system of mandatory long-term care insurance for those born in 1980 or later. Citizens and permanent residents are automatically enrolled in an insurance plan called CareShield Life starting at age 30. They must pay premiums until they retire or turn 67 (whichever comes later) or are approved to use services. The government subsidizes 20 to 30 percent of premiums for those who earn around $2,000 a month or less. Monthly payouts start at about $440. Government subsidies for nursing homes and other institutional care can range from 10 percent to 75 percent depending on ability to pay. Those who make more than $2,000 a month receive no subsidies. CareShield is optional for Singaporeans born in 1979 or earlier; they are covered under an older, voluntary plan. Singapore also provides a means-tested monthly cash grant — this year about $290 — to help with caregiving expenses.Sources: The National Bureau of Economic Research project on international comparisons of long-term care; Kathleen McGarry, an economics professor at UCLA; The Commonwealth Fund; Organization for Economic Cooperation and Development; government websites.Note: Spending comparisons with the United States are based on the most recent O.E.C.D. data and include spending from government and compulsory insurance programs as a percent of each country’s gross domestic product, which is the total monetary value of all the finished goods and services produced within a country’s borders. The comparisons cover people of all ages and exclude spending from voluntary insurance plans and out-of-pocket costs. All currency figures are in U.S. dollars.Jordan Rau is a reporter for KFF Health News, a part of the organization formerly known as the Kaiser Family Foundation.

Natasha Lazartes39, therapist, BrooklynMichelle V. Agins/The New York Times“It’s been a nightmare. They are so desperate to hire workers that they will take anyone.”I am 39 years old. I had to care for my father, who passed from cancer in 2019; my mother, who passed in November 2021 from cancer; and since her passing I have inherited the care of my grandmother. She is 97, diagnosed with moderate dementia and is considered high risk to be left home alone. We had been applying for Medicaid long-term care to receive a home health aide since early November 2021. She finally got a home health aide in January 2022, but it’s been a nightmare. They are so desperate to hire workers that they will take anyone. She was left without an aide on many random days with a late-notice telephone call or text message from the aide needing the day off and the agencies not able to find a replacement in time. I have changed agencies multiple times. My husband has been a great support the entire time. We rely on security cameras we installed in our apartment to see how she is doing while we are at work. How is it on a daily basis? It is emotionally and physically draining. The health care system for the elderly is neglected, broken and inadequate to meet any demands, even the basic needs.Robert Ingenito44, public information officer, Mamaroneck, N.Y.Robert Ingenito caring for his father, Jerry.Maansi Srivastava/The New York TimesMy father, who is now 93, had me late in life, at age 49. My mother died from cancer when I was 19. Literally on her deathbed, she said to me, “Don’t put your father in a nursing home.” Now, at 44, I’m married, I have a 6-year-old daughter, and for the past five years my dad has lived with us. I work about 20 hours a week, which allowed me to do something other than being his caregiver. If I had to put a price tag on the quality of care I provided to my dad, it would probably be the equivalent of a high-end assisted-living facility. But it was becoming really hard for myself, my wife and our daughter. His level of care was getting to the point of something I just could not sustain. He couldn’t be left alone. I wasn’t getting any sleep. Recently, I made the extremely difficult decision to move him into an assisted-living facility. Fortunately, he has the financial resources to do that. For most people, that’s not even an option. I have been happy with the level of care that he’s getting, but when I signed the lease, I felt like I was breaking my promise. I tried my best to follow my mom’s wishes. But there’s only so much I could do, and I had to do it.Karina Ortega43, caregiver, DallasDesiree Rios for The New York Times“I’m the only one with no children and have always been the one who would take care of my parents. If Mom gets worse and I can’t care for her? That’s something I struggle with.”My mother was diagnosed with Alzheimer’s in March 2020, but even before then, I knew something was wrong. One day, she went to visit a family friend and was going to donate some clothes to her. Seven hours later, we still hadn’t heard from her. She got lost. Eventually she found a supermarket that was familiar to her and got home. I’m no longer working at all. This has all taken a toll on my life. I do have a younger brother and an older sister, but my sister has a daughter in college and my brother has a 7-year-old. I’m the only one with no children and have always been the one who would take care of my parents. If Mom gets worse and I can’t care for her? That’s something I struggle with. Putting her in a home? In our culture, that’s looked down upon. I was a rebellious teen and she never gave up on me, so how am I going to give up on her? I just can’t see it in me to leave my mom because she needs me.Gay Glenn61, actor, Topeka, Kan.Gay Glenn moved from Chicago back to Kansas to take care of her mother, Betty Mae Glenn, who had dementia.Arin Yoon for The New York TimesIt was costing us $8,000 out of pocket to have people come into my mom’s house to help her, and that was only eight hours a day. I’m watching her savings just dwindle. And then she fell. And then she fell again overnight. At the hospital, they found she had a cracked sacrum. She was in rehab for the maximum number of days that Medicare will cover and couldn’t return home. Because she owned a house, had two rentals, savings and two cars, she had to pay long-term care costs out of her pocket. I think my mom had about $18,000 in the bank. She had five life insurance policies in her children’s names. We cashed out the policies. In one year, she had to pay $65,000 for her care at the nursing home and spend down an additional $37,000 to be able to be eligible for Medicaid. We just sold her house. She passed in October. The state says we still owe close to $20,000 for the year Medicaid paid for her nursing home. I moved here in February of 2019. I certainly didn’t expect to be here going on five years. It was awful — personally all the time and energy and money to do this for her — and it was great. I was able to protect her and make sure everything was OK for her. I said at the memorial service that my mom was there when I took my first breath, and I was there when she took her last. If that’s not the circle of life, I don’t know what is.Bryan Ness62, biology professor, Angwin, Calif.Bryan Meltz for The New York Times“They told us: Don’t ruin your own retirement over this. Well, agreed, but we’ve got to take care of my mom, too.”We had it all planned. My mom was going to live with us. She has some cognitive issues from the stroke. All of her long-term memory is just fine. Her short-term memory is just nonexistent. We looked at what it would cost for home care. Even if we limited it to just eight hours a day, it’s more expensive than the assisted-living place that’s 10 minutes from our house. It’s a wonderful little place. It’s $4,500 a month. That’s a still a lot. She’s run out of her own money. There’s no more than the $1,500 she gets from Social Security. We talked to the place and got it down to $4,000. I got really good responses from GoFundMe. A lot of my former students and friends put in some chunks. I hate begging for money. My wife and I are at least at the age where we don’t have kids we’re supporting any more. But we’re concerned we are going to hurt our own retirement savings. My wife is already 65. We need to keep our retirement plan going, too. They told us: Don’t ruin your own retirement over this. Well, agreed, but we’ve got to take care of my mom, too. We have a relative who’s giving $500 a month. I’m going to take on some extra work to cover the costs. I felt my career could wind down over the next few years, and now I’ve got an $1,800 bill added to my finances from now until whenever.Stacey Wheeler60, retired, Greenville, S.C.Stacey Wheeler at her home in Greenville, S.C. Her mother moved to an assisted-living facility after she got sick and needed a wheelchair.Will Crooks for The New York TimesMy mom was in independent living. I had someone coming in the morning to get her up. Nobody is getting paid enough to say: “Now, come on, you really want to get dressed. Let’s pick out some earrings.” I should have tried 20 people in hopes of finding one who did that. No one is going to waste time with an old person who doesn’t want to do what they don’t want to do. It’s hard to care about grumpy people when you’re barely putting food on the table. My mom got sick and then needed to be in a wheelchair in assisted living. When she sold her condo, she had about $2,500 a month in retirement and she had about $120,000 in the bank. That starts going fast when you hit $7,000 or $8,000 a month. Everyone’s so worried about being sued by people that every time something happened they wanted her to go to the E.R. I wish I had known that no one was going to help me. I would have kept her in independent living and gone through hiring people until I found one. My husband and I were both retired, fortunately. We couldn’t leave town. We tried twice and had to come back. Ironically, the last place she was in, because she was going to run out of money, was the best place. The room wasn’t as big, but the staff were the best there. Mom died in August 2022.Jeanette Landin55, college professor, Brattleboro, Vt.Kelly Burgess for The New York Times“It’s not something I would wish anybody to ever go through.”There were wildfires where my mother lived out in California that were getting very close and were causing her health problems. Between that and a series of in-home falls and her inability to drive herself to different places, she finally called in November of 2017 and said, “I think I need to come live with you.” We found a house that would be adequate for both my family and her needs. Her dementia started to get worse. We looked at adult day care and found a local place. It was tremendously expensive to do that. But they were good until they got to a point where they contacted me and said she’s not following directions, she’s refusing to do appropriate hygiene. This was early 2022, and we had to pull her out of that service. In early April she started getting violent and would threaten my husband that she was going to kill him by chopping his head off. And then she would tell me she was going to kill my daughters. One night I had her taken to the hospital and they found she had been in kidney failure. She was still very violent. They looked at placement in a nursing home. Because of the fact she was violent, she couldn’t be placed anywhere. They had to send her home with us, and we had to keep her chemically sedated. From the time she came home till the time she died, it was seven days. We kept our daughters from coming upstairs. We didn’t want them hearing and seeing what was happening because it’s not something I would wish anybody to ever go through. It was awful.Jordan Rau is a senior reporter for KFF Health News, part of the organization formerly known as the Kaiser Family Foundation.

Hormonal contraceptives taken by adolescents may influence development of the brain in a way that alters the recognition of risks, a new study in rats suggests.
Scientists at The Ohio State University are exploring how common synthetic hormones used for birth control affect the prefrontal cortex, an area of the brain that continues to develop throughout adolescence.
The researchers found that myelination, the formation of protective coating on axons projecting from the main body of brain cells, increased in rats given hormonal birth control compared to untreated rats, while the number of immune cells of the brain decreased. In behavior tests, the treated rats also showed signs of impulsivity.
“We start the rats on hormonal contraceptives as soon as they go through puberty and give them throughout adolescence, and then do behavioral tasks at the cusp of adulthood,” said Benedetta Leuner, co-senior author of the study and associate professor of psychology at Ohio State. “By the end of adolescence, impulsivity shouldn’t be as much of a thing, but that doesn’t seem to be the case — which, while highly speculative, suggests hormonal contraceptives might be stalling brain maturation.”
In addition, the study was the first to detect synthetic forms of these hormones in adolescent rats’ brain tissue.
“We now know that these synthetic hormones are actually getting to the brain, which is important. No one had ever shown that in adolescence,” Leuner said.
The study was presented in a poster session today (Nov. 12, 2023) at Neuroscience 2023, the annual meeting of the Society for Neuroscience.

An estimated 2 in 5 teenage girls in the United States have sexual intercourse between age 15 and 19. Among those using birth control, almost 5% use hormonal contraceptives — products that are also prescribed to treat acne and heavy periods.
Ohio State behavioral neuroscientists say it’s important to understand hormonal birth control’s effects on the developing brain so individuals can weigh the risks and benefits of their reproductive health choices.
The researchers gave a combination of synthetic estrogen and progesterone typically found in hormonal contraceptives to female rats from early to late adolescence and compared their behavior and brain tissue to untreated rats.
The study focused on myelination and immune cells called microglia because both have essential roles in prefrontal cortex development — and communication between cells in particular — that are controlled in part by natural hormones. Myelination facilitates signal transfer between cells, and microglia play a critical role in sculpting brain circuits.
Because synthetic hormones in contraceptives dampen ovaries’ production of natural estrogen and progesterone to prevent ovulation, the research team is looking at how those hormonal differences affect the brain while it is still developing.
“Synaptic development and myelination are occurring during this adolescent window and are sensitive to pubertal onset of hormones,” said co-senior author Kathryn Lenz, associate professor of psychology at Ohio State. “So we thought that disturbance of that normal pubertal hormonal activity could potentially shift the trajectory of some of those developmental processes.”
When it comes to nervous system communication, keeping it steady is key — too much or too little can lead to dysfunction that affects the mood and behavior. The finding that myelination increased and microglia decreased with hormonal contraception hints at disrupted communication, Lenz said — especially since other research teams have suggested that microglia regulate myelination.

“Shifts in either one or the other direction for both is really important to document and understand,” she said.
In behavior tests of threat appraisal, the rats given hormonal contraceptives were more likely than controls to remain in wide open elevated spaces and sample treats in unfamiliar settings — both considered risk-taking behavior.
A sensitive lab technique called liquid chromatography/mass spectrometry confirmed that the synthetic ethinyl estradiol and levonorgestrel given to the treated rats were present in brain tissue — a powerful piece of evidence that will guide future research.
“We don’t know if these effects are due to shutting down natural hormone production or if these synthetic hormones are acting directly in the brain,” Leuner said. “That’s a very big, open question.”
This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
First author Rachel Gilfarb, a graduate student in Leuner’s lab, presented the poster. Additional co-authors include Sanjana Ranade, Meredith Stewart, Abhishek Rajesh and Courtney Dye.

An intensive three-year intervention to lower the top blood pressure number to less than 120 mm Hg was more effective at preventing death, heart attack, stroke and other cardiovascular events in adults at high risk for cardiovascular disease, compared to the standard treatment target of under 140 mm Hg, according to late-breaking science presented today at the American Heart Association’s Scientific Sessions 2023. The meeting, Nov. 11-13, in Philadelphia, is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science.
“Our study provides evidence to support targeting systolic blood pressure to less than 120 mm Hg in hypertensive patients with high cardiovascular risk and normal or mild-reduced kidney function, regardless of their diabetes status (Type 1, Type 2 or none) or history of stroke,” said lead study author Jing Li, M.D., Ph.D., director of the department of preventive medicine at the National Center for Cardiovascular Diseases in Beijing, China.
The researchers conducted a multi-center, randomized controlled trial to evaluate the effects of an intensive blood pressure-lowering strategy on the incidence of major cardiovascular events, including heart attack, stroke, cardiovascular death, revascularization, or hospitalization or emergency room visit for heart failure, in participants with increased cardiovascular risk.
Participants in the ESPRIT trial were randomized to receive intensive blood pressure treatment with a systolic blood pressure target of less than 120 mm Hg or standard treatment, with a target measurement of under 140 mm Hg over a three-year period. Antihypertensive medication was prescribed to lower blood pressure in both groups. Patients in the intensive treatment group received multiple classes of hypertensive medications and higher doses of antihypertensive medications in comparison to the usual-treatment group. Safety was assessed between treatment groups by comparing serious adverse events among participants.
The researchers found that after two years, participants in the intensive treatment group had significantly better outcomes than those receiving standard care. Compared with the standard treatment, the intensive treatment strategy prevented: 12% of heart attacks, stroke, revascularization procedures, death from cardiovascular causes and hospitalization or emergency room visit for heart failure; 39% of deaths from cardiovascular causes; and 21% of deaths from any cause. There was no significant difference in serious adverse events of low blood pressure, electrolyte abnormality, fall resulting in an injury, acute kidney injury or renal failure.Syncope, or fainting, was one of the serious adverse events used to evaluate safety. Syncope occurred at a rate of 0.4% per year in the intensive group and 0.1% in the standard group. This means that for every 1000 patients receiving the intensive treatment for 3 years, 3 patients would experience a serious adverse event of syncope, while 14 major vascular events and 8 deaths would be further prevented, Li noted.
“These results provide evidence that intensive hypertension treatment focused on achieving systolic blood pressure of less than 120 mm Hg is beneficial and safe for individuals with high blood pressure and increased cardiovascular risk factors,” Li said. “Implementing this intensive treatment strategy for high-risk adults has the potential to save more lives and reduce the public health burden of heart disease worldwide.”
Study details and background: The ESPRIT trial included 11,255 adults in China. Participants had a baseline systolic blood pressure measurement of 130-180 mm Hg and either established cardiovascular disease or at least two major risk factors for cardiovascular disease. Participants were an average age of 64.6 years; 41.3% were identified as women and 58.7% were identified as men, according to their national ID cards. Approximately 27% of the study participants had a history of stroke; approximately 29% had previous coronary heart disease; and approximately 39% had diabetes, Type 1 or Type 2. The trial’s primary outcome was a composite outcome of heart attack, coronary or non-coronary revascularization, hospitalization/emergency room visit for heart failure, stroke or CV death. Secondary outcomes included CV outcomes, kidney outcomes and cognitive outcomes.Study limitations included that the cardiovascular benefits of the intensive intervention emerged after two years, while the intervention only lasted three years, meaning the relatively short study period may underestimate the benefits, Li said. In addition, the study was conducted in China and therefore, the results may not be generalizable to people in other racial and ethnic groups or living in other countries. However, Li also noted that the results were consistent with similar studies in people of other racial and ethnic groups.
Future work will involve examining the longer-term effects of the intensive intervention strategy over the follow-up period.

Intratumoral therapy — in which cancer drugs are injected directly into tumors — is a promising treatment option for solid cancers but has shown limited success in clinical trials due to an inability to precisely deliver the drug and because most immunotherapies quickly dissipate from the site of injection. A team of researchers from Mass General Brigham, in collaboration with colleagues at the Koch Institute for Integrative Cancer Research, has developed a gel delivery system that overcomes these challenges. The gel is injectable but solidifies upon delivery; contains an imaging agent for visualization under CT scan; and can hold a high concentration of drug for slow, controlled release.
In a paper published in Advanced Healthcare Materials, the team reports that using gel-delivered imiquimod (an immune stimulating drug) in combination with checkpoint inhibitor therapy induced tumor regression and increased survival in mouse models of colon and breast cancer that are usually resistant to checkpoint inhibitor therapy. The treatment also appeared to train the immune system to detect and attack distant tumors that were not directly treated, suggesting that it might be a helpful therapy for metastatic cancers.
“This gel tackles the two problems with existing attempts at making intratumoral cancer immunotherapy: making the therapy visible and practical so that interventional radiologists can confirm delivery, and making sure the drug actually stays in the region of interest,” said Avik Som, MD, PhD, of the Department of Radiology at Massachusetts General Hospital, a founding member of the Mass General Brigham healthcare system. “When we inject this gel into a tumor, we’re able to teach the immune system to recognize the cancer and trigger it to attack not only the site where the gel was injected, but also other areas in the body where the same cancer may be hiding.”
The research team, which consisted of both engineers and medical professionals, first developed and optimized the gel-delivery system in the lab by tweaking the gel’s chemical structure. One key aspect of the gel’s design was that it needed to shift from being liquid at room temperature to make it injectable but become solid at body temperature inside the tumor in order to form a drug-releasing depot, while also retaining drug encapsulation and delivery capability, and carrying sufficient imaging agent.
After optimizing the gel in the lab, the team tested its ability to treat mouse models of colon and breast cancer that are usually resistant to immunotherapy. To do this, they used the gel to deliver imiquimod, an FDA-approved immune stimulating drug, in combination with checkpoint inhibitor therapy. Each mouse had two tumors of the same type, but the researchers only treated one tumor per mouse, which allowed them to test the gel’s ability to stimulate both local and systemic immunity.
They showed that treating with gel-delivered imiquimod in combination with checkpoint inhibitor therapy improved survival in both cancer models. The treatment resulted in an all-or-nothing response — mice that responded to the treatment showed complete regression of both the treated tumor and a distantly located tumor (a model for metastasis), while non-responders showed no regression at either site. For the colon cancer model, 46% (6/13) survived when the checkpoint inhibitor therapy was combined with gel-delivered imiquimod. For the breast cancer model, 20% (3/15) survived when treated with the combined therapies.
“These two tumors remain challenging to treat today, even though immunotherapies are transforming how we think about treatment,” said co-corresponding author Giovanni Traverso, MB, PhD, MBBCH, Department of Medicine at Brigham and Women’s Hospital, a founding member of the Mass General Brigham healthcare system and an associate professor in the Department of Mechanical Engineering at MIT. “The fact that we were able to induce responses in distant tumors in these colon and breast cancer models was a big win.”
The researchers are keen to move this technology to the clinic, but it will first need to go through more rounds of testing for safety. They also plan to test its efficacy with a broader panel of drugs.
“This is an early proof of concept, but we’re all actively working together to try and get these technologies to patients,” said Eric Wehrenberg-Klee, MD, assistant radiologist in the Department of Radiology at Massachusetts General Hospital and one of the study’s first authors. “There’s quite a bit of benefit to be gained by being able to treat patients with a single injection, and we think this technology has the potential to help with cancers that are currently challenging to treat.”

A new study by investigators from Mass General Brigham found that one in five individuals taking Nirmatrelvir-ritonavir therapy, commonly known as Paxlovid, to treat severe symptoms of COVID-19, experienced a positive test result and shedding of live and potentially contagious virus following an initial recovery and negative test — a phenomenon known as virologic rebound. By contrast, people not taking Paxlovid only experienced rebound about 2 percent of the time. Results are published in Annals of Internal Medicine.
“We conducted this study to address lingering questions about Paxlovid and virologic rebound in COVID-19 treatment,” said corresponding author Mark Siedner, M.D., MPH, an infectious disease clinician and researcher in the Division of Infectious Diseases at Massachusetts General Hospital. “We found that the virologic rebound phenomenon was much more common than expected — in over 20% of people taking Paxlovid — and that individuals shed live virus when experiencing a rebound, implying the potential for transmission after initially recovering from the virus.”
Paxlovid is an oral antiviral medication used to treat COVID-19. Previous studies demonstrate the medication’s effectiveness in reducing hospitalization and death in cases of severe COVID-19 infection. Since the integration of Paxlovid into COVID-19 treatment, some patients have reported virologic rebound. A previously conducted phase 3 clinical trial known as EPIC-HR suggested that only 1% to 2% of patients taking Paxlovid experienced virologic rebound. However, the study by Siedner and colleagues suggests this phenomenon occurs far more often than previously suspected.
“Paxlovid remains a life-saving drug I prescribe to high-risk patients,” said co-senior author Jonathon Li, M.D., an infectious disease physician and researcher in the Division of Infectious Diseases at Brigham and Women’s Hospital. “This study, while informative, does not change the fact that this drug is very effective at preventing hospitalizations and death. Instead, it offers valuable insights to Paxlovid patients, helping them understand what to expect and how long they might be contagious.”
Siedner, Li and other researchers from Mass General Brigham collected data from the Post-vaccination Viral Characteristics Study (POSITIVES), an ongoing study following individuals diagnosed with acute COVID-19 infections. Between March 2022 and May 2023, 142 individuals were selected for the study based on positive COVID-19 tests, medication prescriptions or physician referrals. Sorting participants by those who took a five-day Paxlovid regimen versus those who did not, they closely tracked patients’ viral loads and symptoms, cultured viral samples and performed whole genome sequencing. Patients who tested positive for COVID-19 after previously testing negative and those who exhibited two consecutive increases in viral loads following an initial reduction were classified as experiencing virologic rebound.
Investigators discovered that 20.8% of participants who took Paxlovid experienced virologic rebound, while only 1.8% of those who didn’t take Paxlovid had a similar rebound effect. Those with rebound also had prolonged viral shedding — for an average of 14 days compared to less than 5 days in those who did not experience rebound — indicating they were potentially still contagious for much longer. Importantly, Siedner’s team found no evidence of drug resistance among these patients.
The findings should not discourage clinicians from prescribing the medication, the researchers noted, but they should prompt them to counsel patients who take the medication about the risk for viral rebound and spreading the virus to others. Advising patients to re-test and isolate in case of rebound should be part of that conversation, the team said.

The original EPIC-HR study assessed outcomes for patients at only two time points. When the Mass General Brigham researchers aligned their data analysis with the select time points from the EPIC-HR study, they observed virologic rebound in only 2.4% of participants, suggesting that the previous study did not capture the full extent of virologic rebound.
“In our study, we were able to closely monitor patients from the onset of COVID-19 infection through treatment and rebound,” explained Li. “Unlike in the EPIC-HR study, which only assessed outcomes at two time points, we followed up with patients three times a week, sometimes for months, and performed in-home sample collection. Having both viral RNA levels and viral culture data also allowed us to paint a more comprehensive and nuanced picture of a patient’s experience with Paxlovid.”
This study is limited in that it was observational and not a randomized controlled trial, so the authors cannot be certain that the increased rebound rate seen in people taking Paxlovid was solely due to use of the drug. The team used a positive viral culture as a marker for one’s risk of transmitting the virus but could not formally measure how contagious someone experiencing virologic rebound was. Additionally, the team could not explain why some people experienced rebound while others did not — something they aim to explore with future studies. They also plan to investigate the biological mechanism behind the rebound phenomenon associated with Paxlovid and determine if changing the regimen length could help combat this rebound effect.
Authorship: Co-lead authors of the study include Gregory E. Edelstein (BWH), Julie Boucau (Ragon Institute of MGH, MIT and Harvard). Additional Mass General Brigham researchers include Rockib Uddin (MGH), Caitlin Marino (Ragon), May Y. Liew (MGH), Mamadou Barry (MGH), Manish C. Choudhary (BWH), Rebecca F. Gilbert (MGH), Zahra Reynolds (MGH), Yijia Li (BWH and MGH), Dessie Tien (MGH), Shruti Sagar (MGH), Tammy D. Vyas (MGH), Yumeko Kawano (BWH), Jeffrey A. Sparks (BWH), Sarah P. Hammond (MGH), Zachary Wallace (MGH), Jatin M. Vyas (MGH), co-senior author Amy K. Barczak (Ragon and MGH), and co-senior author Jacob E. Lemieux (MGH).
Disclosures: AKB reports consulting for ICON Government and Public Health Solutions. JZL reports consulting for Abbvie and research funding from Merck. SPH reports research funding from GlaxoSmithKline and has served on an advisory board for Pfizer.
Funding: This work was supported by the National Institutes of Health (U19 AI110818 and R01 AI176287), the Massachusetts Consortium for Pathogen Readiness SARS-CoV-2 Variants Program, and the MGH Department of Medicine. Additional support was provided by the Ragon Institute BSL3 core, which is supported by the NIH-funded Harvard University Center for AIDS Research (P30 AI060354). Drs. Sparks and Wallace are supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01 AR080659). Dr. Sparks is also supported by the Llura Gund Award for Rheumatoid Arthritis Research and Care. The funders had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication.