In the early 20th century, women used it to ease the pain of labor, but its use declined in favor of more potent analgesia. Now, a small band of midwives is helping to revive its use in the U.S.

One hospital in Rhode Island, South County Hospital in North Kingstown, has just added nitrous oxide, the formal name for laughing gas, to its menu of pain relief options for labor.

Amy Marks jumped at the chance to use it because she wanted to avoid an epidural — an injection in the fluid around the spinal cord that blocks feeling below the waist. The day after she gave birth, she sat with her son, Ethan Thomas, snug in the crook of her arm.

“When the contractions started getting pretty intense, I was like, ‘wow, this is pretty bad,'” she said. “So they brought it in and it really took the edge off.”

Dr. , professor and director of nurse midwifery at the Vanderbilt University School of Nursing, is helping lead the charge to bring back nitrous oxide as one of several options women should be offered for pain relief during childbirth. She sees the effort as being in line with what midwives have always done: advocating for women to have more control of the experience of giving birth.

Prior to the 1950s, Collins said, nitrous oxide was commonly used in labor. But then in the 1950s and 1960s, doctors started using drugs that could make a person drowsy. Women would go to the hospital, be completely knocked out, and wake up with a baby in their arms. The epidural, which came on the scene in the 1970s, gave women the possibility of a pain-free labor while awake. But it came with trade-offs: epidurals can make it difficult to move around and can prolong the second stage of labor.

Collins said women want more options to be more involved in the birth of their babies.

“Now, women are more informed, and they’re demanding that their voices be heard, which is a really great thing in my book,” she said.

Nitrous oxide has continued to be used regularly in Europe, so there’s that shows it’s , especially in smaller doses. It doesn’t reduce pain, like an epidural. Rather, it induces a sense of euphoria or relaxation.

“For some women, the epidural is going to be their number one choice. For other women, they want to be unmedicated and have nothing and that’s their choice. For other women, nitrous oxide is a viable choice,” she said. “It’s seen somewhat like a menu and for everything that’s safe, it should be on that menu and available to the woman.”

Another of this mini-revolution, retired nurse midwife and epidemiologist Judith Rooks, said the gas leaves the body in seconds.

“It does pass the placenta and go into the fetal circulation, but as soon as the baby takes a breath or two, it’s gone,” Rooks said.

The American College of Nurse-Midwives came out with a in 2011, saying it’s important for midwives be aware of nitrous oxide as a good option for women in labor and get trained in how to administer it. Dr. Laura Goetzl, a professor of obstetrics and gynecology at Temple University’s medical school, researches pain relief in childbirth. She considers nitrous oxide a “safe and reasonable” option and she is encouraging Temple to offer it at its hospital.

The American Society of Anesthesiologists and in May 2011, said in a paper that they would like to see more and more rigorous studies on its safety and effectiveness — much of the research is decades old. They also warn that facilities should have a good system for capturing any gas that escapes into the air, so those nearby don’t breathe it in. They note its use in Europe showed, “good safety outcomes for both mother and child.”

Nitrous oxide is less expensive than an epidural by hundreds, sometimes thousands, of dollars. Collins said the disposable breathing apparatus may cost about $25 and the cost of the gas alone, she said, is about 50 cents an hour. An anesthesiologist does not need to administer it — it can be done by a nurse midwife or other trained medical staff. Hospitals are having a hard time figuring out the billing, however, because it’s so new, said Collins.

“The interesting thing is that there’s not a charge code for this particular use of nitrous oxide in labor,” she said. “So places around the country are being very creative in how they’re approaching the charge portion of it.”

One insurer in Rhode Island covers it as it would another painkiller. Some hospitals, says Collins, just swipe a patient’s credit card, or don’t charge at all.

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A new collaboration between the consumers group Families USA and the Institute for Clinical and Economic Review (ICER), an independent nonprofit research organization, released two guides Thursday to help patients and their health care providers decide which screenings and treatments offer the best value in terms of clinical and cost effectiveness for two types of cancer.

The groups plan to produce about six reports each year. Future topics will include lower back pain, ADHD and type 2 diabetes.

The guides rate how well one option works compared to others based on scientific evidence and how a treatment’s cost compares to its long-term benefits.

“These publications will help patients and consumers work with their physicians to think through what is the best course of treatment when you have a significant illness,” said Ron Pollack, executive director of Families USA.  “For many health problems, particularly severe health problems, the choices can be bewildering and they can be very difficult for patients to really think through what’s in their best interest.”

In a report on treatment options for ,  — a high-tech radiation treatment for cancer — is rated as a lower-value option than monitoring the condition, removing the prostate gland through surgery or undergoing radiation.

In a guide covering for women with dense breast tissue, digital breast tomosynthesis, a newer type of mammogram, is a lower-value option than a digital mammogram or an MRI, depending on whether the woman has a low or high overall risk of breast cancer.

The collaboration will help , which produces reports analyzing evidence on the effectiveness and value of drugs and medical services, to distribute its research more broadly.  “We wanted to figure out a better way to have evidence we worked on help patients,” said Steve Pearson, president of ICER and primary author of the guides. “If a patient knows that the evidence says that these two treatment options offer me the same potential benefits, and one’s a lot more expensive than the other one, then I want to pick the less expensive option.”

For Families USA, the new venture will build upon the coverage gains the group won under the 2010 health care law. “Good care really is a question of ‘Can you get good value care, care that is effective in terms of treating an illness and care that is affordable?'” Pollack said.

Initial funding for the venture comes from the Kaiser Permanente National Community Benefit Fund at the East Bay Community Foundation.

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The (PCORI) already has funded 468 studies, and last month opened the second phase of a program to create research networks covering specific diseases and involving millions of patients across the country.

The institute’s work, known as “comparative effectiveness research,” poses deceptively simple questions to find out vital information about which therapy or medication works best in the real world. Institute research goes beyond clinical trials and so-called “best practices” and extracts evidence from the individual experiences of massive numbers of patients.

Early results are encouraging. For example, many older patients fear the side effects of blood thinners, even though they decrease the incidence of stroke by 50 percent, but an of 12,500 stroke patients with atrial fibrillation found that the use of the blood thinning drug warfarin worked just as well without causing undue bleeding for patients over 80 as it did for younger patients. Another  of children suffering from osteomyelitis, a bacterial bone inflammation, found that kids could take antibiotics orally instead of through an IV, a complicated and unpleasant procedure with risk of infection. The study reached that assessment after reviewing data from more than 2,000 children and adolescents treated at 36 children’s hospitals that have various protocols for handling the disease.

“We like studies embedded in real world settings, with big samples,” said Joe Selby, the institute’s executive director who is also a family practitioner, “in part because you want to be sure of the answer.”

Yet, some experts caution that it is too soon to proclaim the institute a success: “The jury is still out,” said Emory University Health economist Victoria Phillips. “We’ll need to look at what they deliver. Does the focus on patients disseminate the evidence more quickly and lead to faster implementation?” she asked. Other questions she raised: Is the integration between patients and researchers a success? Could another party do it more cheaply?

The institute, established in 2011as part of the Affordable Care Act, , with Republican opponents charging that it would be used to ration health care or even to serve as a “death panel” to determine who gets treatment and who does not.  But the work has gone forward and raised few, if any, complaints.

The institute is a nonprofit financed from a trust fund set up by the Affordable Care Act that is expected to provide around $3 billion that must be spent by the end of 2020.

“Our job is to provide evidence,” Selby said. “We do not make policy or write guidelines. What patients and clinicians do with the evidence will be done by them, not us.”

In 2014 the institute launched the Patient-Centered Outcomes Research Networks, a program creating formal organizations overseen by medical professionals with patient participation and capable of conducting research surveys and studies into many diseases and conditions. These include both Clinical Data Research Networks, usually based at large university medical centers with access to repositories of millions of electronic health records, and Patient-Powered Research Networks that link thousands of patient volunteers with academic partners. The institute funded the first phase of the program for $93.5 million. Phase Two began Oct. 1 and will cost $142.5 million for three years.

Instead of merely funding individual studies, the networks give the institute additional tools for researchers to conduct multiple studies with resources already in place. Clinical Data Networks could enable medical professionals to query the records of millions of patients to learn the results of past or current medical care. One set for this network is to determine the optimal daily dose of aspirin to help prevent heart attack or stroke in people with coronary artery disease.

Patient Powered Research Networks partner academic researchers with patients, who help set the research agenda. The networks, working with patient-focused groups, recruit participants and identify concerns for potential studies.

In both types of networks, leaders vet research proposals, query their groups and send the resulting data to the research teams. The teams do not see patients’ individual medical records. Institute-funded studies must be peer-reviewed, and researchers must also prepare separate 500-word summaries of their results for clinicians and patients and post them on the institute’s website.

Each clinical network is required to research one common condition and one rare condition, but over time they are expected to be able to address practically any disease. So far, there are 13 clinical networks examining conditions that include breast cancer, anemia and atrial fibrillation, muscular dystrophy, cystic fibrosis and congenital heart defects.

“We’re trying to build a model that’s cheaper to use and more efficient” than conventional research trials, said Russell L. Rothman, a primary care physician and leader of the Mid-South Clinical Data Research Network, which is based at Vanderbilt University in Nashville but can draw on a sample base of 9 million patients in its region. The network’s early work has focused on coronary heart disease, especially on disparities in care, and sickle cell anemia.

Rothman said the network has spent its first 18 months making record systems compatible and appointing committees of physicians, patients and other health care providers to vet research requests. “We can use electronic health record data, to identify patients with a particular condition and follow them over time,” he added.

Health economist Rachael Fleurence, in charge of supervising the networks and developing reliable methodologies for them, said her program has worked at “getting everybody organized” but the networks have now begun to do research.

One of the more unusual new networks is focused on care for mental health problems, especially depression, in underserved communities in Los Angeles and New Orleans.

Called the , the initiative grew from a collaboration begun by University of California at Los Angeles psychiatrist Kenneth Wells and Loretta Jones, the founder of the Los Angeles-based community organization Healthy African-American Families.

“It was very difficult to get the community to talk about depression,” Jones said, but in 2003 she and Wells sponsored a conference where they asked community members what was needed. The conference helped spur efforts to improve mental health care opportunities in the community. The network they built, now one of the institute’s Phase 2 Patient Participatory networks, expanded its model to New Orleans after Hurricane Katrina, and today involves as many as 250,000 people in Louisiana and California.

The key feature of comparative effectiveness research, no matter how it is conducted, is to “improve patient care,” the Mid-South’s Rothman said. “Clinical trials typically test the effects of drugs against a placebo, while comparative effectiveness research compares one standard treatment to another in a real world situation to see what works better. We’re taking the next step.”

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