November 02, 2017

Persistent Confusion About Confusion

The modern concept of delirium or an acute confusional state has been around for decades, but physicians are still confused about it. A recent review article in the New England Journal of Medicine summarizes what we know about delirium: what it is, how to treat it, and how to try to prevent it. “Delirium in Hospitalized Older Adults,” as the title says, does not address delirium outside the hospital, i.e. in the skilled nursing facility, where it is even less well-recognized, but despite this limitation it is a welcome update of an important topic.
            Older patients—most of the studies define “older” in this context as at least 70—are at high risk of developing the acute onset of confusion after they are admitted to the hospital. Lumping all older people together, regardless of age or reason for admission, roughly one-third will become delirious. Among people who have certain operations such as hip fracture repair or cardiac surgery, the rate is more like 50 percent, and among older patients in the ICU on a ventilator, it rises to 75 percent. What’s particularly striking is that once delirium strikes, it’s hard to get rid of. At the time they are discharged, nearly half of all patients who got delirium in the hospital still have it, and a month later one-third still meet the criteria for delirium. It’s not always “hyperactive delirium,” the agitation we usually think of when we hear the word delirium; in fact, nearly 75 percent of the time it’s the opposite, or “hypoactive delirium,” a more insidious, quieter form of the disorder.
            The article goes through the major triggers of delirium, with medications (especially sedatives, opioid pain medications and other mind-altering substances) at the head of the list. Out-of-whack blood chemistries (technically known as electrolyte disturbances) and infection are two other leading offenders, but the bottom line is that almost anything can result in delirium, from a heart attack to severe constipation. Treatment consists primarily of removing or curing the underlying precipitant—for example, getting rid of the implicated medicine, limiting the heart attack damage, or getting the bowels moving. The author is at pains to tell us that among twelve randomized controlled trials of antipsychotic medications in the treatment of delirium, none of them resulted in decreasing the severity or duration of delirium, none of them lowered mortality rates or length of stay in the hospital. Nonetheless, he indicates that antipsychotic drugs may be prescribed if needed to control particular symptoms.
            Most interesting are the reminders about what works best to prevent delirium. The gold standard is still the 1999 HELP study (Hospital Elder Life Program) that used trained volunteers to make sure older patients wear their glasses and their hearing aids and that they get a back rub rather than a sleeping pill if they have trouble sleeping at night. Another approach that also makes a difference is a proactive geriatric consultation. Especially when initiated on a surgical service, this can assure that older patients are not prescribed sedating medications, that they receive round-the-clock acetaminophen whenever possible instead of as needed opioids, and that they get out of bed and moving as soon as possible. A related approach that the author doesn’t mention is use of the ACE unit (Acute Care for the Elderly), a specially designed inpatient unit that builds anti-delirium measures into its mode of operation.

            But what’s important to emphasize is that even the best delirium prevention strategies are only moderately successful. Delirium is a nasty disorder: it is extremely unpleasant, it’s dangerous, and it lingers. Some people never recover fully, some die. For older people who have some degree of cognitive impairment, those who have significant trouble carrying out daily activities, and those with multiple problems on many medications, the best approach may be to avoid the hospital altogether.

October 29, 2017

Happy Birthday, Medicare

Here's what I wrote for the University of North Carolina Press blog, on the occasion of Medicare's 50th birthday. Medicare is the protagonist of my new book, Old and Sick in America: the Journey Through the Health Care System, published by the UNC Press.

Happy Birthday, Medicare

Fifty years ago this summer, Medicare celebrated its first birthday. After 30 years of unsuccessful attempts to introduce national health insurance, Congress finally took what was supposed to be its first step in the direction of comprehensive coverage, creating the Medicare program for older Americans. The consequences were profound: Medicare has influenced how older people die—where they die, and what they die of—and it has affected how older people live—longer and with less disability. Every site where older people receive medical treatment has been shaped by Medicare, from the office to the hospital to the skilled nursing facility.
Medicare did not achieve all this at once, although already after one year of existence, older people were flocking to the hospital as never before. They were finally tending to those nagging symptoms they had previously neglected or the elective surgery they had put off because they couldn’t afford to go to the hospital. Over time, Medicare evolved to adapt to new realities and to meet new challenges. Medicare hospice, for example, was non-existent in the early days of the program; the benefit was first introduced through federal legislation in 1983.  In its first year of existence, only 200 older people enrolled in hospice, accounting for less than half of one percent of all deaths. By 1986, 7 percent of Medicare patients who died had been enrolled in hospice; by 1998, that percentage had jumped to 19 percent, and in 2013 it soared to 47 percent.
Home care started to become a reality for older Americans after Medicare was expanded in 1972 to cover physical therapy and occupational therapy; it became even more of a reality when federal legislation permitted home services without a prior hospitalization and allowed for-profit agencies to provide the services. The availability of medical care at home—though with the conspicuous absence of physician care—became crucially important after the introduction of prospective payment for hospital care in 1983, which in turn led to dramatically shortened hospital stays. As older individuals were discharged “quicker and sicker,” they desperately needed help, and they quickly learned they could get it through home nursing, home physical therapy, and home health aides—paid for by Medicare.
In a time when the integrity of the Medicare program is under threat—make no mistake, today it is Medicaid that is on the chopping block, tomorrow it will be Medicare—it behooves us to celebrate the program’s successes.
For those older people who were just too debilitated to go home after a hospitalization, even with home care services, another alternative was rehab. This kind of inpatient care, typically provided in a skilled nursing facility (SNF), was virtually unheard of in 1967. It was covered by the initial Medicare legislation, but only took off after prospective payment shortened hospital stays. Today, one in five older patients goes from the hospital to the SNF.
Changes to the Medicare program continue unabated to this day, modifications that have profound ramifications for all older Americans.  The “value-based care” required by the Affordable Care Act is now embedded in the way that Medicare pays for joint replacement surgery: instead of paying the orthopedist, the hospital, and the skilled nursing facility separately for their work, Medicare instead pays the providers a single “bundled” fee that they must apportion among themselves. This means that no longer will the orthopedist be able to wash his hands (it’s usually a he) of what goes on the rehab setting, nor will the hospital regard discharged patients as out of sight, out of mind. In the drama in which the protagonist is the patient with a painful knee and trouble walking and the action revolves around an operation, all the players have to cooperate to make the outcome successful. Thanks to the Medicare Readmissions Reduction Program, hospitals can no longer discharge patients with impunity, before their problems have been adequately attended to and without a robust follow-up plan in place.
In a time when the integrity of the Medicare program is under threat—make no mistake, today it is Medicaid that is on the chopping block, tomorrow it will be Medicare—it behooves us to celebrate the program’s successes. We also need to look closely at how the health care system works, how all the pieces hang together, and the unique opportunity that Medicare presents in the form of a lever with which to manipulate this complex system.

October 22, 2017

Old and Sick in America

I thought of calling the book, “Merchants of Health: How Doctors, Hospitals, Drug Companies, Device Manufacturers and Government Shape the Experience of Illness,” but that title didn’t say anything about old people.

I considered calling it, “Journey through the Health Care System: Aging and Ailing in America,” but both my husband and my editor thought that “ailing” sounded archaic.

“Close Encounters: Aging and Ailing in America,” another contender, had the same problem with the word “ailing” and while the allusion to the movie was cute, it’s far from clear what exactly I mean by “close encounters.”

Then there was, “In the Home of the Sick and the Land of the Aged: How the Health Care Colossus Shapes the Patient’s Experience of Illness,” which didn’t make clear what I meant by the health care colossus.

I considered using the title of this blog, “Life in the End Zone,” but the football metaphor didn’t quite work.

My editor wanted something short and to the point that made clear what the book is about. So it’s called “Old and Sick in America” and the subtitle is “the Journey through the Health Care System,” because I take the reader on a journey, beginning with a visit to the doctor’s office, then to the hospital, then to rehab, and finally back home. The book is out TODAY!

Here’s how the publisher summarizes the content:
“Since the introduction of Medicare and Medicaid in 1965, the American health care system has steadily grown in size and complexity. Muriel R. Gillick takes readers on a narrative tour of American health care, incorporating the stories of older patients as they travel from the office to the hospital to the skilled nursing home, and examining the influence of forces as diverse as pharmaceutical corporations, device manufacturers, and health insurance companies on their experience. A scholar who has practiced medicine for over 30 years, Gillick offers readers an informed and straightforward view of health care from the ground up, revealing that many life-altering medical decisions are not based on what is best for the patient, but rather on outside forces, sometimes to the detriment of patient health and quality of life. Gillick suggests a broadly imagined patient-centered reform of the health care system with Medicare as the engine of change, a transformation that would be mediated by through accountability, cost-effectiveness, and culture change.”

Here’s what a few reviewers had to say:
From Nancy Tomes, author of Remaking the American Patient:
“With this book, Muriel R. Gillick offers a satisfying balance of insight, compassion, and evidence about the many ways that Medicare has transformed the way older Americans live and die. Fusing the skills of the social scientist with those of a physician, Gillick combines compelling personal stories and clear-eyed analysis into a very readable whole. Old and Sick in America is a book that those of us with elderly relatives, or on Medicare ourselves, need to read."

From Sharon Kaufman, author of Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where to Draw the Line:
Old and Sick in America is timely, highly original, and critically important. Everyone who goes to a doctor or hospital will want to know what is in this book.”

It’s available from the University of North Carolina Press, from Amazon (paperback $29.95, Kindle edition $9.99) and other sellers.

October 16, 2017

Why Do We Need Health Insurance Anyway?

            Despite the seemingly endless barrage of articles stimulated by the equally endless efforts of the Trump administration to kill the Affordable Care Act, relatively little attention has been paid to why we need health insurance in the first place. Liberal Democrats assert that health care is a “right” and right-wing Republicans maintain that it’s a “privilege” and that the only business government has with health care is to facilitate the business of medicine. Some of the disagreement among the parties stems from differing assumptions about just exactly what health insurance is for. Is it to protect people in the event of catastrophe—a devastating car accident that results in multiple operations and an extended hospitalization, or metastatic cancer that triggers several rounds of chemotherapy, radiation therapy, and numerous hospital stays? Or is to maintain individual and public health—ensuring that people receive immunizations and cancer screening, along with treatment of high blood pressure and high cholesterol? We can begin to answer the question by looking at the example of one group in American society with universal coverage, the older population.
            Medicare (and its sister program, Medicaid, providing insurance coverage for poor people) went into effect on July 1, 1966, after what was effectively a 30-year battle. Franklin Roosevelt wanted the government to provide health insurance for everyone, but couldn’t make much headway with his idea; Truman campaigned actively for health insurance for all Americans, but his plan failed. Finally, after decades of wrangling, Congress and President Lyndon Johnson agreed to begin with those in greatest need: people who were either old, poor, or both. Medicare had the immediate effect of boosting the number of older people hospitalized—suddenly, they stopped neglecting that chronic cough that turned out to be lung cancer or decided to get medical attention for that stomach pain that proved to be an ulcer. The likely effect (though to be fair, it’s hard to disentangle the effect of Medicare from the effect of other concurrent changes) is that older people began to live longer—a lot longer. But what was really striking were the countless indirect ways in which Medicare promoted the health of the entire older population: for example, by promising to pay for effective technology, it stimulated the development of incredibly successful interventions such as the pacemaker and the artificial hip.
When we compare the health of Americans to that of their counterparts in other developed nations, we find, rather shockingly, that everyone else is generally better off than we are—if they are under 65. Among older people, the stark differences between the U.S. on the one hand and Europe, Australia, and Japan on the other hand vanish. The only plausible explanation is that older people in the U.S. all have health insurance, rendering them comparable to older people in other parts of the world.
            From a population perspective, ensuring that everyone has health insurance is desirable because health is desirable. Good health is like education: without it, we are not productive, creative, prosperous, or happy.  Health insurance is the means to assure good health, so just as public education is a means to a skilled labor force. Environmental regulations are the means to assuring a safer, more healthful country.
            From an individual perspective, health insurance is critical to well-being because it’s the gateway to good health. It’s simply not true that we can expect to stay perfectly healthy as long as we eat well, exercise, and lead a virtuous life. We never know when disease will strike, whether in the form of cancer or heart disease or a chronic neurologic disorder such as Alzheimer’s disease or multiple sclerosis. No matter how cautiously we drive, we cannot guarantee that a drunk driver won’t unexpectedly plow into us, causing no end of medical problems if we survive the crash. Nor can we expect that the cost of even routine medical care will be affordable: a plain x-ray, used to diagnose pneumonia and other lung conditions, typically costs hundreds of dollars when you add up the cost of the procedure and the cost of a radiologist’s reading. 
          Everyone needs basic medical care and it’s not just “catastrophic care” that is expensive. Hence, the rationale for covering each and every American isn’t just that health insurance only works when everyone shares the risk—though it is true that the only way to keep premiums manageable is for everyone, the sick and the healthy, to have coverage, rather than confining coverage to those who are known to be sick and are guaranteed to use huge amounts of service. The rationale for covering everybody is that health care is essential if we are to have enough energetic, healthy, educated workers to provide the services and the innovations that we all need, and the only way to make sure that everyone has access to health care is to provide insurance.
          Health care, and the insurance coverage to pay for it, isn’t a right, nor is it a privilege. But it is critical to promoting a strong, vibrant, capable citizenry.