November 16, 2014

The Five Percent

It’s a dirty little secret that nobody other than professional geriatricians and palliative care doctors seems to know. But inside those circles, most everyone is aware that palliative care is an up and coming field that has tripled in size since 2000, while geriatrics is floundering, with fellowship training slots going unfilled in recent years and the number of board certified geriatricians declining. So an editorial in the Journal of the American Geriatrics Society advocating that the two disciplines work together to promote a joint agenda set me to thinking: why the difference? 

A slew of factors have contributed to the success of palliative care. As Dr. Diane Meier points out in her editorial, the decision to push the field by “making the business case” to hospital CEOs rather than by focusing on getting NIH research funding was crucial. The creation of CAPC, the Center to Advance Palliative Care, which focused on leadership training and skills development, was a brilliant innovation. But I couldn’t help wondering whether the different trajectories of palliative care and geriatrics, which both address the needs of the 5% of the population who are the sickest—and who use half of all health care resources—could be traced in part to different attitudes toward the old and toward the dying. An article by geriatrician Dr. Louise Aronson in a new series of groundbreaking articles on aging in the Lancet suggests attitudes matter. 

Dr. Aronson quotes the comments of Dr. Robert Butler, in many ways the founder of contemporary geriatrics, that “aging is the neglected stepchild of the human life cycle.” Writing 40 years ago, Butler made the case that “ageism” allows people to distinguish themselves from older people, to see themselves as safe from the debility and decline that afflict many in the final phase of life. Aronson tells several anecdotes to emphasize that the disdain for old people persists in medical circles today: a surgeon who laughs at a student who says she wants to go into geriatrics and jokes that the “disease” the student will specialize in is “constipation;” a senior physician joking that the best way to avoid the adverse consequences of hospitalization in the elderly is “never to build nursing homes within 100 miles of hospitals.”

I remember that my decision to do a fellowship in geriatrics was met with the same mix of derision and incredulity 30 years ago. Another young doctor in my medical residency program gave me an extremely backhanded compliment: “But you’re very smart,” she said, “so why would you go into geriatrics?” Could it be that palliative care is thriving because we are ready to face dying but geriatrics is struggling because we are unwilling to face what comes before the end?

Aging is one of the greatest challenges faced in the world today. Throughout the world, people are living longer. Falling fertility rates and rising life expectancy have led to an aging population in the developed world, but the same phenomena are striking the developing world with a vengeance: in the US, it took took 68 years for the proportion of the population over age 65 to double and in France it took 116 years—but in China, it will happen over a period of 26 years and in Brazil in a mere 21 years.  The demographic shift has been accompanied by a shift in the “global burden of disease:” in 2010, 23% of the total disease burden in the world was attributable to disorders in people over age 60. The most burdensome disorders afflicting our aging world include heart disease, stroke, chronic lung disease and diabetes, as well as lung cancer, falls, visual impairment, and dementia. The good news is that we already know a great deal about what we need to do to increase the “lifespan,” as one of the commentaries in the Lancet series calls the length of time that an individual is able to maintain good health. 

We need to use a conceptual framework that focuses on functioning rather than on disease. We need to build and support an appropriately trained workforce—both formal and informal (ie family) caregivers. A comprehensive public health strategy must taken into consideration the physical and the social environment. It needs to be grounded into an approach that begins with comprehensive assessment, elicits patient preferences, and implements a treatment plan that is continuous, coordinated, and multidisciplinary. So if we know what to do, why don’t we do it?

The barriers to a global strategy for aging are many. They include a health care system that focuses on treatment of single diseases in isolation—even though most older people have “multimorbidity” and following guidelines for single diseases leads to over-treatment and excess costs. They include social factors, such as inadequate income protection and lack of caregivers. They include lack of knowledge—as the incidence of heart disease falls and treatment of cancer improves, a larger and larger percentage of older people will die of dementia, a disease with no known treatment. Currently, 44 million people have dementia world-wide, and that number is projected to rise to 136 million by 2050. But perhaps the greatest barrier is ageism, the belief that poor health is inevitable, that all interventions are ineffective, and that better outcomes, even if they can be achieved, are not inherently valuable. 

We need to tackle the global challenge of aging. The World Health Organization has taken an important first step: at the World Assembly last May, it agreed to prioritize work on aging, to develop a “World Report on Ageing and Health,” and then to generate a Global Strategy and Action Plan.

But it cannot just be the WHO who cares about aging. We all need to care.

November 09, 2014

More or Less

True or false?
1) Medications have led to improved health (T)
2) Medications are helpful for many chronic conditions (T)
3) Most older patients have several chronic diseases (T)
4) Most older patients take many medications (T)
5) More pills mean better health (F)

Sometimes, less is more. For patients with advanced dementia, most of whom are in their eighties and many of whom have other chronic conditions such as high blood pressure or high cholesterol, it just doesn’t make any sense to take all the drugs that are usually prescribed for them. In a recent article in JAMA Internal Medicine, researchers looked at a large sample of nursing home patients to determine the proportion taking medications “of questionable benefit.” What they found was that over half of nursing home residents with advanced dementia were taking at least one such drug.

We could get distracted by methodological concerns: after all, the classification used by the researchers was based on the consensus of experts, who in turn relied on whatever data were available, which was virtually never high quality, randomized clinical trials. Moreover, these experts assumed that for patients with advanced dementia, a “palliative orientation to care,” is appropriate, though this is not necessarily what the patients’ surrogate prefer. But the point, as the authors of the current paper argue, is that commonly used medications such as lipid lowering drugs and chemotherapy are at the very least “of questionable benefit.” In fact, as suggested by the editorial accompanying the article, the overuse of medications in advanced dementia is just the tip of the iceberg. Medications of questionable benefit are commonplace in frail elders and older people with moderate dementia, not just in those whose dementia is so advanced that death is imminent.

Greg Sachs, Chief of Geriatrics at Indiana University, proposed a framework for thinking about whether a medication is useful in an older person. He suggested beginning with life expectancy. Older people who are in excellent health and can expect to live for another 5 or 10 years are very different from those who are in the last year of life since some medicines work by immediately ameliorating symptoms and other medicines will only provide benefit after they’ve been taken for years. This leads to the next question: what is the lag time before a medication achieves the desired effect? (Pain medicines, for example, are effective within hours or at most days; some antidepressants work within days, others take weeks to kick in; medicines to control cholesterol are generally intended to prevent heart disease years in the future.) Finally, what are the patient’s goals? Is the patient interested in a longer life, no matter what price he has to pay, in which case he might want to take a medication with a small chance of working and a high risk of side effects (such as certain chemotherapy drugs)? Or is he interested in maximizing quality of life, in which case he might want a medication that makes him feel better regardless of the consequences for his length of life (choosing, for example, pain medication over chemotherapy for cancer).

Deciding whether or not a particular medication makes sense for a given older individual is not always easy. But it’s crucial to realize that more is sometimes less. More medications mean more opportunities for dangerous interactions among drugs. The greater the number of medicines, the greater the risk of an adverse drug reaction. Optimal drug regimens are generally determined by studying younger patients who have only one thing wrong with them—the disease to be treated with that medication. Extrapolating to older people, whose bodies handle drugs differently from their younger counterparts, who have multiple illnesses, and who may have a limited life expectancy, is perilous. Prescribing many medications for the elderly can be an excellent way to treat their diseases—but it might be a trick.

November 02, 2014

Brave New World of High Deductible Health Plans

I’m about to enter the brave new world of high deductible health plans. Not because I want to, but because that’s all my employer offers. The truth is that these plans basically make all health care coverage “catastrophic insurance” in that they don’t pay for much of anything until you’ve racked up a bill of upwards of $1500 per person (as much as $10,000 in some plans). There’s a growing literature on the consequences—good and bad, planned and unintended—of these plans, some of it by my own colleagues, who’ve shown, for example, that poor people are far less likely to go to the Emergency Room, even for a genuine emergency, once they switch from a conventional to a high deductible health plan.  Remarkably, given that 20% of all health plans are now of the high deductible variety, according to a recent Kaiser report (and 80% of plans have some kind of deductible, amounting on average to $1217), we don’t know the effects of this kind of coverage on health outcomes (things like control of diabetes and survival from cancer), we don’t know the effects on the use of life-saving  procedures, and we don’t know the full range of consequences for vulnerable populations. These big picture issues are critically important. But some of the more bizarre features of high deductible health plans are seldom discussed. They are what I’m calling the sickness penalty, the prevention perversion, and the wealth benefit.

The Sickness Penalty
A “well visit,” otherwise known as a “checkup,” is free with a high deductible health plan. Incidentally, there is absolutely no evidence that comprehensive physical examinations for well adults are beneficial. A “sick visit,” by contrast, which is useful, is paid out of pocket until the deductible has been met. The underlying message, it seems to me, is that if I’m sick, it’s my fault and I have to pay. Literally. Now the official justification for making patients pay for care when they get sick is that if they have "skin in the game," they will not over-use health care services. They will only go to the doctor if they are really sick--a policy that might make some sense if patients could be relied on to know when they are really sick. But if this were the only reason for paying for checkups but not for sick visits, why not require a screening phone call before a visit, whether to the doctor's office or the emergency room? Why pay for checkups, which have not been shown to be beneficial and refuse to pay for sick visits, which have? It seems to me that the underlying reason harkens harkens back to the quintessentially nineteenth century view of the “worthy poor” and the “undeserving poor.” Widows and orphans were regarded as justifiably poor—and therefore deserving of charity care. Unskilled foreigners who had on-the-job accidents were less worthy of our compassion, and alcoholics and syphilitics were completely undeserving. The sickness penalty in today’s high deductible health plans likewise takes the idea of individual responsibility to new heights—ignoring genetics and indifferent to chance, it simplistically and preposterously assumes that sickness is the patient’s fault. 

The Prevention Perversion
Checkups are sanctioned by high deductible health plans because the person going for a checkup is not sick. But more than that, the purpose of a checkup is prevention, and preventive care is good. But it turns out that the main type of preventive care that is meritorious (i.e. free) is what epidemiologists call “primary prevention,” doing something now, when you are entirely well, to prevent the onset of illness later. Immunizations—things like flu shots—are an example of primary prevention. Exercise (if it’s to fend off the development of heart disease, but not if it’s to make a sore back better) and diet (if it’s to prevent the occurrence of cancer but not if it’s to treat diabetes) are forms of primary prevention. But suppose that during the course of my check up (ostensibly free), I mention that I’ve had occasional rectal bleeding. I really didn’t think anything of it and I feel fine; I figure I have a hemorrhoid. This prompts my doctor to order a colonoscopic exam, which in principle can detect colon cancer early and allow surgeons to cut it out before it causes any symptoms. As soon as I mention bleeding during my check up, that visit is transformed into a sick visit and is subject to the deductible. If I don't say anything and hope my doctor will discover the blood when performing a rectal exam, then the visit is still free since early detection of occult disease counts as "secondary prevention," which is the other type of prevention for which health insurance will pay.

The Wealth Benefit
There’s another aspect of high deductible health plans that I haven’t heard discussed, and that’s the wealth benefit. Patients can open a health savings account to help pay off the deductible. This involves putting before-tax dollars into a special fund for all those nasty health care costs that you will have to pay for out of pocket. In many cases, employers contribute to the account, which can be supplemented by the employee. So if you set up one of these health savings accounts (HSA) and use the money to defray the deductible, the insurance company can claim that premiums are low when in fact your contribution to the HSA is actually a premium by another name. But what’s diabolical about this is that you don’t pay taxes on the money you deposit into your HSA. This means the cost to you of a $1000 contribution to your HSA if you are in a 40% tax bracket is really only $600. If, by contrast, you are in a 10% tax bracket, the cost to you of that contribution is $900. The richer you are, the less you pay. That’s called a regressive tax, even more regressive than a flat sales tax.

So far, high deductible health plans are mainly for those under 65. The strategy of high deductible health plans for Medicare beneficiaries hasn’t gotten much traction. There are some, with “Medical Savings Accounts” to accompany them. Before we go any further down this path, we need to take a hard look at the assumptions underlying the latest attempt to improve health care quality and lower costs with a market policy.

October 30, 2014

Brave New World

The brave new world of high deductible health insurance: the answer for controlling Medicare costs? The answer for anyone? See my comments this weekend!

October 27, 2014

Not Dying Yet

I used to think that palliative care was just for people who were dying. Then I found out—about a dozen years ago—that palliative care had expanded its original focus on end-stage cancer patients to include people with serious illness throughout the course of their disease (or diseases). Palliative care, I realized, is far more than hospice, a program that in the US is effectively restricted to patients expected to die within 6 months.

With this shift in perspective, I decided to move from an emphasis on the geriatric population, principally the frailest and sickest of the elderly, to a concentration on patients in the last stage of life, regardless of age, and regardless of how long that stage might be expected to last. For some disease states, including cancer, this effectively meant people in the last six or twelve months of life, since it was only at that point that we could determine the seriousness of their condition with reasonable reliability. For other disease states, such as frailty or dementia, the relevant population included people who might live for several years with a progressive, ultimately fatal condition. So I was surprised and dismayed when I read the fine print in an otherwise important and insightful article published this week about palliative care—and discovered that the authors’ wise recommendations were confined to people with a prognosis of one year or less.

The reason that it is so important to move the conversation about goals “upstream,” to start the discussion long before life’s last gasps, is that patients often shift their perspective on what’s most important depending on their underlying health status. People who have moderate dementia, who might expect to live several more years, may well not want life-prolonging treatments that will simply allow them to live long enough to develop advanced dementia, particularly when the treatments are burdensome. People who are becoming progressively frail may not want treatments that are apt to have as a side effect an even greater degree of debility and dependence.

It may not be ideal to limit discussion of the goals of care to patients with a prognosis of one year or less, but maybe it’s better than the current reality, which often involves no discussion at all, or limiting such talk to patients who are moribund. The problem with such an approach is both that it means subjecting the hundreds of thousands of patients with dementia or frailty or progressive heart or kidney disease to invasive tests, procedures, and medications that they may not want and that it risks turning people away by, once again, equating palliative care with dying. Palliative care is not just for imminently dying people. It is for anyone with a serious, progressive, incurable illness. And since we can’t cure diseases such as congestive heart failure or chronic obstructive pulmonary disease or Alzheimer’s disease, and those are precisely the conditions that tend to afflict people 80 and beyond (and some who are younger as well), we need to think about palliative care for this entire population. Palliation is not just for the dying.

October 22, 2014

Swimming Upstream

When is the right time to have a conversation about goals of care? Commentary coming soon.

October 19, 2014

Rating the Ratings

Earlier this month, Medicare announced that it is revising the 5-star rating system currently used to measure nursing home performance. The ratings are available on the Nursing Home Compare website, which allows consumers to learn how a facility they might be considering going to shakes up relative to others. The problem, and the reason the system is being revised, thanks to funding from IMPACT (legislation passed in September), is that it’s not so clear that the vaunted rating system measures anything meaningful.

An investigative piece in the New York Times this past summer dramatically demonstrated the gap between reality and the ratings. The reporter visited the Rosewood Post-Acute Rehab outside Sacramento, California, an attractive facility that had garnered the much sought after 5-star rating from Medicare. But it turned out that the ratings focused entirely on annual health inspections and on 2 measures reported by the nursing home itself—staffing ratios and a quality of care index. The rating left out data from state authorities, even though it is those authorities that supervise the nursing home. In Rosewood’s case, the state of California had fined the facility $100,000 in 2013 for a patient death attributed to inadequate medication monitoring. California had also received 102 patient and family complaints between 2009 and 2013, way over the state’s average. And the facility had been the subject of a dozen lawsuits alleging substandard care. The revised rating system, by drawing on external audits of nursing home quality and electronically submitted staffing data, as well as by incorporating some new measures such as the proportion of residents taking antipsychotic medications, hopes to overcome the shortcomings of the current approach. But will it?

Nursing Home Compare is not the only attempt to come up with a single, composite rating for medical facilities, and nursing homes are not the only medical institutions to be graded in this way. Hospitals are also rated, and multiple organizations offer assessments. I recently stumbled on a fascinating case: in June of 2012, the Leapfrog Institute, a non-profit think tank devoted to measuring and improving safety in medicine, came out with its first hospital ratings. It awarded an A or B to 56% of the hospitals surveyed, a C to 38%, and grades below C to 6%. The UCLA Medical Center was given an F.  At the very same time, US News and World Report came out with its annual hospital rankings. In this report, the UCLA Medical Center was ranked #5 in the country. How can the same hospital get an “F” and an “A+” for its performance? And if you think that maybe UCLA is an unusual case, it’s not. Consumer Reports, which also got into the hospital rating business, ranked MGH below average in the same year (2012) that US News ranked MGH as #1 in the country. 

The answer to why different raters have different results is that the grade depends on the methodology used to compute it. Leapfrog assesses hospitals based entirely on performance in the realm of safety and does not adjust for the severity of illness. Consumer Reports uses a complicated mixture of a safety score, a patient outcomes score, a patient experience score, a hospital procedures score, and then a rating of heart surgery, with several factors going into each of the subscores. US News and World Report looks at outcomes (by which it means mainly mortality), process (which is largely nursing staffing levels), and other factors (a big part of which is reputation).  US News also rates hospital departments (neurology, cardiology, oncology, etc). I was particularly amused a number of years ago when US News ranked the Geriatrics Department of one of the Boston teaching hospitals among the top 10 in the country. It so happened that hospital didn’t have a geriatrics department.

Americans like report cards.  We rank toasters and washing machines and cars. We rate hotels and restaurants and auto mechanics. We have institutions devoted to product evaluation (think Consumer Reports) and thanks to the Internet, we now have a slew of informal, popular evaluations (think Yelp or Trip Advisor). I admit I find these reports very useful: when I was looking for a good bed and breakfast recently, I found it helpful to learn that 50 people gave one particular inn 5 stars. I could also read the individual comments to get a sense of whether the aspects of the inn that other travelers liked were of any particular concern to me.  But can we really come up with a report card for a hospital or a nursing home? Can we really reduce performance to a single grade?

Nursing homes and hospitals will inevitably game the system, just as colleges did when US News and World Report used the number of applications/number of offers of admission as a measure of selectivity. Colleges instructed their admissions officers to travel around the country encouraging students to apply, even if those students couldn’t possibly be accepted, because the more students applied, the more “selective” the college became. Some colleges created a huge waiting list and admitted many of their freshman class from the wait list—but only counted the initial acceptance letters in the computation of “offers of admission.” Some students and families have caught on and the media has started to downplay the annual US News numbers—for the past couple of years, the college rankings haven’t been front page news in the NY Times when the new ones are released. But colleges continue to regard the rankings as important and use them in marketing. Similarly, I’ve noticed big banners in the vicinity of some of Boston’s hospitals proclaiming their latest ranking. And I learned from a terrific piece of investigative reporting produced by Kaiser Health News 
in collaboration with the Philadelphia Inquirer that the hospitals pay to advertise their rankings. US News, Leapfrog, and another rating organization, Healthgrades, charge licensing fees to hospitals for the privilege of trumpeting their “achievement.” These fees are not peanuts: Healthgrades charges $145,000, US News charges $50,000 and Leapfrog charges $12,500.

There are now so many rating agencies, using very different rating scales and arriving at widely discrepant results, that there is even an organization, the Informed Patient Institute, that grades the raters. But the truth is that it is impossible to distill the performance of a complex institution such as a hospital or a nursing home to a single measure. Such efforts will inevitably hide the very real variability in performance depending on just exactly what is looked at. What you need to know depends on why you need to know it. Are you an insurance company, deciding whether or how much to reimburse a facility for a particular service? Are you a patient choosing a hospital (actually, you probably won’t have much say in the matter; in case of emergency, you will be taken to the nearest facility; and in other somewhat less urgent situations, where you go is typically determined by who your doctor is). Are you a patient or family member choosing a nursing home for long term care (you may have a fair amount of choice)? For short term rehab (you will have less choice in the matter)?

So will the revised ratings of nursing homes (coming in January, 2015) make grades meaningful? Probably not. Requiring nursing homes to report data on staffing electronically will likely improve the accuracy of their reporting—but is the degree of improvement worth the millions of dollars that will be spent on this? Including the rate of antipsychotic medication prescribing as a quality indicator might tell us something about whether nursing homes are unnecessarily and inappropriately sedating their residents—assuming the measure has corrected for the rates of serious psychiatric illness in the facility. The bottom line is that a single grade cannot capture all the features of a medical facility’s performance that are relevant to all the different individuals and groups for whom the ratings are intended. It’s time to abandon composite ratings.