June 25, 2017

The Worthy and the Unworthy

One of the most illuminating and insightful articles I ever read was written by historian of medicine David Rosner. Entitled “Health Care for the ‘Truly Needy’: Nineteenth Century Origins of the Concept.” I read it when it was first published and I’ve remembered it since—and that was 35 years ago. The nineteenth century concept of the “worthy poor” or “deserving poor,” and its Reaganesque reformulation is sadly reflected in the Republican health care bill revealed today.

Rosner points out that at a time of relative ethnic homogeneity in pre-industrial, pre-Civil War America, the poor were often seen, in the light of Christian teaching, as individuals who would be rewarded with salvation. As an added bonus, the presence of poor people gave the wealthy an opportunity for charity, which would likewise be rewarded. But then, in the second half of the nineteenth century, millions of destitute immigrants arrived on American shores. At the same time, Americans suffered from tremendous economic dislocation related to urbanization. As a result, “a general consensus developed among the native-born equating poverty...sinfulness, and individual failure with foreign birth. Conversely, wealth, American nativity, and material success were equated with righteousness and moral behavior.”

The Surgeon General of the US in 1891, Dr. John Shaw Billings, remembered for introducing the collection and maintenance of “mortality and vital statistics” records, also accepted the notion of a meaningful distinction between the worthy and unworthy poor saying “there is a distinct class of people who are…almost necessarily idle, ignorant, intemperate, and more or less vicious, who are failures…and who for the most part belong to certain races,” by which he meant Catholics, Jews, Irish, Italians, and Eastern Europeans. He accepted the need to provide medical care for this group—but only to prevent the spread of infectious diseases to the remainder of the population.

And then we have Dr. Stephen Smith, another public health giant, who cautioned that medical charity can be “the inlet through which the habit of pauperism first creeps into the poor man’s house.” That is, helping people who are poor fosters dependency and is to be avoided. Remember Romney’s 47 percent? The people who are “dependent on the government” and who should simply “take personal responsibility” for their lives?

After discussing the way that concepts of the worthy and unworthy poor evolved in tandem with the growth of the hospital in the early part of the twentieth century, Rosner concludes by arguing that “although the language used today is significantly different from the angry, moralistic, and class biased rhetoric of the nineteenth-century debates, there is a similarity of meaning and analysis in arguments over definitions of the ‘truly needy, over the proper eligibility criteria for a variety of health programs like Medicaid and Medicare, and for the scope of other social service programs such as food stamps and welfare.” He was writing in 1982, but he could equally well be writing today, as we learn who it is that the Republican senators, or at least those who crafted the latest version of the health care bill, deem worthy. Full-time employees of well-heeled companies are worthy and older people, provided they don't live in nursing homes, are worthy. It's unclear if fetuses are worthy: health plans may be excluded from the insurance exchanges if they cover abortion, but health plans may also be allowed (through a waiver) although they fail to cover maternity care. Everyone else, the senators assume, could purchase health insurance—or better yet, not get sick—if only they had the necessary moral fortitude.

This isn’t how any other democratic nations in the world view health, medical care, or their citizens. They assume that everyone is "worthy" of basic medical care. They regard it as the responsibility of government to promote the health of their citizens, just as it government's responsibility to keep them safe and educated. Tell your senator that  enshrining archaic concepts of worthiness into law by severely restricting access to medical treatment is not the way to keep America great.

June 18, 2017

The Other American Drug Problem

With all the attention paid to the opioid epidemic, another drug overuse problem has gone relatively unnoticed--the widespread use of antipsychotic medications in nursing home residents. A perspective article in JAMA this week focuses on this other drug problem—and an intervention that the authors think might just have solved it.
Interestingly, antipsychotic medications were a problem in an earlier era. Then along came OBRA87, or the Nursing Home Reform Act, mandating a variety of strategies limiting the use of drugs to sedate patients with dementia who had behavioral problems: nursing home patients were to be free of “chemical restraints;” staff were supposed to try non-pharmaceutical approaches before resorting to drugs, and they were expected to taper the medication after several months. The regulations seemed to be effective: the percent of nursing home residents receiving an antipsychotic fell from 34 percent pre-OBRA to 16 percent several years afterwards.
But after the atypical antipsychotics were introduced in the early 1990s, beginning with risperidone and then going on to a variety of other agents such as quetiapine and olanzapine, the rate of use began climbing again. By 2011, it had reached 24 percent among nursing home residents. Today, however, it’s back down to its historic low of 16 percent.
In their article, Gurwitz et al regard the turning point as the Office of Inspector General report of 2011, “Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents.” In response to this alarming report, the Centers for Medicare and Medicaid Services (CMS) developed a multi-pronged strategy to combat the problem. It launched its “National Partnership to Improve Dementia Care in Nursing Homes,” which combined public reporting, educational resources, and renewed regulatory enforcement. Gurwitz et al assume that it was this partnership that led to the fall in use of antipsychotic medications.
But that’s not the whole story.
If we look at why the use of antipsychotic medications began to rise again in the 1990s, what we see is a massive push by Big Pharma to peddle these drugs to nursing homes, even though they are not FDA approved for the treatment of the symptoms of dementia. Not only have studies failed to demonstrate that the antipsychotics (whether “typical” antipsychotics such as haloperidol or the “atypicals” such as risperidone) work in dementia, but the FDA also issued a black box warning indicating that they have been associated with sudden death. The drug companies were undeterred. They employed various strategies to achieve spectacular sales of atypical antipsychotics in the nursing home.
Janssen, a subsidiary of the mega-company Johnson &Johnson, went so far as to create what it called “ElderForce,” a special group of drug reps who were deployed to market the antipsychotic Risperdal (risperidone) to doctors in nursing homes. Now it’s perfectly legal for doctors to prescribe an FDA-approved drug “off label,” that is, for some other non-approved use. But it’s not legal to advertise drugs for non-FDA-approved indications. What Janssen did was to pay its ElderForce reps a commission for every prescription the doctors wrote. J&J was not alone in promoting antipsychotics to nursing home physicians for use in their troublesome patients with dementia. Eli Lilly did the same for its atypical antipsychotic, Zyprexa (olanzapine). It was evidently a winning strategy: Astra-Zeneca followed suit with its drug, Seroquel, and, not to be left out, Bristol-Myers-Squibb tried it with Abilify. The leading distributor of prescription drugs to nursing homes, Omnicare, got a piece of the action when it instructed its pharmacists to provide disinformation to nursing home doctors—in return for a kickback from Abbott, the company that manufactured the drug it was pushing for treating the behavioral symptoms of Alzheimer’s disease, the anti-seizure medication, Depakote (which like the antipsychotics, is not approved for this indication).
Slowly and methodically, the Department of Justice reacted. And what followed was a dramatic series of investigations that ultimately resulted in penalties for the malfeasants. Sometimes the payouts were probably too small to have much of an effect—the $520 million that Astra-Zeneca paid in 2010 to settle charges of illegally marketing Seroquel (quetiapine) in nursing homes could be viewed as just the cost of doing business. But even for Eli Lilly, the $1.4 billion it paid to settle civil and criminal charges relating to the marketing of Zyprexa  (olanzapine) was substantial. And when Johnson&Johnson paid $2.2 billion in criminal and civil fines in 2013 to settle accusations that it improperly promoted Risperdal (risperidone) for use in nursing home residents, all the drug companies took notice.
So yes, I think CMS is onto something when it acknowledges that the problem of the overuse of antipsychotics in nursing homes is multifactorial, and it’s right to look to nursing home chains and physicians, as well as to educational tools and regulatory incentives in its quest for reform. But let’s not forget that one of the “stakeholders” is the drug companies and that the legal system can be a powerful change agent.

June 11, 2017

Parachuting through Life

Last week I saw the play “Ripcord” at the Huntington Theater in Boston, a hilarious comedy by David Lindsay-Abaire, and one of the rare plays that features life among the older set. Ignore the unrealistic depiction of assisted living—the playwright does not seem to distinguish between assisted living facilities and nursing homes—or the mischaracterization of who live in assisted living—the play features two women who are entirely too vigorous to require assisted living, let alone the nursing-home-like facility in Ripcord. It’s nonetheless a vivid, if exaggerated portrait of some of the poignant struggles of older life. Ripcord introduces us to two of the zaniest and most memorable elderly fictional characters in recent memory, Abby and Marilyn, forced by circumstance to become roommates.

Both Abby and Marilyn, in their own very different ways, need to come to terms with troubled relationships. Marilyn was married to an alcoholic and perhaps abusive man; Abby’s only son is a drug addict from whom she has long been estranged. Both women find themselves in a new phase of life and have to adapt to straitened circumstances, a task that Marilyn performs with grace and Abby with vitriol. But redemption comes for both of them, as Marilyn’s ability to see the good in everyone, from the aide at the facility to her lugubrious roommate finally rubs off on Abby, and Abby’s insistence on telling-it-like-it-is allows Marilyn to acknowledge and accept the flaws in her marriage.

In its eccentric and sometimes over-the-top fashion—the “ripcord” of the title refers to the cord the two older women must pull to open their parachute while skydiving—this play brings to life one of the major insights of contemporary geriatrics: at least as important as pills and procedures for a good quality of life in old age is a robust social network. In the end, it is not fame or fortune that mark a life as having been worth living, but the relationships we forge with others.

June 04, 2017

One of the major mile posts in biomedical ethics was the passage of legislation that today’s medical residents—and I daresay most Americans—have never heard of, the Patient Self-Determination Act of 1990. Certainly all those who inveighed against “death panels” and who balked at the idea that the Affordable Care Act might include provisions allowing Medicare to reimburse for advance planning conversations never heard of it. This act, as its title indicates, was intended to put patients in the driver’s seat, to allow them to weigh in on the approach to medical care they would get at the end of life, even if they were unable to participate in decisions at the time those decisions need to be made. It officially sanctioned advance directives by enshrining them in federal law. 

What the PSDA says is that any health care institution receiving government funds, which is to say virtually all health care institutions, is obligated to ask patients if they have an advance directive, to offer them the opportunity to complete one if they don't, and to prominently display a copy of that directive in the medical record if they do. The PSDA put advance care planning on the map. It also put advance care planning squarely in the legal domain and that, as the authors of a new article in the New England Journal assert, was a big mistake.

What “Delegalizing Advance Directives—Facilitating Advance Care Planning” argues is that a major reason that advance directives haven’t caught on is that they typically have to be signed by two witnesses (or a notary), and in some states (North Carolina, South Carolina Virginia, and Missouri) a notary; some states also require use of a specified form. I agree that these requirements are an impediment to widespread use of advance directives. I agree that the POLST (Physician Orders for Life-Sustaining Treatment) model, which uses a medical order rather than a legal document and just requires the signature of the patient and the physician, puts advance care planning unambiguously within the medical sphere. But I don’t think that simply allowing patients or prospective patients to designate a health care agent, or surrogate decision-maker, without use of a mandated form and without witnesses would solve the problem. 

The real problem is not just that people don’t bother with the forms and that the forms don’t always make it into the hands of clinicians. The real problem, as Charlie Sabatino of the American Bar Association put it in a 2010 article, is that advance directives are based on a transactional view of advance care planning rather than a communications model. And what we now understand is that advance care planning has to be founded on dialogue between a clinician and a patient.

The problem with advance directives is not that they have to be witnessed or written on special forms. If that was the problem, we’d expect to see much higher utilization rates in Idaho, where there are no witness or notary requirements, and somewhat higher utilization rates in Utah, where only one witness is required. The problem is that they reduce advance care planning to completing a form, to checking off boxes on a list. 

In Idaho, for example, individuals have the opportunity to say that if they are ever unable to communicate and “have an incurable or irreversible injury, disease, illness or condition,” and that a medical doctor, based on a physical examination, has concluded that the “injury, disease, illness or condition is terminal” and that “death is imminent” no matter what is done, and that the “application of artificial life-sustaining procedures” would only artificially prolong life, then they would (or would not) want medical treatment and procedures, nutrition and hydration, hydration but not nutrition…

The lawyers who design such forms believe they allow people to indicate with great precision just what they would want and under what circumstances they would want it. But in fact, as many others have observed, it is far from clear what exactly it means for a condition to be terminal. I would argue that dementia is a terminal disease—but with a typical time course of about five years from the time of diagnosis to death. Ah, you might say, but the advance directive forms include the qualifier that death must be imminent. But that's not good enough. How imminent? In a matter of hours? Days? Months? And if we could agree, based on a careful reading of the text of the directive (which I’m not so sure we can), that what is meant is the person has a  disease that in the normal course of things results in death within six months and that the person's disease has progressed to the point where death will occur within at most days; then is it really so useful to specify that in those very limited circumstances we wouldn’t want treatment that won’t make a difference anyway? Is that all the advance care planning is about—stopping futile treatment in the 72 hours of life? And what about “treatment” that is symptomatic, that is intended to ameliorate suffering, rather than to prolong life, though it might, as an unintended consequence, prolong life. Are such “medical treatment[s] and procedures” to be rejected?

Advance care planning, as we have come to understand it over the last several decades, is not about procedures or treatments—or checking boxes. It is about reflecting on what’s important, in the context of a realistic understanding of a person’s medical condition. It's about figuring out what medical treatments are most consistent with achieving whatever it is that the patient deems important in life. 

Making it easier to complete a form will not transform advance directives. Conceptually, advance directives are legal documents, whether or not they must be witnessed or notarized or completed on special paper. What people need is not a better document. It’s a different process, a process that is built on communication and that deals with the purpose of medical treatment, not the technical means of achieving those ends.


May 29, 2017

Where Do All the Dollars Go?

The editor-in-chief of one of my favorite health news sources, Kaiser Health News, recently published her first book—for over twenty years she has been a journalist at the New York Times—and it’s an important one. An American Sickness: How Healthcare Became Big Business and How You Can Take it Back, by Elisabeth Rosenthal, is a powerful if somewhat monotonous recounting of the evils of American health care. But it only seeks to explain one weakness of contemporary American medicine, albeit an important one: it costs too much. Or, more accurately, prices are too high. As Uwe Reinhardt put it years ago, “it’s the prices, stupid.” 

Understanding the behavior of physicians, hospitals, drug companies, health insurers, and device manufacturers, as this book seeks to do, is critical if we are to change the system. The problem that they create, however, isn’t just that health care costs consumers too much; it’s also that the quality lags behind what is achievable—is evidenced by the poor standing of the US compared to other developed countries. Failing to consider both quality and cost is regrettable—we might, after all, be willing to tolerate the enrichment of drug company shareholders if what we got in return was an excellent, if pricey, product.

The litany of shenanigans by big business may be familiar to many readers, but Rosenthal's comprehensive and detailed accounting is impressive and compelling. Consider the first chapter on “the age of insurance.” The book recounts the story of how the same treatment costs orders of magnitude more--$100,000 vs $19,000 per medication infusion for a drug given monthly—when administered at NYU’s Langone Medical Center than when provided at another nearby facility. For the patient, whose treatment was covered by insurance, it didn’t much matter over the short run. But for the system as a whole, and ultimately for all patients through higher insurance premiums, it did matter. And the reason for the discrepancy is that NYU negotiated a better deal with third party payers than did the competition. What Rosenthal outlines but does not emphasize is that more powerful hospital systems and physician researchers interact with (some might say collude with) health insurance companies to produce this result. She explains that because of an arrangement with the NYU researcher who was largely responsible for creating the drug, NYU derived profit if total sales of the drug exceed a particular threshold. By negotiating a very high payment for the drug from the insurer, NYU is likely to exceed the threshold and cash in. So it’s not just the motivations of physicians, hospitals, and insurance companies acting separately that impact the health care system; it’s the way all of these forces work together that is crucial to achieving the end result.

Rosenthal presents one disturbing case after another. There’s the way hospitals and physicians game the system to assure that patients essentially have to use out-of-network providers when their insurance company will only cover in-network providers, forcing patients to shoulder what can be enormous costs. There’s the notorious “facility fee” that enables hospitals to charge insurers vastly more for a simple procedure such as injecting anti-inflammatory medication into a joint if it is done in an outpatient clinic than if it is done in a private office. What she neglects to explain is the way the system conspires to provide what is often inferior medical care to patients. Maybe this is more egregious with older patients than younger ones, and her focus is overwhelmingly people who aren’t enrolled in Medicare: either those with private insurance or no insurance at all. The facility fee example, for instance, doesn’t just mean higher costs. For a frail older person to get to a hospital clinic may mean going by car, negotiating a confusing parking garage, and walking a considerable distance from the garage to the office, none of which is so easy if you’re 85, have severe arthritis (the reason for going for the joint injection in the first place), and maybe have a little cognitive impairment to boot. The enthusiasm for high tech procedures, driven in part by the manufacturers of the devices used in the procedures, doesn’t merely drive up costs: for vulnerable, older individuals, such technological intervention may cause more harm than good. The anesthesia may result in confusion and the hospital stay in functional decline—quite apart from the effect on the cost of medical care.

Alas, the fixes the author proposes, the part of the book devoted to taking "health care back" from big business, aren’t going to fix the system. She calls for creative insurance plan design, for example plans that cover “essential” treatment fully and levy co-pays for “semi-elective” treatment. That’s much like what the ACA does when it requires full coverage for preventive services such as a screening colonoscopy, but allows the same colonoscopy to be billed in full (if the patient has a high deductible health plan) if the procedure is ordered to remove a cancerous polyp. Maybe that’s a good idea, although it leads to some bizarre incentives—better to get that polyp removed at the end of the plan year, when you might already have burned through your deductible, than at the beginning of the year, when the growth might be more curable; better to say nothing to your doctor about the blood you’ve noticed in your stools and just have a “screening test” than to mention the blood and undergo the procedure to treat a “disease.” But whether or not “benefit redesign” is a good idea—and one of the last major benefit redesign ideas wasn't so thrilling, it was those very high deductible health plans that are conquering the market—it’s not going to help patients now. Even the suggestions that could, in principle, help right away, such as “demanding price transparency” when getting an MRI, are a bit pie-in-the sky. You’re in the doctor’s office and s/he wants you to get a scan right away. You’re supposed to get a list of 5 centers that do MRIs and compare their prices? Really? What about quality? What about accessibility of the image to your physician? What about transportation to these other sites?

An American Sickness goes a long way to uncovering the workings of the health system and for that it is to be lauded. It is extensively and for the most part carefully researched, though there are errors. Rosenthal says pharmacists should be able to prescribe birth control pills because they all have PhDs and shouldn’t just be relegated to counting pills. Maybe they should be able to prescribe birth control pills, but most pharmacists have a BPharm (a bachelor’s degree), not a PhD. She says the website GoodRx allows comparison of prices for prescription drugs only for Medicare patients. Maybe that was once true, but it is no longer. But read this book for the insight it may give you on how the design of the system affects outcomes. We will need to build on that scaffolding to investigate the full range of systemic consequences—for quality as well as cost of health care, and to engage in meaningful reform.

May 21, 2017

Money Down the Drain

This month, the Commonwealth Fund, a private foundation that supports independent research on the health care system, released a report on just how much Medicare beneficiaries pay out of pocket for health care. The news is sobering: on average, they spend $3,024 and that doesn’t include what they pay for premiums.

I’m not sure why premiums are considered separately, but they’re pricey, too. While Medicare part A (hospital coverage) is free for almost everyone over age 65, Medicare part B (doctors’ fees, outpatient care, and lab tests) costs $134 per person per month. That is, if you’re single and earned less than $85,000 in 2015, or married and jointly earned no more than $170,000. After those thresholds, the premium rises steeply, first to $187 per person per month (for joint incomes of up to $214,000) and then on up to a maximum of $429 for the most affluent. Then there’s part D for medications. The average monthly cost for a drug plan this year is $42 per person. And finally, there are Medigap plans if people want coverage for their deductibles and co-pays—the national average for those plans is $183 per person per month.

Looking at averages is not terribly enlightening, but fortunately, the report delves far deeper. It turns out that among  people with three or more chronic medical conditions (30 million of the 56 million people enrolled in Medicare), 29 percent spent at least 20 percent of their incomes on out-of-pocket medical care plus premiums. Among the nearly 14 million people with a serious physical and/or cognitive impairment, 38 percent spent at least 20 percent of their incomes on out-of-pocket medical care plus premiums. The poorest people are particularly hard hit: among the 17 million people with three or more chronic conditions or functional limitations whose incomes is less than 200 percent of the federal poverty level, 42 percent spend at least 20 percent on medical expenses.

After reading the report, I had two questions. First, how do Medicare beneficiaries in Medicare Advantage plans fare compared to those in conventional, fee-for-service Medicare? They pay part B premiums plus a part C premium—which is instead of Part D but also includes more comprehensive coverage with fewer co-pays and deductibles. The actual part C premiums vary tremendously, both within a given insurance company (in Massachusetts, for example, Blue Cross offers 6 different Medicare Advantage plans, with monthly premiums ranging from 0 to $295 per person; a middle-of-the-road plan costs $79 per month) and across companies. My suspicion is that people with multiple chronic conditions or functional impairment are less likely than their healthier peers to choose Medicare Advantage—but that they would have lower out-of-pocket costs if they did. Someone should do the analysis.

Second, how would the ACA-Repeal-and-Replace bill passed by the House of Representatives affect Medicare? The answer seems to be that it would only affect it indirectly, mainly by  cutting federal spending on Medicaid by $880 billion over ten years. This would profoundly impact the 11 million people who are currently enrolled in both Medicare and Medicaid. It would also worsen the overall solvency of the Medicare program. The ACA levies an extra payroll tax of 0.9 percent on individuals earning over $200,000 a year ($250,000 for couples), a tax that is due to expire in 2018. The new bill would end the payroll tax a year early—thus ensuring that the Medicare trust fund, which pays for part A, will run out of money before 2025.

The take home message? Find out if there’s a good Medicare Advantage program available to you and what it costs. It just might be a better deal than regular Medicare. And lobby your senators to make sure that any new variant of repeal-and-replace doesn’t gut Medicaid or bankrupt Medicare.

May 15, 2017

Brave New World of Genetic Testing

In a provocative piece in the NY Times last week, science writer Gina Kolata suggests that the long term care insurance industry may be in a “death spiral.” The culprit, she argues, is genetic testing, which got a boost last month when the FDA approved testing by the company 23andMe. Previously best known for providing genealogical information to those who send in a saliva sample and a $99 fee, the personal genomics company is now authorized to provide information about genetic risk factors as well—for only an additional $26.

One of the ten conditions about which companies may offer information is Alzheimer’s disease. And perhaps the best established genetic risk factor for late-onset Alzheimer’s disease (sometimes called LOAD) is apoE. A gene that codes for a protein involved in cholesterol metabolism, apoE comes in three varieties, prosaically named apoE2, apoE3, and apoE4. Everyone has two copies of the apoE gene, so there are six possible genotypes, of which the most common are E2/E2, E3/E3, E4/E4, E2/E3, and E3/E4. The majority of people (63 percent, in one study of the distribution of the allele in 9 different populations) are E3/E3.

But while there is no way to definitively predict who will develop Alzheimer’s disease, fully 40 percent of people who develop LOAD are among the 25-30 percent of people who carry the e4 variant of the gene. And roughly half the residents of nursing homes have Alzheimer’s disease. As a result, according to spokesmen from the industry, a growing number of people are seeking testing from 23andMe to see if they have the e4 gene. If they have it, they buy long term care insurance. If they don’t, they take their chances.

If this trend continues—and as of 2017, 2 million people have obtained the direct to consumer genetic analyses---the pool of people buying long term care insurance could be heavily weighted towards those who actually will develop the disease. The health insurance industry, however, as consumers are perhaps finally coming to understand in the ongoing Obamacare wars, depends on pooled risk; it only works if the people who buy insurance include some people who will get sick and others who won’t. 

The reason the direct-to-consumer marketing of genetic information potentially spells doom for the long term care industry is that Americans are protected by the Genetic Information Nondiscrimination Privacy Act, which prevents insurers from requiring gene tests or using the results of genetic testing in coverage decisions. That means that ordinary people, without any physician input, can find out if they are at high risk, they can make decisions about buying coverage based on that assessment—and the insurance companies are powerless to intervene. If most of the people who are destined to get Alzheimer’s disease end up with insurance, the insurance company will end up paying out a lot more than they originally anticipated—leading to enormous increases in the rates or bankruptcy of the industry.

Now there are plenty of other reasons that the long term care insurance industry may collapse, and a good number of pre-existing reasons why it’s a poorly designed program. The amount of money it actually provides people is rarely enough to cover their actual costs, whether of home or institutional care. There are many barriers in the way of people using their benefits—for example, many policies require three months of disability before they kick in, which may be three months too long, especially if they are only going to be in a nursing home for three months. And Medicaid is currently available as a back up to pay for institutional care, provided people have “spent down” their personal savings, so the value of long term care insurance derives from its ability to shelter assets.

Analyzing the value of long term care insurance is a conversation for another blog post. But the point I want to make today is that before you rush out and get tested for Apo E, you should be aware of the limited predictive value of the test. While the likelihood of getting LOAD if you are one of the 2.6 percent of the population who have two copies of E4 is 91 percent, the likelihood of getting LOAD if you are one of the 22 percent of the population with one copy of the E4 allele falls to 47 percent. And if you are one of the 76 percent of the population with no E4 alleles, you still have a 20 percent of getting Alzheimer’s. Because the poor “negative predictive value”—because even with a negative test, you have a substantial risk of getting the disorder—physicians and organizations such as the Alzheimer’s Association have for years recommended against routine Apo E screening.

Interestingly, Apo E determination has been available to Europeans as a direct to consumer test for years. A study to find out what the short- and long-term psychological consequences were for patients with a positive test. Though the study only looked at people who requested testing, it found that there were no significant adverse consequences of getting bad news. So fear that you will become anxious or depressed is probably not grounds for resisting the impulse to be tested for Apo E4. But you should remember that it’s just a risk factor—and one over which you have no control—and plenty of people who test negative will still develop Alzheimer’s disease.

May 07, 2017

Falling Down on the Job

In the sixties, physicians routinely prescribed bed rest for patients who had suffered a heart attack. Then along came the recognition that bed rest led to clot formation in the lower extremities, clots that sometimes broke off and traveled to the lungs, causing potentially life-threatening pulmonary emboli. Bed rest also led to deconditioning—when patients finally were allowed to get up, they found they were often weak and wobbly. And so bed rest was out and early mobilization was in. But now, concurrent with a vigorous attempt to prevent falls among older hospitalized patients, bed rest is back in—and with more complications than ever, as reported in a thoughtful article in JAMA Internal Medicine last week.

In 2008, in response to the observation that “injurious falls” were responsible for increased hospital costs and were clearly bad for patients, the Centers for Medicare and Medicaid Services introduced a program incentivizing hospitals to prevent falls. Currently, a fall resulting in significant injury (such as a fracture) is one of eight hospital-acquired conditions that collectively determine whether hospitals will be penalized for poor performance. To address the CMS initiative, hospitals introduced a variety of techniques designed to keep older patients from falling such as bed alarms and “fall risk” signs on the door. According to Growdon and colleagues, the result has been a “national epidemic of immobility among hospitalized older adults.”

Paradoxically, the means used by hospitals to prevent falls don’t work. Bed (and chair) alarms are ineffective—which is not entirely surprising, as by the time a nurse responds to the buzzer indicating the patient has gotten out of bed (or chair), the person is probably already on the floor. Even a multi-prong study from Australia using a variety of different approaches simultaneously was unsuccessful.

But all those bed alarms and signs on the door do achieve something, and that’s to keep patients at bed rest. And just as bed rest was bad for heart attack patients in the sixties, it’s bad for older patients today. Bed rest promotes the development of confusion (delirium) and worsens mobility, so when patients finally do get out of bed, either late in their hospital stay or after they get home, they are more likely to fall.

Growdon, a resident in internal medicine at a major Boston teaching hospital, and his colleagues at a VA Hospital in Florida and at Hebrew Senior Life, a teaching nursing home, are rightfully indignant. They advocate promoting mobility rather than penalizing falls, arguing that “although hospital falls can lead to harm, treating them as ‘never events’ has led to over implementation of measures with little efficacy for falls [prevention] yet profound contribution to immobility.” They are, no doubt, correct. But why? Why should an incentive program based on outcomes lead to the adoption of a strategy that does not lead to the desired outcome?

If CMS had used a process measure, if it had offered extra payments to hospitals that introduced fall prevention programs, I wouldn't have been surprised that it resulted in hospitals adopting programs for the sake of having something, regardless of efficacy. But instead it opted to penalize hospitals for performing poorly, which should by rights have led to hospitals choosing to take steps that made a difference. What is it about the culture of hospitals or the leadership of hospital CEOs or the knowledge base of physicians and nurses that lets them make such irrational choices?

I wish I knew the answer. In the meantime, perhaps CMS would do well to offer carrots rather than sticks, and to be specific about the kind of carrots that it likes the most. If programs that promote mobility work, directives to get patients out of bed early and to consult physical therapy—both to prevent falls and to maintain function—then it’s those specific programs it should endorse and pay for.
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