If 75 is the new 40, what's 85?

You've probably heard repeatedly that 70 is the new 40--and perhaps also that 80 is the new 65.  If that's true, then quality of life for people who used to be considered old should be much better than previously. It turns out that the perception that things are better for the elderly is true—but only sort of.

A recent study by the well-known health economist David Cutler and his colleagues carefully analyzes data from the Medicare Current Beneficiary Survey, a rich source of information about the health and welfare of all 47 million Americans enrolled in Medicare. After painstaking study, the authors conclude that the “compression of morbidity” is for real: Americans truly have more years of life without disability today than they did 20 years ago. Someone who turned 65 in 1991 could anticipate living another 17.5 years, of which exactly half were spent with disability. Someone who turned 65 in 2003, by contrast, could look forward to living 18.2 years, of which fully 10.4 years would be disability-free, leaving 7.8 years of disability.

But all these averages--the average life expectancy at 65, average number of disability-free years--hide an important truth. What a given person will actually experience, just how much impairment he has in his final months or years, depends on what medical conditions he has. In fact, for some people, the experience of old age has gotten a great deal better; for others, it has gotten far, far worse.

Roughly speaking, people follow one of three possible paths in the last year or two of life and a similar pattern may well describe what happens in the last 5 or more years of life. One group of people die quite quickly and do well until the very end--these include people who have the most common forms of cancer and those who die very suddenly, perhaps from an accident or a heart arrhythmia. People in this group tend to die at a relatively young age and account for about 20% of all people who die. A second group of people have chronic organ system failure, for example congestive heart failure or chronic obstructive pulmonary disease, and have a course of slow decline, punctuated by periods of acute worsening followed by improvement. They do pretty well until the final 6-12 months of life and account for another 25% of the population.  A third group of people have poor long term function and have a slow decline, either because of dementia or because of that nebulous condition known as frailty in which multiple interacting medical problems interfere with daily activities. These include many of the oldest old and constitute 40% of deaths. The percentages do not add up to 100 because the remaining 15% cannot be readily classified as fitting into any of the 3 main groups.

What this means is that if you are in Group Three, what you will experience is not a "compression of morbidity," but a long, drawn-out period of decline. And the reality is that this third group, which is comprised largely of people with dementia, is going to grow as the other groups shrink.

It's already happening. Between 1997 and 2007, the death rate from heart disease fell 25%. Many people with heart disease are in that middle group who have pretty good functioning until their disease gets so severe that it gets in the way of what they want to do, though some have other diseases as well and are in the third, frail, group. So improvements in the prevention and treatment of heart disease--interventions such as exercise, diet, medications, and pacemakers--have meant fewer people dying of heart problems. But in the same ten year period, the death rate from Alzheimer's Disease increased by 50%. And all those people are in Group Three, those with the slow fade. 

So are things better or worse for older people? Maybe that's the wrong question. Maybe the answer is, it depends. 

Dementia Redux

A few months ago I wrote about my father’s experience in the nursing home where he lives, commenting on the difficulty of implementing  the “culture change movement” that is supposed to promote quality of life for residents. Many readers responded that they, too, had been disappointed with attempts by nursing homes to improve care for people with dementia. Since then, I've been keeping my eyes peeled for studies that examine what approaches to nursing home care actually make a difference for residents.

This month I found a an article in a major geriatrics journal that asked a related question: what characteristics of residential facilities are associated with better health outcomes and better psychosocial outcomes for residents with dementia? The authors looked at organizational characteristics (for-profit vs non-profit, urban vs rural, special care units vs no special care units, nursing homes vs assisted living, culture change vs conventional), structures of care (staffing level, proportion of private rooms, staff expertise), and processes of care (activity programs, family involvement, resident-centered care). What was shocking about this report is that although the investigators reviewed 6209 articles written between 1990 and 2012, they only found 14 that met even the rudimentary scientific standards needed to be included in their analysis (for example, a study had to have enough cases to allow the authors to draw meaningful conclusions and it needed to compare two different strategies used in otherwise similar facilities so the investigators could figure out if one strategy was better than the other). Out of the 14 studies the authors identified, 10 reported specifically on psychosocial outcomes, the issues I am most concerned. These 10 studies showed that “person-centered care,” which is at the heart of the culture change movement, did lead to slight improvement in well-being. Overall, however, quality of life was pretty much the same (and not very high) in all the facilities studied, regardless of whether there were private rooms or special activities and whether or not the nursing home was for-profit.

In most nursing homes, unfortunately, the relevant question is far more basic than whether pets or plants or "therapeutic touch" can make a difference for residents. I learned this week from an article in the Boston Globe that my own state of Massachusetts is hoping for the first time to require residential facilities with dementia “special care units” to actually give specialized training to their staff. Right now, dementia care is principally provided by certified nursing assistants (CNA) and, to a lesser extent, by registered nurses. To become a CNA in Massachusetts, you have to take 75 hours of coursework and have 100 hours of hands-on training in subjects such as giving a bath and taking a blood pressure. A CNA training program, which typically last 2-6 months, does not necessarily include much about dementia. Once a CNA is hired in a nursing home, he or she is assumed to have adequate expertise to care for all residents and, until now, no additional training is mandated.

A total of about 1.7 million people live in nursing homes in the US, of whom 70% have dementia. Another 1.2 million people live in some other form of residential care facility such as assisted living, of whom 42% have dementia. So it is reassuring that Massachusetts is likely to join the 16 other states that mandate some kind of training for direct care workers in facilities that claim to provide specialized dementia care. It's frightening that this new regulation will mean that workers will receive a mere 8 hours of training initially and 4 additional hours each year--acquiring real expertise in dementia care would surely require at least two or three times as many hours. It's also distressing that nursing home administrators immediately responded to the proposed regulations by protesting that they cannot possibly afford to spend so much time teaching their staff such essentials as gentleness, patience, and tolerance of repetition or techniques for handling such common problems as paranoia, agitation, and wandering.

We have come a long way since the appearance of great muckraking books like Tender Loving Greed exposed the nursing home industry nearly 30 years ago. We still have a long way to go.

Location, Location, Location

It's true: how much Medicare spends on you if you are old and sick depends on where you live. Researchers at the Dartmouth Institute for Health Policy and Clinical Practice have been saying this for years, but the skeptics insisted that maybe the people who had more tests and treatments were sicker, and maybe people just happened to be sicker in certain parts of the country than in others. Or maybe patients in some areas insisted on more aggressive treatment than patients elsewhere. Now, a new study carried out by the independent, well-respected Institute of Medicine suggests that the Dartmouth researchers were right all along. 

Not only are there parts of the country where both prices and “resource utilization,” or the intensity of tests and treatments, are higher than others, not only are these differences very large, but they have remained unchanged for the past 20 years. What’s going on here?

The new study finds that some of the geographic variation is related to the patients’ health status—people really are sicker in certain places than in others. But most of the difference between the high cost, high intensity regions and low spending regions is driven by the utilization of “post-acute services,” or care in places such as rehab centers after hospitalization. If post-acute care were the same everywhere, the variation in Medicare spending would fall by 73%. The rest of the difference between the high spending regions and the low spending areas is due to acute care, ie hospitalization. If hospitalization rates and hospital care were the same everywhere, the variation in Medicare spending would fall by 27%.

The authors of the IOM study suggest that the fix to the variation problem is to promote the “clinical and financial integration of health care delivery systems.” In other words, if hospitals and rehab centers and primary care doctors all shared responsibility for taking care of patients, if they had to share a fixed payment from Medicare, or so the argument goes, then each sector would behave efficiently so as to avoid penalizing both themselves and everyone else. This is the arrangement in the Accountable Care Organization model, currently being tested by Medicare in 32 sites across the country. 

Preliminary data suggest that the ACO approach may work to make the member organizations (hospitals, physician practices, etc.) more efficient. It may bring down costs. But concluding that ACOs are the way to control cost while maximizing quality, along with other forms of integration such as the “patient-centered medical homes” and “bundled payments,” begs the question of why there is geographic variation in the intensity of both acute care and post-acute care. If lack of integration is the culprit, is there less integration in some parts of the country than in others? Are rehab centers and hospitals doing more because they can get away with it, or for some other reasons?

Location clearly matters. But before you decide where to live based on your preference for a lot of medical interventions or few medical interventions (with little evidence of any consequence for your health either way), and before Medicare goes ahead and "incentivizes" integration within health care systems, we need some more answers.