February 09, 2014

Barking Up the Wrong Tree

When I was a medical resident at Boston City Hospital, a large, public, inner city hospital, I began wondering whether hospitals sometimes caused as many problems as they cured. Over and over, I saw older patients admitted with one disease such as pneumonia or a heart attack, who ended up falling and breaking a bone or getting a blood clot from being confined to bed. So I did a study in which I measured how often older people became confused, stopped eating, developed incontinence, or fell while they were in the hospital. I tried to separate out those cases in which the new symptom could be plausibly related to the admitting diagnosis: for example, someone who was hospitalized with a stomach ulcer would normally stop eating during the initial treatment, and someone with a stroke might well be confused. Then I compared the rates at which people over 70 developed these unexpected complications with the rates at which younger people developed them. Finally, I speculated that each of these problems might trigger a cascade of adverse events: a patient who became incontinent might have a catheter placed in his bladder, which in turn might cause a urinary tract infection; a patient who got confused might be physically restrained and his immobility might lead to a blood clot. 

What I found was that among the 502 patients I examined, a startling 41% of those over 70 developed 1 or more of the 4 problems I was interested in compared to only 9% of the younger group—and these were all problems that could not clearly be related to the acute illness for which the patient was being treated. It made me question whether hospitals were a safe place for older patients. 

Of course the older patients might have developed the same difficulties if they had been cared for at home, but I was skeptical. I thought that the unfamiliar environment of the hospital might be causing the confusion so common in hospitalized older individuals. I believed that being in a strange place might lead people to have trouble finding the bathroom at night and to fall as they groped trying to find their way.  And certainly the response of doctors and nurses to these new symptoms—putting in a catheter or using physical restraints or sedating medications—was far less likely to occur in the home setting.

Stimulated by my study and others like it, some physicians tried to design safer hospitals. That’s a noble endeavor and the result, the ACE unit (acute care for elders) has made it somewhat less likely that patients develop the kinds of complications I enumerated and far less likely that doctors and nurses responded to those complications, when they did occur, in the unfortunate ways I wrote about. But desite these improvements, older hospitalized patients have an unacceptably high risk of becoming acutely confused, receiving sedating medications, and falling, among other problems. 

At the same time that older patients continue to do poorly in the hospital—particularly the oldest and the frailest of the old—they have very high rates of repeat admissions to the hospital, sometimes within 30 days of discharge. As a consequence, many frail elderly patients have not just one opportunity to develop complications in a short period of time, but several chances. As it turns out, Medicare is very concerned about the high rate of readmissions, not so much because the Medicare program recognizes that hospitals can be hazardous for your health, but because repeated hospitalizations are very expensive. Not only that, but Medicare officials suspect that the reason older patients are being readmitted is that they weren’t properly taken care of the first time round. So the solution, Medicare reasons, is to penalize hospitals for high readmission rates, thus strongly incentivizing them to assure they get things right during the initial hospitalization.

It is a nice idea, and there is quite a bit hospitals can do to prevent readmissions. They can make sure patients are taking the medications they are supposed to take once they get home. They can check that they have a follow up appointment with their primary care physician within a few days of discharge. They can guarantee that the primary care physician receives a good summary of what happened in the hospital. But the assumption underlying the push to decrease readmission rates is that if only doctors do a good job with their frail, old patients, those patients won’t get sick again. The truth is that frail, old patients will inevitably get sick, even if physicians and nurses and hospitals do the best possible job taking care of those patients. The reason for this sad reality is that the essence of frailty is a heightened vulnerability to illness. So frail people will, by definition, repeatedly become sick.

Which brings me full circle to the study I did in the 1980s about the adverse consequences of hospitalization in the elderly.  The question, as I posed back when I wrote up my findings many years ago and again in an article I published in the Annals of Internal Medicine this week, is how we should respond when frail elders get sick. And my answer, then as now, is that we should try very hard to keep them out of the hospital. That means developing viable alternatives to hospital treatment. Frail, old people will sometimes want to be hospitalized for their acute medical problems. The hospital may prove to be the best site for achieving certain goals of care. But if they are interested in maximizing their quality of life, as many frail elders are, and if they have the option of home rather than hospital care, many of them would choose that route. 

The secret that policymakers do not seem to have recognized is that doing all these good things could save Medicare billions of dollars. Hospital care makes up 25% of Medicare spending and frail elders account for a disproportionate share of hospital days. So if we want to avoid hospital-induced iatrogenesis and assure that treatment conforms to patients’ goals and save money, we need to design new ways to treat patients outside the acute care hospital. 

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