They All Add Up

With so much attention rightfully devoted to big ticket items in medicine such as the new drug for hepatitis C that costs $1000 a pill or high tech devices such as the continuous flow left ventricular assist device, which costs on average about $200,000 to insert, not many people are talking about the little ticket items. But the reality is that spending a small amount per person on a huge number of people adds up to just as much—or maybe more—than spending an enormous amount  per person for just a few individuals. So I was very pleased to see a research letter in JAMA Internal Medicine about that lowly test, the urinalysis. 

I was pleased that the authors looked at the consequences of the rampant ordering of urine tests in people with no symptoms suggestive of either an infection in the bladder or kidneys or acute kidney dysfunction, the only circumstances in which urinalyses have been found to be meaningful. The reason, quite simply, that most urine tests are useless or, as the article suggests, actually harmful, is that the majority of older people have bacteria in their urine. What this means is that the injudicious ordering of a urine test will far more often produce a “false positive” result than a “true positive.”

It so happens that twice in one morning of seeing patients this week, I was asked to order a urine test for no good reason. To be fair, the well-meaning daughters of the patients who requested the test, quite insistently, I might add, thought it was with good reason. Their mothers were being diagnosed with dementia, a condition that had developed insidiously over a period of at least a year and probably several, and they were hoping I would identify a “reversible cause” of this otherwise progressive, ultimately fatal illness. Neither patient, however, had any symptoms to suggest a bladder infection: they did not have burning on urination, they did not have urinary frequency, they had no fever or flank pain. One lady was 96; the other was 91. Since the majority of elderly women have bacteria in their urine, I was concerned that if we got a sample from these two (no mean feat if we wanted a “clean catch” specimen, uncontaminated by bacteria from the surrounding skin and from stool), it would show bacteria. But if we did anything with the result—and what was the point of getting the test unless we were planning to treat the ladies in the vain hope that a course of antibiotics would cure their dementia—we would do little more than expose them to a risk of another problem such as clostridium difficile colitis, a potentially serious, occasionally lethal infection common in debilitated older people that typically results from killing off other bowel bacteria with antibiotics.

So what did the new study find? The authors looked at 403 consecutive adult patients admitted to the general medical service of a hospital in 2014 and 2015. They found that in this group, who somewhat surprisingly had a median age of 79, 62% had a screening urinalysis at the time of admission. Fully 84% of these individuals lacked any symptoms suggestive of a urinary tract infection. Of the asymptomatic patients who were screened with a urinalysis, 30% had a positive test. Of those with a positive test, 22% were treated with antibiotics.

Maybe this is actually reassuring: only 30% of asymptomatic patients had bacteria in their urine, not the 90% the authors quote from the literature. And only 22% of the asymptomatic patients with a positive test were given antibiotics, not everyone. 

The research letter in JAMA Internal Medicine leaves many questions unanswered. We don’t know why so many asymptomatic patients had a urine test ordered—perhaps the physicians believed that the fall or fainting episode that triggered the hospitalization was in fact caused by a bladder infection, which is conceivable, even if dementia (what my patients suffered from) is not. We don’t know what proportion of those who were needlessly treated developed complications because of the antibiotics they received. We can’t measure just how much the injudicious use of antibiotics in situations such as this contributes to the development of bacteria that are resistant to multiple antibiotics, bacteria that go on to cause real disease that is phenomenally difficult to treat. 

We do know that there are over half a million people age 65 and over hospitalized each year according to the National Hospital Discharge Survey. If over half of them have an unnecessary test, and if a third of those tests are positive, and a fifth of those positive tests lead to potentially risky treatment, that’s still a lot of bad decisions. All those small ticket items add up, and we need to pay attention to the little decisions we make every day, not just to the big decisions we make once in a while.

Those Small Ticket Items

Those small ticket items can really add up--see blog post coming this weekend.

Palliative Care Comes of Age

Last week, the New England Journal of Medicine published a short review article entitled “Palliative Care for the Seriously Ill.” Eleven years ago, the NEJM also published a review of “Palliative Care,” at that time putting it in the section of the journal called “Clinical Practice.” What has changed over the decade? What has remained the same?

Comparing and contrasting the two short articles, both of which emanate from the Mount Sinai School of Medicine, reveals some interesting changes. Perhaps the first change worth noting is that the Mount Sinai School of Medicine is now the Icahn School of Medicine at Mount Sinai. That a venerable school of medicine should now be named after a business magnate known as a ruthless corporate raider instead of after the alleged birthplace of the Ten Commandments says worlds about developments in the field of medicine. Palliative care itself has been affected by the widespread corporatization of medicine, with 2/3 of all hospice providers for-profit in 2013, compared to 5% in 1990. But the article rightly concentrates on describing the field of palliative care rather than one specific program, hospice care. The authors carefully distinguish between the population who stand to benefit from palliative care--those with serious illness--and those who may benefit from hospice care--those who are in the last months of life.

What stood out reading the new and older articles side by side is that in 2004, Morrison and Meier were at pains to explain the rationale for the very existence of palliative care. They emphasized the under-treatment of symptoms such as pain, delirium, and nausea in very sick patients. They discussed the fixation of American medicine on cure, even when cure was not possible, and the false dichotomy between cure and comfort. In 2015, Morrison, writing this time with Kelley, a young colleague (also a marker of change as a new generation of physicians rises to prominence in palliative medicine), do not feel the same need to justify palliative care. To the extent that they do feel obligated to explain why palliative care should exist, they provide data, itself a welcome development over the past decade, offering a graph showing the prevalence of ten specific symptoms in advanced illness, broken down by disease category (cancer, congestive heart failure, chronic obstructive pulmonary disease, advanced kidney disease, dementia, and AIDS).

Another area discussed in some detail in the new article but scarcely mentioned in 2004 is the various delivery models for palliative care. Ten years ago, palliative care consisted principally of in-hospital consultation and of home-based hospice. Today, it is both of those but it is also increasingly provided in the outpatient arena and in the nursing home.

The discipline of palliative care is much the same today as it was a decade ago: it is based on the three-legged stool of communication (which includes establishing the goals of care and planning for the future), symptom management (which addresses symptoms from pain to constipation), and psychosocial and spiritual support (which is targeted to families along with patients). But it has grown into a mature field with a small but robust and burgeoning research base. It is an interdisciplinary form of care that offers an “added layer of support” to conventional care (words chosen from market research done by the Center for the Advancement of Palliative Care); it is for the “seriously ill,” (as the authors quietly insert into the title of their article), not just for the dying; and it is for people of “any age,” not just for older people (who seemed to be the primary target in the earlier article that emphasized the graying of the population).

The field has made remarkable strides. I have just one nagging concern. In its eagerness to view palliative care as a supplement to rather than a replacement for conventional care, the field has a tendency to ignore the important truth that when palliative care clinicians review the prognosis and the options with patients, the conclusion may well be that less is more. And in its excitement over the surprising finding in one important study that patients with palliative care may actually live longer than those receiving usual cancer care, the field glosses over the importance of making trade-offs between life-prolongation, comfort, and maximizing function. Sometimes, to be sure, there are no life-prolonging options: the aggressive chemotherapy that oncologists offer and patients seize upon simply won't work and may paradoxically shorten life. But sometimes--and I would argue more often--there is a potentially life-prolonging option. That course of treatment, however, is typically very risky. Its likelihood of succeeding may be extremely small and its probability of causing misery extremely high. What palliative care does in this scenario is to lay out the alternatives and figure out which makes most sense for a patient and family in light of their goals of care. What palliative care does not do, however, is deny the importance of making trade-offs. 

Perhaps when the New England Journal publishes a review article about palliative care in another ten years, the authors will not feel the need to view the field as an add-on, but rather as the more realistic and comprehensive approach to the management of advanced illness. The truth is that most of the diseases that kill people today--heart disease, many cancers, and dementia, for example--are chronic diseases. They cannot be cured. All treatment for these conditions is inherently palliative. Cardiologists, oncologists, and neurologists all practice palliative care all the time; they just don't do as good a job as they might. Here's to Palliative Care 3.0!

Til Death Do Us Part

Why did this image go viral? In case you haven’t seen it before, it depicts a couple who were admitted to separate rooms in a Georgia hospital. Thanks to the wisdom of the nursing staff—and some bending of the rules—they were reunited. I think the photo struck a chord because it captures the important reality that what matters most as we get older—and perhaps at any age—is relationships.

We devote an inordinate amount of effort when we are younger to being “successful,” which we tend to define in terms of fame and fortune. And then, when we retire, we focus on living longer, on diet and exercise, on health and on experiences. But what so clearly mattered most to the couple in this photo is each other. Yes, the oxygen flowing through the plastic tubing is important. Yes, the intravenous catheter (not visible in the photo but I’m reasonably sure it was there) was useful for delivering potentially life-prolonging medication. But what makes life meaningful above all is our connections to others.

Lisa Berkman, a prominent social epidemiologist, has found compelling evidence that social networks—our links to our community—even affect our physical health. They influence whether we get a heart attack or stroke in the first place and how we fare if we get one. They affect our propensity to develop cognitive impairment and how well we cope if dementia strikes. But perhaps George Vaillant said it best when summarizing his book, Triumphs of Experience: the Men of the Harvard GrantStudy. This ambitious, longitudinal project followed 268 men who graduated from Harvard in the 1940s with a series of in-depth interviews over the course of their lives. Of course, generalizing rom these privileged Americans, all male and all born in one era, to the rest of us is risky. But despite their talents and their opportunities, these men had their share of alcoholism, of poverty, of suffering, and of disease. The inescapable conclusion that Vaillant reached  was, as he put it himself: “It was a history of warm, intimate relationships—and the ability to foster them in maturity—that predicted flourishing in all aspects of these men’s lives.” And that's the message conveyed by the photo of the two nonagenarians in their hospital johnnies, holding hands.

Food for Thought

The global anti-aging industry is valued at over $195 billion and will grow to $275 billion by 2020. But the assessment of the effectiveness of its products made by three leading scientists in 2002 has not changed. And what they said is that “no currently marketed intervention—none—has yet been proved to slow, stop, or reverse human aging, and some can be downright dangerous.” They then go on to say that "the public is bombarded by hype and lies." Or, as one of the triumvirate put it in a recent NY Times article, "as soon as the scientists publish any glimmer of hope, the hucksters jump in and start selling."  

In light of this reality, my internal alarms started going off when I saw the headline in last week’s NY Times, “My Dinner with Longevity Expert Dan Buettner (No Kale Required).” Granted, the article was in the “Fashion and Style” section of the Times, not the health section and not the science section. Now don't get me wrong: diet and exercise do matter: eating well and remaining active decrease the chance of developing disease and disability. Not only that, but modifying what you eat in the hope that it will promote longevity is far more benign than purchasing expensive supplements or herbal remedies that have no proven efficacy and are quite possibly harmful. But still—is Dan Buettner really a “guru of the golden years” who has spent “the last 10 year unlocking the mysteries of longevity?” He traveled to five of the places on the globe with the longest lived people: Icaria, Sardinia, Okinawa, the Nicoya Seaside of Costa Rica, and Loma Linda, California and wrote up his interviews. He was not funded by the NIH as the report would have us believe: he was funded by National Geographic to report on peoples who were being studied by teams of scientists funded by NIH. He did write a cover story for National Geographic in 2005 about the people he met on his travels and how they lived, particularly how they ate. And he converted his article into a book, The Blue Zone Solution, published by National Geographic Press this past spring.

            National Geographic ran a cover story about diet and longevity once before. The magazine reported in 1973 on Dr. Alexander Leaf’s travels to the Caucasus where he studied people who ostensibly were 120 years old. It would turn out that these human marvels were actually only in their nineties, at best. In fact, according to Dr. Tom Perls, head of the New England Centenarian Study, 98% of claims of age over 115 are false, as are 65% of claims to be 110. 

            I’m not sure why the NY Times ran this story. But I was sufficiently intrigued to look into what we do know about diet and longevity.

         For starters, it’s important to distinguish between people who live a long time and people who live a very long time. What is pretty clear is that the variability in life span for people in the first category can be explained by a mixture of environmental and genetic factors. We can’t control who our parents were, but we can control, to some extent, our environment. So what we eat is one of the things that does matter, at least as far as increasing our chances of making it into our eighties is concerned. Exceptional longevity—centenarians and “super-centenarians” (people over age 110) are a different story. For this group, it’s all about genetics. 

            But can we say much more than what was concluded from the Whitehall study, a longitudinal study of aging in Canada that found the 4 behaviors that increased the chances of being in good health after age 60 are regular physical activity, eating fruits and vegetables daily, drinking alcohol in moderation, and not smoking? What do we learn by looking at  the dietary habits of people in Buettner’s “blue zones” of above average longevity?  

          For several decades, geriatrician Bradley Willcox and his twin brother, anthropologist Craig Willcox, have been leaders of the Okinawan Centenarian Study. They have identified a variety of factors which, together, seem to account for the long lives of Okinawans. It’s not just about diet. It’s also about living in a culture that values group activities and fosters a strong sense of community. It’s about living in a slower paced, low pressure world where people get around by bicycle. But yes, it’s also about diet. And while each of the longevity hot spots of the world has its own culinary specialties, they all have much in common. They all feature a high intake of unrefined carbohydrates and a moderate intake of protein, mainly from fish and legumes. Their foods have a low glycemic load, include a goodly number of anti-oxidants, and are low in saturated fats.

         How much of a role diet plays in the 30-50% of longevity that is due to environmental factors is unclear. Also unclear is whether diet interacts with social factors to make a difference. It’s conceivable that what you eat matters, but it matters a good deal more if you also live in an all-embracing community. At least as interesting as the Sardinians and the Costa Ricans are the Seventh Day Adventists of Loma Linda (whom, to be fair, Buettner visited as well). The people of Loma Linda are physically active and tend to be vegetarians. They are also very involved in their community and deeply committed to their religious faith. So maybe, just maybe, it’s not only what we eat that determines how long we live. Just some food for thought.