All Things Dartmouth

For the last 20 years, the Dartmouth Institute for Health Policy and Clinical Practice—it’s added a few words to its name over time—has produced the “Dartmouth Atlas,” a compendium of information about the American health care system, principally culled from Medicare data. Some people are highly critical of the Atlas because it analyzes health care resource utilization (including hospital, ICU, SNF, physician visits, medications, procedures) in the last six months or the last two years of life—which requires starting with the time of death and looking backwards. The problem with this approach is that we don’t know in advance who’s going to die when, at least not with any degree of certainty. It’s easy to use the retrospectoscope and say that a patient shouldn’t have spent so much time in the ICU or gotten a feeding tube, given that he was going to die soon. But the intent of sending him to the ICU or putting in the tube was to enable him to live longer, or at least better, and it wasn’t so clear up front that the endeavor would fail.

The critics have a legitimate gripe, but I confess that for all its faults, I love the Dartmouth Atlas. I’m fascinated by its principal finding, which is that whenever you look at “preference-sensitive care,” at areas of medical treatment where there is no unequivocally right answer for what to do, what happens to patients varies enormously across the country. And while some kinds of care track together—in Portland, Oregon, patients spend less than the national average number of days in the hospital and in the ICU and more days enrolled in hospice, whereas in New York City, they spend a higher than average number of days in the hospital and the ICU and fewer days enrolled in hospice—the data are full of surprises. Given my general level of enthusiasm for all the reports that come out of the Dartmouth Atlas project, I was very happy to discover, by chance, I might add, that a new report was released just last week, “Our Parents, Ourselves: Health Carefor an Aging Population.”

Much of what’s in this report covers familiar ground. It summarizes the data on the average number of days that older patients spend in the hospital in the last six months of life, it talks about where people die, and reviews how much, or rather how little, time they spend enrolled in hospice. But some of what’s here is new, or at least presented in a different way, and it’s enlightening.

Because the focus of the new report is on the older patient’s experience of the health care system—which incidentally is what the book I’m writing is about—the authors have come up with a few ways of quantifying that experience. They define a new measure, the average number of “contact days,” by which they mean the total amount of time a person interacts in some way with American medical care, the number of days they have a doctor’s appointment, the number of days they go for a test or a procedure, and the number of days they are inpatients in a hospital or a skilled nursing facility. 

I’m not entirely satisfied with a measure that counts a day on which you have a doctor’s appointment or a test as a full day rather than attempting to add up the number of hours you actually spend going to the office, waiting, being seen, and coming home and translating that number into a fraction of a day, but it’s a good first step at measuring the intensity of exposure to the health care system. For what it’s worth, the average number of “contact days” in 2012 was 17, but in certain areas, such as Long Island, New York, it was 25.

Other useful sections of the report address “areas needing improvement” and “areas where we have made progress.” The list of areas needing improvement starts with screening for prostate cancer in men over 75 (we shouldn’t be ordering PSA tests for this group but 20% of older men get them overall and 30% of men in Miami get them). Similarly, there’s screening for breast cancer in women over 75. That’s an area that’s more controversial since its utility depends on life expectancy and there are plenty of 75 year old women who will live another 10 or 15 years and thus may benefit from screening. 

Then there’s late referral to hospice: as many as 27.3% of the residents of Fort Lauderdale who die in hospice were enrolled in the last 3 days of life, way too late to reap much benefit. Next comes feeding tubes in patients with advanced dementia, a subject near and dear to my heart since I’ve written quite a bit about it. It’s still the case, or it was in 2012, that 6% of people who die with dementia got a feeding tube in the preceding 6 months—though this happens less than 2% of the time in Portland, Oregon and as much as 12.8% of the time in Los Angeles. 

Finally, there’s the old favorite, days spent in an ICU in the last 6 months of life. Interestingly, the situation here has gotten worse, if you assume that the time in spent in an ICU before death is very uncomfortable and not at all beneficial. How much time people spend in an ICU is also tremendously variable, ranging from 1 day to 9 days, with La Crosse, Wisconsin at the low end of the spectrum and Miami and LA at the upper end.

And then there are the areas where we’ve made progress, according to the report. There is less use of high risk medications, there is more widespread monitoring of diabetics, there has been a decline in preventable hospital admissions, and there’s been a decrease, albeit slight, in readmissions to the hospital within 30 days of discharge. Finally, the opportunities for coordination of care and for advance care planning, which for some reason are lumped together, have increased.

What’s missing from the report is a compelling explanation of why the things that have improved have gotten better and why those that haven’t improved are still problematic—and why there’s so much variability in what happens where. The authors argue that there are different factors at work: there’s less use of high risk medications because one of the bad actors (propoxyphene, or Darvon) was taken off the market; and there are fewer readmissions because there’s better discharge planning. But Darvon was taken off the market in all 50 states and the rate of use of so-called high risk medications varies between 10% and 30%, depending on geography. Why? The national average for readmissions fell (though not terribly dramatically) between 2008 and 2012, but why did it fall for some hospitals and not others? If we know how to prevent readmissions, at least some of them, why doesn’t everybody do it?

I guess I still need to write that book.

Geriatric "Our Bodies, Ourselves?"

Not quite "Our Bodies, Ourselves," but the new report from the Dartmouth Atlas is all about the older person's experience of health care! See upcoming blog post.

Some News is Good News

The Framingham Heart Study has been ongoing since 1948 and it continues to provide answers, or at least insights, into all kinds of important medical questions. The latest news from Framingham is that the incidence of dementia, the rate at which new cases develop, has been declining over a period of 30 years, and that’s good news indeed.

It’s not exactly news, as several other epidemiologicstudies have pointed in the same direction, but many of those studies were either methodologically flawed or, though suggestive, did not yield statistically significant results The Framingham Study has the great virtue of using consistent, standard diagnostic criteria for dementia; it has monitored the cognitive status of the people it’s been following since 1975 (with even more extensive monitoring beginning in 1981); and it makes use of a special “dementia review panel,” which includes a neurologist and neuropsychologist to evaluate the evidence in every case of possible dementia. Because the Framingham Study collects all sorts of other data as well, including blood pressure readings, cholesterol levels, body-mass index, and information about diabetes, heart disease, cigarette smoking, and education, the investigators are able to control for all these factors.

The conclusion: since 1977, there has been a decline in the incidence of dementia averaging 20 percent per decade. But there are a few caveats. This study identified a total of 371 cases of dementia. That’s it. The 371 cases were scrupulously identified from among just over 5000 study participants, but it’s nonetheless a fairly small number of people. And if you look at the rate at which new cases of dementia were identified by “epoch,” you will see that the rate went from 3.6/100 in the first epoch to 2.8/100 in the second period, to 2.2/100 in the third period, to 2.0/100 in the final epoch. That is, the rate has fallen steadily but the most dramatic decline took place years ago. Things seem to be leveling off.

And there’s another issue that’s worth dwelling on: if you separate out the cases of Alzheimer’s disease from the cases of vascular dementia, you find that the rate of new cases of vascular dementia has fallen significantly, but there has been no statistically significant fall in the rate at which Alzheimer’s disease develops. This is not entirely surprising as we have made enormous inroads in cutting the rate of heart disease, in large measure by controlling blood pressure, treating high cholesterol, and persuading people to stop smoking—or better yet, never start. Exactly the same risk factors affect the development of heart disease and vascular dementia: prevent one, and you’ll prevent the other. But we have made no progress at all in preventing Alzheimer’s disease, which is thought to be responsible for the majority of cases of dementia.

The good news—and it really is good news—is that the progress in preventing heart disease has spilled over into the prevention of vascular dementia. The not-so-good news is that most dementia isn’t due to vascular disease. We should still vigorously combat vascular dementia, which after all causes some cases of dementia, and which also interacts with Alzheimer’s disease, in those unlucky people who are afflicted with both, to produce symptoms that are worse than would be expected from the combination of the two conditions. But there’s still a long way to go.

Integrated Mobile Healthcare

What do Arkansas, Idaho, Maine, Minnesota, Tennessee, Washington, Missouri, Nevada, and Ohio have in common? No, they're not the states that hold primary elections on Super Tuesday (though several will). They're the states that have approved some kind of Mobile Integrated Health Care System, and as of December 31, Massachusetts joined the pack. What this means is that ambulances can be dispatched to patients’ homes to do something quite different from what they usually do, which is to bring patients to the hospital. Their mission is to institute treatment that will keep patients out of the hospital. And that’s exactly what frail older people need.

A few years ago, several of my colleagues and I were brainstorming about how our medical practice could improve care for our frailest, older patients. We lamented that most patients had to choose between staying at home with hospice care or going into the emergency room when they developed any kind of acute illness. Many of them felt hospice care was too little (it only addressed their symptoms but made no attempt to fix the underlying problem, even if it was something simple such as a urinary tract infection) and emergency room care was too much (when an 85-year-old with multiple medical problems and a fever shows up in the emergency department, a slew of tests and admission to the hospital are virtually guaranteed).

The available in-between solutions weren’t good enough: a visiting nurse was rarely equipped to diagnose and treat, and urgent care centers were often inaccessible or unavailable. One nurse practitioner came up with a great idea: she proposed that we buy a van, outfit it with supplies ranging from a portable EKG machine to the apparatus for starting an iv and giving intravenous fluids, and organize a mobile acute-care-at-home service. But the organization felt the investment was too great and the benefits too uncertain. Mobile Integrated Health Care will do just what we envisaged, but with a twist: it will take advantage of paramedics’ training, of the fact that they routinely carry just the right kind of the equipment in their ambulances, and that many ambulance services have a fair amount of down time.

The Massachusetts legislature passed a law authorizing the Department of Public Health to oversee such a service in November, 2015, effective December 31. An 18-member “Mobile Integrated Health Advisory Council” has already been appointed by the Commissioner of Public Health to carry out the mandate to create such a service. Ambulance companies, fire departments, emergency medicine physicians, home care companies, and others are all coming together to try to make this work.

Two critical pieces that ought to get a lot of attention as the Council proceeds with its work are interactions with primary care physicians and advance care planning. Traditionally, it’s been emergency room doctors sitting in hospital emergency departments who give direction to paramedics in the field; for this new model to work well, primary care physicians should be the ones calling the shots. They will be providing the follow-up care, not the emergency room staff. And this system could dovetail beautifully with the Massachusetts Orders for Life-Sustaining Treatment (MOLST), a system already in place that allows patients to spell out the approach to care they want if they develop an acute illness. A completed MOLST form should be available to the paramedics to help them understand just what treatments the patient decided, well before the stress of the acute situation, were appropriate to consider.

The idea of Mobile Integrated Health Care is terrific, but we need to look carefully at its outcomes. So far, existing systems have been described but not studied. We have a chance to design a promising program and then to actually figure out whether it’s working. What a novel idea indeed.

Paramedics to the Rescue?

A New Use for Ambulances--see Post on Sunday

Calling on Calculus

Can calculus help identify when it's time to change the goals of care? See post on Sunday.

The Tipping Point

When I wanted to figure out whether it was time to replace our 2004 Toyota Camry, which runs beautifully and is the most comfortable and reliable car we’ve ever owned, I pulled out its repair records and graphed money spent on fixing the car as a function of time. What I was looking for was an inflection point or, as Malcolm Gladwell might call it, a tipping point. I wanted to know whether our annual maintenance expenses for the car had begun to creep up or, more importantly, if the curve had abruptly gotten a lot steeper. I was pleasantly surprised to discover that after the first couple of years, when our only costs were for oil changes, the annual costs had remained rock stable. The car has 125,000 miles on it; at this rate, it might make it to 200,000.

Now I can’t be certain that this calculation has any prognostic significance. It’s possible that there could be one very expensive year, a year when some particularly costly part needs to be replaced, but that large outlay is a blip on the curve; after that one year, annual expenditures might go back to normal. Drawing conclusions after looking at the high expenditure year and not waiting to see what happened the next year could lead to the erroneous conclusion that the vehicle had begun a period of relentless decline. And I have no evidence that even if my system makes sense when applied to cars, it would also work for people, but it set me to wondering.

The problem with people, and the reason that I’m hoping the car analogy might prove helpful, is that sometimes it’s hard to know when to stop “doing everything,” as patients often put it. Occasionally, it’s easy: there are patients, for example, with widely metastatic cancer who are clearly and unequivocally dying. They may not want to accept that the end is near, but it’s obvious to any good oncologist or palliative care physician. It is often obvious to families and even to the patient as well. There are patients with very advanced heart failure whose hearts can barely pump any blood and who are far too sick to withstand highly invasive treatment such as a heart transplant; they also may not want to acknowledge that they are dying. Their situation may be compounded if their doctors also don’t want to admit that they're dying, but there is compelling objective evidence that they are at death’s door.

Much of the discussion about death and dying these days centers on patients like these. And yes, it can be difficult emotionally to let go, but the truth is that these aren’t the hard cases. The hard cases are people who aren’t, as Katy Butler put it in her book about a better path to death, knocking on heaven’s door. The challenge is to figure out when to pull back before you reach that point and not necessarily to pull out all the stops, to go from maximal medical care to an exclusive focus on comfort, but rather to something in between. I have talked a great deal about this kind of intermediate care, particularly for frail older people. But how do you know when it’s time to switch gears—not necessarily from fourth gear to first gear, but perhaps to second or third?

Palliative care physicians have to deal with this question all the time. We have to figure out “eligibility criteria” for palliative care consultations. A recent state initiative in Massachusetts mandates that “suitable patients” be told about the availability of palliative care for people in their condition. Some useful guidelines have been developed: patients with heart failure who have had two or more hospitalizations or emergency room visits in the past year are good candidates; patients with dementia who have lost a great deal of weight or have had recurrent infections would benefit. Several interesting studies have identified “markers” for the beginning of frailty: a serious fall, for example, or admission to a nursing home. But the reality is that we don’t have a great way of identifying patients who are likely to be entering the final phase of their lives. It would be very useful to figure out who such patients are by using “administrative databases,” that is, insurance company records of doctor visits or hospitalization or lab tests. Hence my interest in inflection points.

I noticed recently that someone in my family had an abrupt increase in the monthly number of doctor visits, lab tests, and procedures. Instead of seeing her primary care doctor once or twice a year, she was going every month or two. Instead of very rare visits to sub-specialists—a trip to the ear doctor once a year to have wax removed, a visit to the dermatologist once a year for a skin exam, and an annual appointment with the eye doctor—she was seeing these specialists more frequently, along with other doctors: a surgeon, a rheumatologist, a gastroenterologist. I couldn’t help wondering whether she had passed a tipping point.

We have to tread carefully here. After a single, isolated acute illness, a patient might have a transient increase in “health care utilization,” as the economists put it. When mapping trajectories in the last year or two of life, we know that some patients don’t follow a steady path but instead become transiently frail—say after a small stroke or a hip fracture—only to return to their previous level of functioning after rehab.

So we have to plot out doctor visits and lab tests over a long enough period of time to be able to distinguish between a blip and an inflection point. If we insist on too long a time frame, then the approach ceases to be useful—by the time we know for sure that there was an inflection point, the person could be dead. 

I never used to like the people-as-machine metaphor—patients in many ways aren’t like machines whose parts wear down. But maybe, just maybe, old people are a bit more like old cars than I thought.